Decision making in treatment of symptomatic severe aortic stenosis: a survey study in Dutch heart centres.

AIM: To provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL]. METHODS: A questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment. RESULTS: All 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients' functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres 'often to always' do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are 'sometimes to regularly' available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed 'sometimes to regularly' in heart team meetings (n = 10). CONCLUSIONS: Dutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.

[Geriatric rehabilitation care: Doing the right things right]. / Geriatrische Revalidatiezorg: De juiste dingen goed doen.

BACKGROUND: Geriatric rehabilitation concerns short-term integrated multidisciplinary care aimed at functional recovery and social participation for relatively frail elderly. Given the geriatric clients' complex care issues, nurses should possess sufficient and appropriate competencies in order to identify and assess the relevant symptoms and intervene effectively. Yet, nurses experience a certain apprehensiveness to perform their tasks and express difficulties in multidisciplinary communication and collaboration in a constructive manner. In addition to the client's and informal care giver's perception of their input in the geriatric rehabilitation process, this study provides an in-depth understanding of the way nurses perceive their role in geriatric rehabilitation. METHODS/DESIGN: This descriptive study entails a quantitative and a qualitative component. The quantitative component concerns questionnaires for clients, informal care givers, nurses, and team leaders. The qualitative component aims to obtain in-depth information (i. e. opinions, meanings, and reflections) with regard to the decision making process and the performance of the rehabilitation care by means of open-ended questions (in the questionnaire) and semi-structured interviews. RESULTS: Clients and informal care givers rate specific themes in geriatric rehabilitation in a more negative light than nurses and team leaders do. These themes concern the provision of information in the hospital (prior to admission in the rehabilitation facility), involvement in the draw-up of the treatment plan and rehabilitation goals, geriatric rehabilitation as a 24/7 activity, and taking into account the client's other life events. The latter three findings in particular, are caused by nurses' apprehensiveness to perform their tasks adequately. DISCUSSION: Nurses working in geriatric rehabilitation, experience apprehensiveness to perform their tasks adequately. Uncertainty about the client's reaction or fear of damaging the relationship of trust, results in nurses not involving the clients and informal care givers in the draw-up of the rehabilitation goals. Apprehensiveness also submerges as the lack of experience or specific competences in considering the client's other life events. The recommendations address these aspects in particular.

[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]. / Integrale interventie ter voorkoming van functieverlies bij ouderen tijdens ziekenhuisopname: het Zorgprogramma voor Preventie en Herstel.

BACKGROUND: Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age. METHODS/DESIGN: To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline. DISCUSSION: This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

Haemolytic anaemia in cattle in NSW associated with Theileria infections.

Several outbreaks of anaemia, jaundice, abortion and mortality in cattle in New South Wales were attributed to the intracellular parasite, Theileria buffeli. Disease occurred predominantly in periparturient animals that had been moved from inland to coastal areas. Diagnosis was made via exclusion of other causes of haemolytic anaemia and observation of the parasite in blood smears. Treatments included both registered and non-registered products. There is a possibility of a new strain of Theileria sp. in Australia and the possible vectors encountered in NSW are discussed.

Vector fields of risk: a new approach to the geographical representation of childhood asthma.

One of the major challenges in health studies with a spatial dimension is to produce valid and meaningful geographical representations of risk. This issue has arisen in our research on childhood asthma and proximity to traffic in Perth, Western Australia. To illustrate the spatial variation in risk over the study area, we developed a method for constructing a "risk field" map and applied this method to our study population. Cases and controls aged 0-19 years were defined using emergency department presentations from 2002 to 2006. For each asthma case, two matched controls were obtained. Geocoded residential addresses were used to calculate "vectors" or arrows of risk across the study area. This allows a rapid interpretation, with the risk of asthma greatest in the direction of the head of the vector relative to the vector's tail. This approach clearly indicated that the risk of asthma presentation at hospital emergency departments is higher for children living closer to the major urban city centers. Application of our method to the study population suggests that the "vector" approach may be useful as an exploratory tool for the spatial investigation of risk of other health outcomes.

Residential traffic exposure and children's emergency department presentation for asthma: a spatial study.

BACKGROUND: There is increasing evidence that residential proximity to roadways is associated with an elevated risk of asthma exacerbation. However, there is no consensus on the distance at which these health effects diminishes to background levels. Therefore the optimal, clinically relevant measure of exposure remains uncertain. Using four spatially defined exposure metrics, we evaluated the association between residential proximity to roadways and emergency department (ED) presentation for asthma in Perth, Western Australia. METHOD: The study population consisted of 1809 children aged between 0 and 19 years who had presented at an ED between 2002 and 2006 and were resident in a south-west metropolitan area of Perth traversed by major motorways. We used a 1:2 matched case-control study with gastroenteritis and upper limb injury as the control conditions. To estimate exposure to traffic emissions, we used 4 contrasting methods and 2 independently derived sources of traffic data (video-monitored traffic counts and those obtained from the state government road authority). The following estimates of traffic exposure were compared: (1) a point pattern method, (2) a distance-weighted traffic exposure method, (3) a simple distance method and (4) a road length method. RESULTS: Risk estimates were sensitive to socio-economic gradients and the type of exposure method that was applied. Unexpectedly, a range of apparent protective effects were observed for some exposure metrics. The kernel density measure demonstrated more than a 2-fold (OR 2.51, 95% CI 2.00 - 3.15) increased risk of asthma ED presentation for the high exposure group compared to the low exposure group. CONCLUSION: We assessed exposure using traffic data from 2 independent sources and compared the results of 4 different exposure metric types. The results indicate that traffic congestion may be one of the most important aspects of traffic-related exposures, despite being overlooked in many studies on the exacerbation of asthma.

Immunity following use of Australian tick fever vaccine: a review of the evidence.

OBJECTIVE: To review the evidence available on the degree and duration of immunity provided by Australian tick fever vaccines against Babesia bovis, B. bigemina and Anaplasma marginale infections in Australia and overseas. BACKGROUND: Vaccines containing attenuated strains of B bovis and B bigemina as well as A. centrale grown in splenectomised calves have been used in Australia since 1964 to immunise cattle against tick fever. About 800,000 doses of vaccine are supplied annually and much of the evidence for protection is field evidence rather than conventional immunological measures or pen trials. CONCLUSIONS: Immunity to Babesia bovis and B. bigemina--A single inoculation generally provides sound, long-lasting protection both in Australia and overseas. No evidence was found of a loss of immunity with time. Vaccine failures to B. bovis do occur, but are uncommon and evidently caused by a number of factors, including immune responsiveness of the vaccinated animals, and immunogenicity of the vaccine strain. Immunity to Anaplasma marginale--The vaccine containing A. centrale provides partial, variable protection against A. marginale. Protection against challenge in Australia is adequate in most cases to prevent disease and use of the vaccine in this country appears to be justified. Protection against antigenically diverse, highly virulent stocks of A. marginale in other countries is, at times, clearly inadequate and better vaccines are required in situations where the challenge is severe.

Vaccination against bovine babesiosis.

Bovine babesiosis is an important disease caused by Babesia bovis, B. bigemina, and B. divergens. Solid immunity develops after infection and this feature has been exploited with the use of live attenuated organisms as immunogens. Attributes of live vaccines include a durable immunity to heterologous challenge after one vaccination. To overcome disadvantages relating to poor quality control (risk of contamination and adverse reactions), production procedures have been modified to meet the requirements of codes of good manufacturing practice. This includes development of methods to allow production of cryopreserved vaccine and limit antigenic drift. Killed vaccines have also been used on a limited basis and consist of antigens extracted from cultured material or blood of infected calves, and given with adjuvant. The degree and duration of immunity against heterologous challenge is not well documented. Attempts are being made to develop subunit vaccines but the progress has been slow. A better understanding of the mechanisms involved in the expression of protective immunity against Babesia spp will aid in the identification of protective antigens.

Effect of breed of cattle on transmission rate and innate resistance to infection with Babesia bovis and B bigemina transmitted by Boophilus microplus.

OBJECTIVE: To assess the effect of breed of cattle on the transmission rates of and innate resistance to Babesia bovis and B bigemina parasites transmitted by Boophilus microplus ticks. DESIGN: Groups of 56 purebred B indicus and 52 B indicus cross B taurus (50%, F1 generation) steers were placed in a paddock seeded with and also naturally infested with B microplus which were the progeny of females ticks fed on B taurus cattle specifically infected with a virulent isolate of B bovis. The cattle were placed in the infested paddock 50 days after seeding had started. PROCEDURE: Cattle were inspected from horseback daily for 50 days. Clinically ill cattle were brought to yards and assessed by monitoring fever, depression of packed-cell volume, parasitaemia and severity of clinical signs. Any animals that met preset criteria were treated for babesiosis. Blood samples were collected from all cattle on day 28, 35 and 42 after exposure and antibodies to Babesia spp and packed cell volume measured. RESULTS: All steers, except for one crossbred, seroconverted to B bovis and B bigemina by day 35 and 75% of the crossbred steers showed a maximum depression in packed cell volume of more than 15% due to infection with Babesia spp compared with only 36% of the B indicus group. Ten of the 52 crossbreds and 1 of the 56 B indicus steers showed severe clinical signs. Two of the crossbreds required treatment of which one died 2 weeks after initial treatment. CONCLUSIONS: Pure-bred B indicus cattle have a high degree of resistance to babesiosis, but crossbred cattle are sufficiently susceptible to warrant the use of preventive measures such as vaccination. Transmission rates of B bovis and B bigemina to B indicus and crossbred cattle previously unexposed to B microplus were the same.

Effect of breed of cattle on innate resistance to infection with Anaplasma marginale transmitted by Boophilus microplus.

OBJECTIVE: To assess the innate resistance of and transmission in naive Bos taurus cross Bos indicus and purebred Bos indicus cattle when placed in a paddock with cattle infected with Anaplasma marginale and carrying Boophilus microplus ticks. DESIGN: A group of 49 purebred B indicus, and 48 B indicus cross B taurus (50%, F1 generation) 24-month-old steers were kept in the same paddock with cattle artificially infected with a virulent isolate of A marginale and Boophilus microplus. The cattle were seronegative for A marginale at the start of the trial but had previously been exposed to Babesia bovis and B bigemina. PROCEDURE: Cattle were inspected twice weekly for 118 days. Whole blood, blood smears and serum samples were collected from the cattle on day 37 after exposure and then at regular intervals to day 83 after exposure to measure packed-cell volumes, parasitaemias and antibody titres to A marginale. Any animals that met preset criteria were treated for anaplasmosis. On day 83 all cattle were treated with an acaricide and cattle infected with A marginale were removed from the rest of the group. RESULTS: A marginale was detected in blood smears from 14 crossbred and 9 B indicus steers between days 56 and 72 after exposure. Five and two of the infected crossbred and B indicus steers required treatment, respectively. One of the Bos indicus cattle died as a result of the A marginale infection despite treatment. Antibodies to A marginale were detected in the 23 infected cattle. The mean packed-cell volume depression was 40 and 37% in the affected crossbred and Bos indicus groups, respectively. There was no significant difference detected in susceptibility between these two groups. CONCLUSIONS: Innate resistance of purebred B indicus and crossbred cattle was not significantly different. The results confirm that purebred B indicus and crossbred cattle are sufficiently susceptible to warrant the use of vaccination against Anaplasma infections.

Development of effective living vaccines against bovine babesiosis--the longest field trial?

Between 1959 and 1996, research was performed to change a vaccine against babesiosis in Australia and to improve it as actual or threatened untoward field responses became apparent. The most significant change occurred in 1964 with the traditionally used carriers of Babesia being replaced as vaccine donors by acutely infected splenectomised calves. This ensured the infectivity of the vaccine and was fortuitously associated with a reduction in the virulence of Babesia bovis in vaccine. Since then, more than 27 million doses of highly infective vaccine have been supplied from the laboratory at Wacol near Brisbane. This vaccine reduced serious losses from babesiosis in vaccinated cattle in Australia to very low levels and has now gained acceptance worldwide. Research to ensure the continuing effectiveness of the vaccine has proved to be essential.

Effect of breed of cattle on innate resistance to infection with Babesia bovis, B bigemina and Anaplasma marginale.

OBJECTIVE: To assess the innate resistance of naive Bos taurus, Bos taurus cross Bos indicus and Bos indicus cattle to virulent Babesia bovis, B bigemina and Anaplasma marginale parasites. DESIGN: Groups of 10, pure B indicus, 1/2 B indicus cross, 1/4 B indicus cross and pure B taurus steers were infected with virulent B bovis, B bigemina and A marginale parasites [corrected]. PROCEDURE: Sequential infections were carried out by intravenous inoculation of infected blood containing 1 x 10(8) parasites of B bovis, followed by B bigemina and then A marginale. To assess resistance, measurements were made of parasitaemia, rectal temperature, packed cell volume and the number within a group requiring chemotherapy to control infection. There was a recovery period between each infection. RESULTS: Infection with B bovis showed that pure B indicus steers were significantly more resistant to B bovis infection than the other groups, with none of this group requiring treatment. There was no significant difference between 1/2 B indicus cross and 1/4 B indicus cross with 30% and 20%, respectively, of steers in these groups requiring treatment [corrected]. The pure B taurus steers were significantly more affected then those in the other three groups with 80% requiring treatment. Infections of B bigemina produced a mild response in comparison to that of B bovis and none of the steers required treatment. However, the pure B taurus group was significantly more affected than the other three groups for all other measurements. After the A marginale infection, B indicus steers were moderately affected with 50% requiring treatment, whereas 70% of the 1/2 B indicus group, 80% of the 1/4 B indicus cross group and 100% of the pure B taurus group required treatment [corrected]. CONCLUSIONS: All breeds of cattle, ranging from pure B indicus to pure B taurus may be at risk of severe disease if exposed to virulent A marginale. The results confirm that pure B indicus cattle are relatively resistant to B bovis, but there could be a significant risk of severe mortalities if cross-bred herds are exposed to virulent infection.

Review of Australian species of Theileria, with special reference to Theileria buffeli of cattle.

This review describes 4 species of parasites in Australia generally regarded as Theileria. The physiological and epidemiological characteristics of the species that occurs in cattle are discussed. Confusion still surrounds the relationship of this species with benign species of Theileria in other countries. Arguments are presented to support the proposal that the bovine species in Australia is correctly designated Theileria buffeli and that this name should apply to all the benign species of Theileria of cattle in Eurasia. The other 3 species considered in the review are proposed species from marsupials. Of these, only Theileria tachyglossi can confidently be included in the genus Theileria, because schizonts have yet to be detected in the other 2 species.

Studies on failure of T strain live Babesia bovis vaccine.

Field investigations of the protection afforded by the Australian live Babesia bovis vaccine used in the early 1990s (T strain) revealed inadequate vaccine-induced protection in certain herds. Vaccination/challenge trials using 207 experimental cattle were conducted to evaluate the protection afforded by T strain B bovis against field isolates from these herds. The trials investigated whether isolates that could 'break-through' T strain immunity were present in the field, the ability or inability of specific cattle to develop protective immunity after vaccination with T strain and the effect of attenuation and maintenance procedures on the immunogenicity of T strain. The results showed that B bovis parasites present early in the process of attenuation of T strain were more protective than those remaining late in the process. They also showed that cattle from properties experiencing vaccine failures were less protected by T strain vaccination than Bos taurus cattle randomly selected from the general population if vaccinated with highly attenuated T strain. A hypothesis is offered to explain these findings.

A survey of cattle producers in the Boophilus microplus endemic area of Queensland to determine attitudes to the control of and vaccination against tick fever.

A survey by mail was used to determine the views of beef producers in the Boophilus microplus endemic area of Queensland on the control of and vaccination against tick fever. Data from 448 questionnaires were analysed, representing 2.7% of beef producers in the survey area. Producers considered buffalo fly (Haematobia irritans exigua) infestation as the most important problem whereas tick fever ranked sixth overall. Private veterinarians were regarded as the most important source of information on vaccines for cattle followed by a weekly rural newspaper. From the survey we estimate that about 33% of producers used the tick fever vaccine produced by the Tick Fever Research Centre of Queensland Department of Primary Industries but there were significant (P < 0.05) variations between regions and herds. Large herds (> or = 400 head) in south-east Queensland were the most likely to be vaccinated against tick fever. Of the producers who did not use the vaccine, over 70% replied that there was no need to vaccinate because of the low risk of the disease in their herds. In 52% of unvaccinated herds the treatment of animals with acaricide was considered the most important means of tick fever control and 61% of these herds comprised Bos indicus x Bos taurus or Bos indicus cattle.

Current state and future trends in the diagnosis of babesiosis.

An overview is given of the currently available methods to diagnose babesiosis in livestock. Microscopic techniques are still the only appropriate techniques to diagnose acute disease. Thin or thick blood films stained with Giemsa's stain are sufficient. The sensitivity ranges from 10(-5) to 10(-6), i.e. one parasite per 10(5)-10(6) erythrocytes can be detected. Thick films stained with acridine orange (sensitivity approximately 10(-7)) and the Quantitative Buffy Coat (QBC) analysis tube system (sensitivity approximately 10(-7)-10(-8)) are applicable for diagnosis in the laboratory. DNA probes are very specific tools to identify haemoparasites in organs post mortem and in ticks. For the identification of carrier animals the sensitivity (approximately 10(-5)-10(-6)) is generally not sufficient. For the latter the polymerase chain reaction (PCR) technique is a very powerful tool (sensitivity approximately 10(-9)). Many different serodiagnostic tests have been described; however, the immunofluorescence antibody test is the most widely used, while the enzyme-linked immunosorbent assay (ELISA) is the test system which holds the greatest promise for the future. Thus far, improvements to the ELISA have been limited as the quality of antigen preparations made from infected blood is generally poor with a few exceptions (Babesia bovis, Babesia caballi). Potentially, most of the problems associated with crude antigens can be overcome by the production of recombinant antigens. Several ELISAs based on highly defined recombinant antigens have been described and show promise. None of these tests has been validated to the extent that it could be applied globally. Future research requirements as well as the need for coordination of the research effort and collaboration between institutions involved in the diagnosis of babesiosis are discussed.

Analysis of the composition of samples of Babesia bovis and the influence of different environmental conditions on genetically distinct subpopulations.

A recombinant DNA probe specific for a tandemly repeated sequence located within the BoVA1 gene of Babesia bovis was used to analyse 10 independent samples of B. bovis. Twelve different alleles of the BoVA1 gene and flanking regions were identified in the 18 different subpopulations analysed. Most samples of B. bovis originally derived from single animals contained more than one genetically distinct subpopulation. However, only one population of parasites was identified in samples of the Ka line used in Australia from 1979 until 1990 as the live attenuated vaccine strain. In contrast, the replacement attenuated vaccine line, Ta, contained two genetically distinct subpopulations of parasites. Changes in the ratios of subpopulations of parasites were identified during attenuation and under different culture conditions. Batch-to-batch variation in the composition of doses of the live attenuated vaccine may lead to differences in efficacy and in severity of the infection associated with vaccination.