Understanding the drivers of mortality in African savannah elephants.

Populations of African savannah elephants (Loxodonta africana) have been declining due to poaching, human-elephant conflict, and habitat loss. Understanding the causes of these declines could aid in stabilizing elephant populations. We used data from the Great Elephant Census, a 19-country aerial survey of savannah elephants conducted in 2014 and 2015, to examine effects of a suite of variables on elephant mortality. Independent variables included spatially explicit measures of natural processes and human presence as well as country-level socioeconomic measures. Our dependent variable was the carcass ratio, the ratio of dead elephants to live plus dead elephants, which is an index of recent elephant mortality. Carcass ratios are inversely proportional to population growth rates of elephants over the 4 yr prior to a survey. At the scale of survey strata (n = 275, median area = 1,222 km2 ), we found strong negative associations for carcass ratios with vegetation greenness at the time of the survey, overseas development aid to the country, and distance to the nearest international border. At the scale of ecosystems (n = 42, median area = 12,085 km2 ), carcass ratios increased with drought frequency and decreased with human density and overseas development aid to the country. Both stratum- and ecosystem-scale models explained well under one-half of the variance in carcass ratios. The differences in results between scales suggest that the drivers of mortality may be scale-specific and that the corresponding solutions may vary by scale as well.

Response rate does not affect patient-reported outcome after lumbar discectomy.

PURPOSE: Quality registers give unique possibilities to achieve information from large groups of patients, but outcome must be interpreted carefully due to less stringent data collection and lower follow-up rates than in research projects. We tried to quantify any outcome differences between a national spine quality register and a prospective observational study. METHODS: Adult patients treated with lumbar discectomy between 2004 and 2010 were retrieved from the Swedish Spine register (Swespine) (n = 7791) and from the single center lumbar disc herniation study (LDHS) in Stockholm (n = 177). The mean follow-up rates at 1 and 2 years were 73 and 62%, compared to 98 and 99%, respectively. Patient-reported outcome measurements included VAS for back and leg pain, ODI, EQ-5D, patient satisfaction, and global assessment. RESULTS: When comparing the two cohorts at baseline, there were minor differences in the patient-reported outcome measurements, all within reported minimal clinical important differences (MCID). Mean outcome improved significantly in both groups after surgery. All outcomes at 1 and 2 years were similar and within the reported MCID in both groups. Complications and reoperations were similar, except for more surgical site infections in the LDHS group. CONCLUSIONS: Higher response rates than seen in Swespine are not needed to achieve reasonably representative data on patient-reported outcome for large cohorts. Two-year data do not seem to add additional information. These slides can be retrieved under Electronic Supplementary Material.

Similar result after non-elective and elective surgery for lumbar disc herniation: an observational study based on the SweSpine register.

PURPOSE: Surgery for lumbar disc herniation (LDH) is most often elective, but intense pain may require more urgent, non-elective, treatment. It was hypothesized that non-elective treatment could be associated with a less favourable outcome than elective surgery. The aim of this study was to compare 1-2-year outcome after non-elective and elective surgery for treatment of para-median LDH using data from the Swedish Spine register (SweSpine). METHODS: Pre- and postoperative data were available for 301 non-elective and 2364 elective cases. Patient reported outcome measures (PROMs) were; Visual Analogue Scale (VAS) leg and back pain, Oswestry Disability Index (ODI), EuroQol five-Dimensions (EQ-5D) and patient satisfaction. Postoperative p values were adjusted for baseline differences. RESULTS: Preoperative mean (SD) in the non-elective and elective groups were for VAS leg pain 81 (22) and 65 (24), for VAS back pain 51 (33) and 45 (28), for ODI 66 (20) and 45 (17) and for EQ-5D 0.024 (0.35) and 0.31 (0.33), respectively, (p for all <0.001). Postoperative VAS leg pain was 23 (28) in the non-elective group and 20 (26) in the elective group (p = 0.19). Corresponding figures were for VAS back pain 25 (27) and 24 (27) (p = 0.69), ODI 19 (17) and 17 (17) (p = 0.052) and for EQ-5D 0.70 (0.28) and 0.73 (0.29) (p = 0.73). Patient satisfaction did not differ between the groups (p = 0.78). CONCLUSIONS: Even if non-elective patients preoperatively had substantially more pain, higher disability and poorer quality of life than elective patients, postoperative differences were clinically small. Patient satisfaction did not differ.

Markers of inflammation and fibrinolysis in relation to outcome after surgery for lumbar disc herniation. A prospective study on 177 patients.

PURPOSE: The role of inflammation and fibrinolysis for the development of back pain and sciatica has been discussed. The aim of this study was to assess the relationship between markers of inflammation and fibrinolysis, to predict the outcome after surgery for lumbar disc herniation. METHODS: 177 patients were recruited. High sensitive C-reactive protein (hsCRP), plasminogen activator inhibitor 1 (PAI-1), fibrinogen, and D-dimer were analyzed preoperatively. Visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and EuroQol 5 Dimensions (EQ-5D) were assessed preoperatively and at 6 weeks, 6-, 12-, and 24- months postoperatively. Dichotomization was made at the median for the laboratory analyses, and between the worst quartile and the other three quartiles for the outcome variables. Logistic regression was used to determine the odds ratios (OR) and 95 % confidence intervals (CI). RESULTS: The associations between PAI-1 and outcome seemed to be most prominent at the 6 and 12-month follow-up. When being in the upper half of PAI-1, the OR for being in the worst quartile of VAS back pain 12 months postoperatively was 3.33 (1.56-7.10). The corresponding OR for VAS leg pain was 2.46 (1.18-5.10), for ODI 2.83 (1.35-5.94) and for EQ-5D 2.73 (1.30-5.75). The OR for hsCRP was 2.10 (1.03-4.29) for being in the worst quartile of VAS back pain. Fibrinogen or D-dimer was not associated with any outcome variable. CONCLUSIONS: High PAI-1, a marker of fibrinolysis, was fairly consistently associated with poor outcome, while hsCRP, fibrinogen, and D-dimer were not.

Auditing a breast MRI practice: performance measures for screening and diagnostic breast MRI.

PURPOSE: Breast MRI is increasingly used for both screening and diagnostic purposes. Although performance benchmarks for screening and diagnostic mammography have been published, performance benchmarks for breast MRI have yet to be established. The purpose of this study was to comprehensively evaluate breast MRI performance measures, stratified by screening and diagnostic indications, from a single academic institution. METHODS: Institutional review board approval was acquired for this HIPAA-compliant study. Informed consent was not required. Retrospective review of the institutional database identified all breast MRI examinations performed from April 1, 2007, to March 31, 2008. After application of exclusion criteria, the following performance measures for screening and diagnostic indications were calculated: cancer detection rate, positive predictive value (PPV), and abnormal interpretation rates. RESULTS: The study included 2,444 examinations, 1,313 for screening and 1,131 for diagnostic indications. The cancer detection rates were 14 per 1,000 screening breast MRI examinations and 47 per 1,000 diagnostic examinations (P < .00001). The abnormal interpretation rate was 12% (152 of 1,313) for screening and 17% (194 of 1,131) for diagnostic indications (P = .00008). The PPVs of MRI were lower for screening [PPV1 (abnormal findings) = 12%, PPV2 (biopsy recommended) = 24%, PPV3 (biopsy performed) = 27%] compared with diagnostic indications (PPV1 (abnormal findings) = 28%, PPV2 (biopsy recommended) = 36%, PPV3 (biopsy performed) = 38%]. CONCLUSIONS: Breast MRI performance measures differ significantly between screening and diagnostic MRI indications. Medical audits for breast MRI should calculate performance measures for screening and diagnostic breast MRI separately, as recommended for mammography.

Improving education for the management of contrast reactions: an online didactic model.

PURPOSE: Radiologists could improve their knowledge of contrast reaction management. The aim of this study was to evaluate to what degree the implementation of a didactic module resulted in improved technologist, nurse, and physician knowledge and comfort levels regarding the appropriate management of adverse reactions to contrast media. METHODS: After institutional review board approval was obtained, nurses, technologists, and physicians involved in contrast administration were required to complete the educational module. Premodule and postmodule assessments were designed online. Each assessment included knowledge-based questions regarding the appropriate management of different types of contrast reactions, as well as questions regarding each respondent's comfort level with the treatment of various types of adverse contrast reactions. Comfort level was measured using a 6-point, Likert-type scale. Premodule and postmodule assessment scores were compared using McNemar's test. RESULTS: After module completion, physicians demonstrated a statistically significant improvement in knowledge regarding the proper administration route, concentration, and dose of intramuscular epinephrine. Physicians demonstrated significantly increased comfort with the administration of intramuscular epinephrine to adult and pediatric patients after module completion (P < .05). Module completion resulted in statistically significant improvements in respondents' comfort levels with the treatment of an adverse reaction to contrast media, although 19% of personnel still reported feeling uncomfortable after completing the module. CONCLUSIONS: Didactic instruction in contrast reaction management results in improved knowledge and comfort levels for physicians, nurses, and technologists. However, a significant percentage of personnel still reported feeling uncomfortable treating an adverse contrast reaction after module completion, suggesting that didactic instruction alone may be inadequate.

Logging concessions can extend the conservation estate for Central African tropical forests.

The management of tropical forest in timber concessions has been proposed as a solution to prevent further biodiversity loss. The effectiveness of this strategy will likely depend on species-specific, population-level responses to logging. We conducted a survey (749 line transects over 3450 km) in logging concessions (1.2 million ha) in the northern Republic of Congo to examine the impact of logging on large mammal populations, including endangered species such as the elephant (Loxodonta africana), gorilla (Gorilla gorilla), chimpanzee (Pan troglodytes), and bongo (Tragelaphus eurycerus). When we estimated species abundance without consideration of transect characteristics, species abundances in logged and unlogged forests were not different for most species. When we modeled the data with a hurdle model approach, however, analyzing species presence and conditional abundance separately with generalized additive models and then combining them to calculate the mean species abundance, species abundance varied strongly depending on transect characteristics. The mean species abundance was often related to the distance to unlogged forest, which suggests that intact forest serves as source habitat for several species. The mean species abundance responded nonlinearly to logging history, changing over 30 years as the forest recovered from logging. Finally the distance away from roads, natural forest clearings, and villages also determined the abundance of mammals. Our results suggest that logged forest can extend the conservation estate for many of Central Africa's most threatened species if managed appropriately. In addition to limiting hunting, logging concessions must be large, contain patches of unlogged forest, and include forest with different logging histories.

Bushmeat supply and consumption in a tropical logging concession in northern Congo.

Unsustainable hunting of wildlife for food empties tropical forests of many species critical to forest maintenance and livelihoods of forest people. Extractive industries, including logging, can accelerate exploitation of wildlife by opening forests to hunters and creating markets for bushmeat. We monitored human demographics, bushmeat supply in markets, and household bushmeat consumption in five logging towns in the northern Republic of Congo. Over 6 years we recorded 29,570 animals in town markets and collected 48,920 household meal records. Development of industrial logging operations led to a 69% increase in the population of logging towns and a 64% increase in bushmeat supply. The immigration of workers, jobseekers, and their families altered hunting patterns and was associated with increased use of wire snares and increased diversity in the species hunted and consumed. Immigrants hunted 72% of all bushmeat, which suggests the short-term benefits of hunting accrue disproportionately to "outsiders" to the detriment of indigenous peoples who have prior, legitimate claims to wildlife resources. Our results suggest that the greatest threat of logging to biodiversity may be the permanent urbanization of frontier forests. Although enforcement of hunting laws and promotion of alternative sources of protein may help curb the pressure on wildlife, the best strategy for biodiversity conservation may be to keep saw mills and the towns that develop around them out of forests.

Acute rheumatic fever associated with Henoch-Schönlein purpura: report of three cases and review of the literature.

AIM: To describe a possible relationship between Henoch-Schönlein purpura and rheumatic fever. METHODS: Patients with features of both diseases were identified by reviewing the hospital records. Medline and reference lists from published articles were used to search for previous reports of the two conditions occuring simultaneously. RESULTS: Three newly described cases, and three previous reports of Henoch-Schönlein purpura associated with rheumatic carditis or chorea were identified. CONCLUSIONS: The coexistence of these two disorders in some patients supports the view that Group A streptococcus may have a pathogenic role in Henoch-Schönlein purpura.

The Hebrew version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Hebrew language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Hebrew CHAQ-CHQ were fully developed with 3 forward and 3 backward translations. A total of 144 subjects were enrolled: 80 patients with JIA (12% systemic onset, 34% polyarticular onset, 23% extended oligoarticular subtype, and 31% persistent oligoarticular subtype) and 64 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the JIA patients having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Hebrew version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Multifactorial mortality in bongos and other wild ungulates in the north of the Congo Republic.

Wildlife mortality involving bongos, Tragelaphus eurycerus, and other ungulates was investigated in the north of the Congo Republic in 1997. Four bongos, one forest buffalo, Syncerus caffer nanus, and one domestic sheep were examined and sampled. Although an outbreak of rinderpest had been suspected, it was found that the animals, which had been weakened by an Elaeophora sagitta infection and possibly also by adverse climatic conditions, had been exsanguinated and driven to exhaustion by an unusual plague of Stomoxys omega.