Development of 'gastrostomy tube - is it for me?', a web-based patient decision aid for people living with motor neurone disease considering having a gastrostomy tube placed.

Objective: To develop and pilot a web-based patient decision aid (PDA) to support people living with motor neurone disease (plwMND) considering having a gastrostomy tube placed. Methods: In Phase 1, content and design were informed by semi-structured interviews, literature reviews and a prioritization survey. In Phase 2, the prototype PDA was tested with users and developed iteratively with feedback from surveys and 'think-aloud' interviews. Phase 1 and 2 participants were plwMND, carers and healthcare professionals (HCPs). In Phase 3, the PDA was evaluated by plwMND using validated questionnaires and HCPs provided feedback in focus groups. Results: Sixteen plwMND, 16 carers and 25 HCPs took part in Phases 1 and 2. Interviews and the literature review informed a prioritization survey with 82 content items. Seventy-seven per cent (63/82) of the content of the PDA was retained. A prototype PDA, which conforms to international standards, was produced and improved during Phase 2. In Phase 3, 17 plwMND completed questionnaires after using the PDA. Most plwMND (94%) found the PDA completely acceptable and would recommend it to others in their position, 88% had no decisional conflict, 82% were well prepared and 100% were satisfied with their decision-making. Seventeen HCPs provided positive feedback and suggestions for use in clinical practice. Conclusion: Gastrostomy Tube: Is it for me? was co-produced with stakeholders and found to be acceptable, practical and useful. Freely available from the MND Association website, the PDA is a valuable tool to support the shared decision-making process for gastrostomy tube placement.

An extradural cyst in a French Bulldog.

CASE HISTORY: A 7-year-old, male neutered French Bulldog was referred to a specialist veterinary hospital for evaluation of progressive paraparesis of 6-months' duration. The owners reported both faecal and urinary incontinence at home. CLINICAL FINDINGS: The dog presented with ambulatory paraparesis and pelvic limb ataxia that was more pronounced in the right pelvic limb. The pelvic limb withdrawal response and sciatic myotatic response were reduced bilaterally. Postural reaction responses were delayed in both pelvic limbs, and this was more obvious in the right pelvic limb. The anal tone and perineal sensation were normal at the time of examination.An L4-S3 myelopathy was suspected. CT of the spine revealed a compressive, bilobed, extramedullary, cyst-like structure within the vertebral canal, between L7 and S3. Surgical removal of the cyst via a L7-S1 dorsal laminectomy was performed. Histopathological examination and additional immunohistochemistry of the excised structure indicated a probable ependymal cyst with a ciliated lining. The dog recovered well post-operatively, and at follow-up 3 weeks later had some improvement of his neurological signs. The paraparesis and pelvic limb ataxia had improved; however, the remaining neurological examination was similar to the pre-surgical examination. DIAGNOSIS: Extradural cyst. CLINICAL RELEVANCE: Spinal cysts can contribute to clinical signs that resemble other common chronic spinal cord diseases, such as intervertebral disc disease. Therefore, this disease should be considered as a differential when dealing with cases of progressive paraparesis and pelvic limb ataxia. This case report may potentially provide opportunities in the future for further understanding of the pathogenesis, behaviour, outcomes and subclassification of spinal cysts in dogs.

Disseminated protothecosis with central nervous system involvement in a dog in New Zealand.

CASE HISTORY: A 1-year-old Border Terrier presented with acute onset of neurological signs and neck pain. CLINICAL FINDINGS: Severe generalised ataxia, muscle tremors and cranial nerve deficits were noted. Multifocal brain lesions were suspected based on neurological examination. Computed tomography revealed an abdominal mass and cerebellar herniation through the foramen magnum. LABORATORY AND PATHOLOGICAL FINDINGS: Cytological and histopathological analysis of the abdominal mass revealed necrotising and granulomatous lymphadenitis with intralesional algal elements most consistent with Prototheca spp.. Culture of a sample from the mesenteric lymph node confirmed the presence of Prototheca spp. which was identified as P. bovis based on sequencing of a DNA fragment amplified by PCR. Following inadequate response to symptomatic therapy and poor prognosis, the dog was subjected to euthanasia. Histopathological evaluation of the central nervous system lesions, identified granulomatous meningitis and ventriculitis with the presence of intralesional algae. DIAGNOSIS: Disseminated protothecosis with granulomatous meningitis and ventriculitis caused by Prototheca bovis (formerly P. zopfii gen. 2). CLINICAL RELEVANCE: This is the first case report of disseminated protothecosis with central nervous system involvement in a dog in New Zealand.

Endolymphatic Sac Tumor in Two Dogs.

Endolymphatic sac tumors (ELSTs) are rare neoplasms of the inner and middle ear described in humans. Diagnosis of such neoplasms is difficult and largely dependent on a combination of histologic, immunohistochemical, and clinical findings. Although the neoplastic cells lack cellular features of malignancy, these are clinically aggressive tumors that often invade the surrounding temporal bone. Here, we describe 2 dogs with middle ear masses that share morphologic, immunohistochemical, and clinical similarities with human ELSTs. Advanced imaging of the masses revealed evidence of aggressive behavior such as bony lysis of the temporal bone. Histologically, the neoplastic epithelial cells formed papillary structures, lacked mitotic figures, and had mild anisocytosis and anisokaryosis. The neoplastic cells were immunohistochemically positive for cytokeratin AE1/AE3 but were negative for chromogranin, synaptophysin, and thyroglobulin. Local invasion and bone destruction but no evidence of metastases suggest a clinical behavior similar to human ELSTs.

Cognitive-behaviour therapy for post-traumatic stress in schizophrenia. A randomized controlled trial.

BACKGROUND: There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia. METHOD: A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive-behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale. RESULTS: Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes. CONCLUSIONS: The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.

Expression of fibroblast growth factor 23 by canine soft tissue sarcomas.

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome of humans. Some mesenchymal tumours (often resembling haemangiopericytomas) express molecules that normally regulate phosphorus metabolism; most frequently, fibroblast growth factor 23. Patients develop renal phosphate wasting and inappropriately low serum concentrations of 1, 25 (OH)2 vitamin D3 , leading to osteomalacia. Surgical removal of the tumour is curative. The authors examined expression of canine fibroblast growth factor 23 in 49 soft tissue sarcomas, and control tissues from normal adult dogs. RNA extracted from bone or formalin-fixed, paraffin-embedded tissues was analysed by end point and quantitative reverse transcriptase-polymerase chain reaction. Fibroblast growth factor 23 expression was detected in bone, lung, kidney, lymph node and thymus. Fifteen of 49 sarcomas (31%) expressed fibroblast growth factor 23, three of these had high relative expression and some features resembling phosphatonin-expressing mesenchymal tumours of humans. Further work is required to determine whether TIO may occur in dogs.

Study on the use of toltrazuril to eliminate Neospora caninum in congenitally infected lambs born from experimentally infected ewes.

To determine if toltrazuril was effective in eliminating Neospora caninum infection from congenitally infected lambs. Twenty-eight ewes were allocated to 3 groups where animals in Groups A and B were inoculated with 1 × 10(7)N. caninum tachyzoites on Day 120 of gestation and Group C was maintained as a negative control group. Lambs born from ewes in Group A were treated with toltrazuril (20mg/kg) on Days 0, 7, 14 and 21 after birth. Lambs in Groups B and C were untreated. All lambs in Groups A and B were seropositive at 12 weeks of age. At 12 weeks of age, no differences between lambs in Group A and Group B were observed in serological results (ELISA and western blot), presence of N. caninum-related brain histopathological lesions or the number of organisms detected by qPCR. Group C remained negative for serology, detection of N. caninum DNA as well as histopathology throughout the study. Results indicate that N. caninum congenitally-infected lambs had a continuing infection with N. caninum despite being treated with toltrazuril.

Fibroblast Growth Factor 23: A New Dimension to Diseases of Calcium-Phosphorus Metabolism.

Traditionally, control of phosphorus in the body has been considered secondary to the tighter control of calcium by parathyroid hormone and vitamin D. However, over the past decade, substantial advances have been made in understanding the control of phosphorus by the so-called phosphatonin system, the lynchpin of which is fibroblast growth factor 23 (FGF23). FGF23 binds to the klotho/FGFR1c receptor complex in renal tubular epithelial cells, leading to upregulation of Na/Pi cotransporters and subsequent excretion of phosphorus from the body. In addition, FGF23 inhibits parathyroid hormone and the renal 1α-hydroxylase enzyme, while it stimulates 24-hydroxylase, leading to decreased 1,25-dihydroxyvitamin D3. FGF23 is intimately involved in the pathogenesis of a number of diseases, particularly the hereditary hypophosphatemic rickets group and chronic kidney disease, and is a target for the development of new treatments in human medicine. Little work has been done on FGF23 or the other phosphatonins in veterinary medicine, but increases in FGF23 are seen with chronic kidney disease in cats, and increased FGF23 expression has been found in soft tissue sarcomas in dogs.

Vertical transmission in experimentally infected sheep despite previous inoculation with Neospora caninum NcNZ1 isolate.

Recent reports indicate N. caninum has a possible role in causing abortions in sheep in New Zealand. Knowledge about the mode of transmission of neosporosis in sheep in New Zealand is limited. This study aimed to determine the rate of vertical transmission that would occur in lambs born from experimentally inoculated ewes and to determine if previous inoculation would protect the lambs from N. caninum infection. A group of 50 ewes was divided into 2 groups with one group being inoculated with 5×10(6) N. caninum tachyzoites prior to pregnancy in Year 1. In Year 2, each of these groups was subdivided into 2 groups with one from each original group being inoculated with 1×10(7) N. caninum tachyzoites on Day 120 of gestation. Inoculation of N. caninum tachyzoites into ewes prior to mating resulted in no congenital transmission in lambs born in Year 1 but without further inoculation, 7 out of 11 lambs in Year 2 were positive for N. caninum infection. Ewes that were inoculated in both years resulted in all 12 lambs born in Year 2 being positive for N. caninum infection. This indicates that previous inoculation in Year 1 did not result in any vertical transmission in that year but did not provide any protection against vertical transmission in Year 2. These results suggest that vertical transmission occurs readily once the ewe is infected.

Identification of the first New Zealand case of equine multinodular pulmonary fibrosis.

CASE HISTORY: A 10-year-old polo mare presented with a history of weight loss, poor condition and inappetance. CLINICAL FINDINGS: The mare was tachycardic, tachypnoeic and febrile. Harsh lung sounds were auscultated over all lung fields. The mare initially responded to treatment with antibiotics, anti-inflammatory drugs and bronchodilators. Throughout the course of treatment, there was a variable lymphocytosis, monocytosis and fluctuation in concentrations of fibrinogen. The mare also developed a mild anaemia, most likely due to chronic disease. Despite treatment, the mare's condition deteriorated over the following 2 months, and she was subject to euthanasia. PATHOLOGICAL FINDINGS: On post mortem examination, white to pale tan, large coalescing fibrous nodules up to 5 cm in diameter were found distributed throughout the lungs. Histopathology revealed a multifocally severe interstitial pneumonia with superimposed bronchiolar or alveolar inflammation, fibrosis, Type II pneumocyte hyperplasia and histiocytic intranuclear inclusion bodies, consistent with the findings previously reported for cases of equine multinodular pulmonary fibrosis (EMPF). DIAGNOSIS: Equine multinodular pulmonary fibrosis based on characteristic gross and histopathological findings. The diagnosis was strengthened by detection of DNA for equine herpesvirus 5 in the lung tissue. CLINICAL RELEVANCE: This report describes the first recognised case of EMPF in New Zealand. The affected horse did not respond to treatment and was subject to euthanasia. The prognosis for horses with EMPF, based on a limited number of cases worldwide, is currently considered poor.

Transcoelomic spread and metastasis of a squamous cell carcinoma of presumed pancreatic duct origin in a cat.

CASE HISTORY: A 13-year-old female spayed domestic shorthaired cat was examined because of lethargy, inappetance and weight loss. CLINICAL FINDINGS: No clinically significant haematological or biochemical abnormalities were detected, but an abdominal mass was palpated. Abdominal examination using ultrasonography revealed soft tissue masses in the cranial abdomen, involving the spleen, as well as the liver and abdominal wall; the pancreas was not identified. Despite supportive therapy the condition of the cat rapidly deteriorated and euthanasia was performed. PATHOLOGICAL FINDINGS: Cytological preparations from the cranial abdominal mass revealed a population of pleomorphic epithelial cells consistent with a squamous cell carcinoma. On post-mortem examination, firm creamy white to yellow nodular masses were present in the region of the pancreatic left limb, spleen, liver, diaphragm, right abdominal wall and in the left lung. Sections of all masses were examined histopathologically and demonstrated infiltration by neoplastic epithelial cells indicative of squamous cell carcinoma (SCC). DIAGNOSIS: Squamous cell carcinoma of presumed pancreatic duct origin. CLINICAL RELEVANCE: There are few reports of haematogenous or lymphatic metastasis of SCC in cats, and none reporting transcoelomic spread. This report describes the clinical and pathological features of a case of presumed primary pancreatic ductal SCC, and should alert veterinarians to the potential for metastasis and carcinomatosis.

Real time training for mental health staff working in an in-patient setting.

Concerns around acute in-patient mental health care including staff training are becoming increasingly prominent (Sainsbury, 1998; Sainsbury 1997). A training solution is proposed in this paper, which aims to deliver content derived from evidence based practice actually within the practitioner's own clinical workplace during their working hours. The benefits of this approach are discussed together with examples of content and methods for evaluating learning outcomes.

Assessment of mental health nursing competence using level III academic marking criteria: the Eastbourne assessment of practice scale.

The assessment of clinical competence in nursing represents a challenge to the profession. There is a need for assessment of practice skills through evaluative observation of performance but unfortunately such methods are not regularly used as a basis for assessment within most academic nursing institutions. Instead there is still a reliance upon more traditional types of academic assessment usually done through a written medium. Such methods whilst academically rigorous do not easily assess actual real life competence. This paper will describe how this tension was addressed through the development of a tool that combines observation of real life practice and viva style questioning with an assessment marking grid whose descriptors represent level III practice. Its inter rater reliability (rs = 0.88, P < 0.01) was established by 14 clinical nurse specialists in cognitive behaviour therapy who assessed a single video taped recording of a post-registration students performance whilst undergoing training in cognitive behaviour therapy.

Reduction of ocular lens dosage in dacrocystography.

Irradiation of the lens of the eye in dacrocystography is largely avoidable. We have measured the lens dosage in bilateral dacrocystography in vivo and in a phantom. We describe simple protective measures which can reduce the lens dosage by over 95% to less than one mGy.