Concordance between epidemiological evaluation of probability of transmission and whole genome sequence relatedness among hospitalized patients acquiring Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae.

OBJECTIVES: We aimed to evaluate the concordance between epidemiologically determined transmission and genetic linkage of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp). METHODS: We included consecutive KPC-Kp carriers between December 2016 and April 2017 in a hospital endemic for KPC-Kp. We assessed epidemiological relatedness between patients by prospective investigations by the infection control team. The probability of epidemiological relatedness was classified into four groups: no suspected transmission, low, moderate and high probability of transmission. Whole-genome sequencing of isolates was performed. Genetic linkage between KPC-Kp isolates was expressed by distance between isolates in single nucleotide polymorphisms (SNPs). We established an SNP cut-off defining a different strain based on the reconstructed phylogenetic tree. We compared the epidemiological and genetic linkage of all isolates from all patients. RESULTS: The study included 25 KPC-Kp carriers with 49 isolates. SNP variance was available for 1129 crossed patient-isolate pairs. Genomic linkage, based on a cut-off of 80 SNPs to define related isolates, was found in 115/708 (16.2%) of isolates with no transmission suspected epidemiologically, 27/319 (8.5%) of low, 11/26 (42.3%) of moderate and 64/76 (84.2%) of high epidemiological transmission risk determination (p < 0.001 for trend). Similar results and significant trends were shown on sensitivity analyses using a lower SNP cut-off (six SNPs) and patient-isolate unique pairs, analysing the first isolate from each patient. CONCLUSIONS: While significant concordance between epidemiological and genomic transmission patterns was found, epidemiological investigations of transmission are limited by the possibility of unidentified transmissions or over-estimation of associations. Genetic linkage analysis is an important aid to epidemiological transmission assessment.

Canine sterile steroid-responsive lymphadenitis in 49 dogs.

OBJECTIVES: To report clinical and laboratory features, treatment responses and outcome in dogs diagnosed with sterile steroid-responsive lymphadenitis in the United Kingdom. MATERIALS AND METHODS: Medical records of dogs diagnosed with sterile steroid-responsive lymphadenitis from 2009 to 2016 at six specialist referral centres were evaluated retrospectively. RESULTS: The study included 49 dogs. Springer spaniels appeared to be over-represented (16 of 49 dogs). Young dogs (median age: 3 years and 9 months) and females (31 of 49) were frequently affected. Clinical presentation was variable, with pyrexia (39 of 49), lethargy (35 of 49) and anorexia (21 of 49) the most commonly reported clinical signs. Lymph node cytology or histopathology demonstrated neutrophilic, pyogranulomatous, granulomatous or necrotising lymphadenitis without a detectable underlying cause in all cases. Because a sterile immune-mediated aetiology was suspected, all dogs received prednisolone, which was followed by rapid resolution of clinical signs and lymphadenopathy in most cases. CLINICAL SIGNIFICANCE: Sterile steroid-responsive lymphadenitis should be considered in dogs with pyrexia of unknown origin with inflammatory lymphadenopathy if no underlying cause can be found and often responds well to immunosuppressive corticosteroid therapy.

The association between infection control interventions and carbapenem-resistant Enterobacteriaceae incidence in an endemic hospital.

BACKGROUND: Israel experienced a national outbreak of carbapenem-resistant Enterobacteriaceae (CRE) starting in 2006. AIM: To assess the association between infection control (IC) interventions implemented in a referral hospital in Israel and CRE incidence. METHODS: Retrospective quasi-experimental study of prospectively collected data. CRE incidence, defined as the number of patients newly acquiring CRE in surveillance or clinical samples per 100,000 hospital-days, was plotted quarterly between 2005 and 2016. IC interventions were applied at different time-points throughout this period. Data were collected on IC staffing, number of rectal surveillance cultures, and carbapenem consumption. Autocorrelated segmented linear regression analysis was used to assess the time-points at which a significant change in the CRE incidence trend occurred, and the association between the timing of IC intervention implementation and observed CRE trends was assessed. Trends between time-points were expressed as quarterly percent change (QPC) with 95% confidence intervals (CIs). FINDINGS: Between 2005 and 2008, CRE incidence increased significantly (QPC: 19.7%; CI: 11.5-28.4), reaching a peak of 186.6 new acquisitions per 100,000 hospital-days. From mid-2011 until the end of follow-up, there was a significantly decreasing incidence trend (QPC: -4.5; CI: -6.4 to -2.5). Cohorting of patients, screening of contacts and high-risk patients on admission were insufficient to control the epidemic. Improved hand hygiene compliance, cohorting with dedicated nursing staff, addition of regular screening in high-risk departments, and carbapenem restriction were required. Decreasing CRE incidence was observed with an infectious diseases/IC staffing of 1.2-1.5 per 100 beds and 20,000-36,000 yearly CRE surveillance samples. CONCLUSION: A multi-faceted hospital-wide intervention programme is required to control CRE in hospital settings.

Predicting Outcome in dogs with Primary Immune-Mediated Hemolytic Anemia: Results of a Multicenter Case Registry.

BACKGROUND: Outcome prediction in dogs with immune-mediated hemolytic anemia (IMHA) is challenging and few prognostic indicators have been consistently identified. OBJECTIVES: An online case registry was initiated to: prospectively survey canine IMHA presentation and management in the British Isles; evaluate 2 previously reported illness severity scores, Canine Hemolytic Anemia Score (CHAOS) and Tokyo and to identify independent prognostic markers. ANIMALS: Data from 276 dogs with primary IMHA across 10 referral centers were collected between 2008 and 2012. METHODS: Outcome prediction by previously reported illness-severity scores was tested using univariate logistic regression. Independent predictors of death in hospital or by 30-days after admission were identified using multivariable logistic regression. RESULTS: Purebreds represented 89.1% dogs (n = 246). Immunosuppressive medications were administered to 88.4% dogs (n = 244), 76.1% (n = 210) received antithrombotics and 74.3% (n = 205) received packed red blood cells. Seventy-four per cent of dogs (n = 205) were discharged from hospital and 67.7% (n = 187) were alive 30-days after admission. Two dogs were lost to follow-up at 30-days. In univariate analyses CHAOS was associated with death in hospital and death within 30-days. Tokyo score was not associated with either outcome measure. A model containing SIRS-classification, ASA classification, ALT, bilirubin, urea and creatinine predicting outcome at discharge was accurate in 82% of cases. ASA classification, bilirubin, urea and creatinine were independently associated with death in hospital or by 30-days. CONCLUSIONS AND CLINICAL IMPORTANCE: Markers of kidney function, bilirubin concentration and ASA classification are independently associated with outcome in dogs with IMHA. Validation of this score in an unrelated population is now warranted.

Stakeholder consultation on tracking in UK veterinary degrees: part 2.

There is ongoing debate in the profession as to whether veterinary students should focus on one (or a small number of) species during their undergraduate training (ie, track). This paper presents the qualitative data from surveys evaluating UK stakeholder opinion on introducing partial tracking (whereby students continue to qualify able to practise in all species) and full tracking (students qualify in a limited number of species with restricted registration). Surveys were distributed to practitioners, students and university staff; 1061 responses were completed. Thematic framework analysis was conducted on the free-text responses; responses were coded to a hierarchical framework developed inductively from the data. Six major themes were identified: choice, flexibility, competency and knowledge, stakeholder implications, specialisation and 'what is a vet?'. The majority of the themes related to both full and partial tracking, usually being more pronounced in full tracking. The theme 'choice' is particularly important in light of the study's quantitative findings on students' awareness of the profession and their career aspirations (presented in a previous paper); should tracking be implemented, veterinary schools will need to take a proactive role in educating and assisting students while making career choices.

Stakeholder consultation on tracking in UK veterinary degrees: part 1.

There is on-going debate regarding whether veterinary students should focus on one (or a small number of) species during their undergraduate training (ie, track). The aims of this study were to: evaluate UK stakeholders' opinion on partial tracking (whereby students continue to qualify able to practise in all species) and full tracking (students qualify in a limited number of species necessitating restricted registration); and evaluate students' career aspirations in relation to the UK veterinary profession's employment profile. This paper presents the quantitative results of surveys completed by practitioners, students and university staff. The majority of respondents (69.4 per cent) disagreed or strongly disagreed with full tracking, however, there was widespread support for partial tracking (79.0 per cent agreed or strongly agreed). Students favoured partial tracking more so than practitioners (P<0.001). Univariate analysis of demographic factors did not identify differences in opinion regarding tracking within stakeholder groups. Students' knowledge of the UK veterinary employment profile appeared accurate. However, their career aspiration changed with year of the course, and only final year students' intentions were aligned with the profession's current profile. Qualitative data from these surveys are presented in a second paper and include the advantages, disadvantages and implications of partial and full tracking.

Serum haptoglobin concentrations in dogs with liver disease.

Dogs with liver disease have been shown to have increased serum C-reactive protein (CRP) concentrations. However, it is unclear whether dogs with liver disease also have increased serum haptoglobin concentrations. The aim of the study was to measure serum haptoglobin concentrations in healthy dogs, hospitalised dogs and dogs with liver diseases. Haptoglobin concentrations were measured in 30 healthy dogs, 47 hospitalised dogs with non-hepatic illness, 46 dogs with congenital portosystemic shunt (cPSS) and 11 dogs with primary hepatopathy. Haptoglobin concentrations were not significantly different between cPSS dogs with and without hepatic encephalopathy (HE), thus all cPSS dogs were considered as one group. Haptoglobin concentrations were significantly different between the remaining groups (P<0.0001). Hospitalised ill dogs had significantly higher haptoglobin concentrations than healthy dogs (P<0.001), dogs with cPSS (P<0.001) and dogs with primary hepatopathy (P<0.05). There was no significant difference between haptoglobin concentrations in healthy dogs, dogs with cPSS and dogs with primary hepatopathy. Haptoglobin concentrations were not significantly increased in dogs with liver diseases or in dogs with cPSS and HE. This is in contrast with the previously reported CRP results. This study demonstrates that liver function should be considered when interpreting haptoglobin concentrations in dogs.

Infectious agent screening in canine blood donors in the United Kingdom.

OBJECTIVES: Transfusion of blood products is an important component of veterinary emergency medicine. Donors must be carefully selected to minimise risk of transmission of blood-borne infectious agents. This study was devised to assess the prevalence of such agents in healthy, non-travelled UK dogs screened as prospective donors. METHODS: Ethylenediaminetetraacetic acid blood samples from dogs donating blood between August 2007 and January 2012 were screened by polymerase chain reaction for haemotropic mycoplasmas, Bartonella, Babesia, Leishmania, Ehrlichia and Anaplasma spp. Dogs with positive or inconclusive results underwent repeat polymerase chain reaction testing. RESULTS: Four of 262 dogs had positive or inconclusive results at initial screening. Repeat polymerase chain reaction testing in each dog was negative, and none of the dogs developed clinical signs of disease. CLINICAL SIGNIFICANCE: The positive results on initial screening may have represented false positives from sample contamination or amplification of non-target DNA. It is also possible that dogs were infected at initial sampling but successfully cleared infection before repeat testing. The low number of positive results obtained suggests that prevalence of these agents in a population of healthy UK dogs is low and that use of blood products is unlikely to represent a significant risk of transmission of these diseases.

Dogs with congenital porto-systemic shunting (cPSS) and hepatic encephalopathy have higher serum concentrations of C-reactive protein than asymptomatic dogs with cPSS.

Hepatic encephalopathy (HE) is a cause of significant morbidity and mortality in patients with liver disorders and a wide range of rodent models of HE have been described to facilitate studies into the pathogenesis and treatment of HE. However, it is widely acknowledged that no individual model perfectly mimics human HE and there is a particular need for spontaneous, larger animal models. One common congenital abnormality in dogs is the portosystemic shunt (cPSS) which causes clinical signs that are similar to human HE such as ataxia, disorientation, lethargy and occasionally coma. As inflammation has recently been shown to be associated with HE in humans, we hypothesised that inflammation would similarly be associated with HE in dogs with cPSS. To examine this hypothesis we measured C-reactive protein (CRP) in 30 healthy dogs, 19 dogs with a cPSS and no HE and 27 dogs with a cPSS and overt HE. There was a significant difference in CRP concentration between healthy dogs and dogs with HE (p < 0.001) and between dogs with HE and without HE (p < 0.05). The novel finding that there is an association between inflammation and canine HE strengthens the concept that HE in dogs with cPSS shares a similar pathogenesis to humans with HE. Consequently, dogs with a cPSS may be a good spontaneous model of human HE in which to further examine the role of inflammation and development of HE.

Haemoplasma infection is not a common cause of canine immune-mediated haemolytic anaemia in the UK.

OBJECTIVE: The aim of this study was to investigate whether the two canine haemoplasma species, Mycoplasma haemocanis and "Candidatus Mycoplasma haematoparvum," are commonly associated with immune-mediated haemolytic anaemia (IMHA) in UK dogs. METHODS: Three groups of dogs were recruited to the study: anaemic dogs with primary IMHA (n=37); anaemic dogs not meeting the inclusion criteria for primary IMHA (n=77) and non-anaemic dogs (n=113). DNA was extracted from 100 µl of blood and subjected to real-time quantitative polymerase chain reaction (qPCR) assays for both species of Mycoplasma. Each assay incorporated co-amplification of canine glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as an endogenous internal control. RESULTS: Canine GAPDH was successfully amplified by qPCR from all 227 canine blood samples but none contained M. haemocanis or "Candidatus M. haematoparvum" DNA. CLINICAL SIGNIFICANCE: Haemoplasma infection is uncommon in dogs in the UK and no evidence was found that these organisms act as triggers for IMHA.

Development and use of real-time PCR to detect and quantify Mycoplasma haemocanis and "Candidatus Mycoplasma haematoparvum" in dogs.

Two canine haemoplasma species have been recognised to date; Mycoplasma haemocanis (Mhc), which has been associated with anaemia in splenectomised or immunocompromised dogs, and "Candidatus Mycoplasma haematoparvum" (CMhp), recently described in an anaemic splenectomised dog undergoing chemotherapy. The study aim was to develop quantitative real-time PCR assays (qPCRs) incorporating an endogenous internal control to detect Mhc and CMhp and to apply these assays to DNA samples extracted from canine blood collected in Northern Tanzania (n=100) and from dogs presented to a Trinidadian veterinary hospital (n=185). QPCRs specific for Mhc and CMhp were designed using 16S rRNA gene sequence data, and each was duplexed with an assay specific for canine glyceraldehyde-3-phosphate dehydrogenase (GAPDH). The assays detected < or =10 copies of a sequence-specific haemoplasma plasmid per reaction and neither assay showed cross-reactivity with 10(6) copies of the sequence-specific plasmid from the non-target canine haemoplasma species. Nineteen of the 100 Tanzanian samples (19%) were positive for Mhc alone and one (1%) was dually infected. One Trinidadian sample was negative for canine GAPDH DNA and was excluded from the study. Of the 184 remaining Trinidadian samples, nine (4.9%) were positive for Mhc alone, five (2.7%) for CMhp alone, and two (1.1%) dually infected. This is the first report of canine haemoplasma qPCR assays that use an internal control to confirm the presence of amplifiable sample DNA, and their application to prevalence studies. Mhc was the most commonly detected canine haemoplasma species.

Pattern of Coombs' test reactivity has diagnostic significance in dogs with immune-mediated haemolytic anaemia.

OBJECTIVES: To investigate the clinical significance of the pattern of Coombs' test reactivity in dogs with immune-mediated haemolytic anaemia. METHODS: Sixty-five anaemic dogs with a positive Coombs' test were included. Coombs' testing was performed at 4 and 37 degrees C with polyvalent canine Coombs' reagent and antisera specific for each of canine immunoglobulin G, immunoglobulin M and complement factor C3. The impact of performing testing with only polyvalent antiserum at 37 degrees C was assessed. Chi-squared tests were used to compare Coombs' test reactivity in dogs with primary immune-mediated haemolytic anaemia (group A) and in dogs with concurrent/underlying disease (group B). Following Bonferroni correction, significance was set at P < or = 0.003. RESULTS: Eleven dogs would have been regarded as Coombs' negative had they been tested with polyvalent antiserum at 37 degrees C alone. Group A dogs were significantly more likely to be positive with polyvalent antiserum and/or anti-dog immunoglobulin G at 4 and/or 37 degrees C (P < or = 0.001) and tended to be less likely to be positive with anti-dog immunoglobulin M at 4 degrees C (P=0.040). CLINICAL SIGNIFICANCE: Testing of anaemic dogs with polyvalent Coombs' reagent at 37 degrees C was less sensitive than testing with monovalent reagents at 4 and 37 degrees C. The pattern of Coombs' test reactivity differed significantly between dogs with primary immune-mediated haemolytic anaemia and those with concurrent/underlying disease.

Dilatation of the right atrium in a dog with polymyositis and myocarditis.

A nine-year-old, female, neutered golden retriever was referred for investigation of weakness. Immune-mediated polymyositis with mixed mononuclear cell inflammation and fibrosis was diagnosed in muscle biopsy specimens from several sites. A soft tissue opacity was noted radiographically cranial to the cardiac silhouette. The dog failed to respond to treatment with prednisolone and was euthanased. At post-mortem examination, the structure observed radiographically was showed to be an enlarged right atrium. Histopathological examination of samples collected at post-mortem confirmed polymyositis. Additionally, mononuclear cell infiltrations and fibrosis were observed in areas of endocardium and/or myocardium in the walls of all four cardiac chambers. Myocarditis has not been reported previously in canine polymyositis but is well recognised in people. Enlargement of the right atrium has also been reported in association with polymyositis and myocarditis in people.

An evaluation of the efficacy of the national immunization programme for hepatitis B.

We report an evaluation of the Israeli national immunization programme for hepatitis B in the Haifa subdistrict. We used a convenience sample of blood tests reported positive for HBsAg over a 6-year period from children who were born after routine immunization began in 1992. We identified 11 children with presumed chronic hepatitis B virus infection who were residents of the Haifa subdistrict, three of whom were born in Israel. All three were immunized at the appropriate age and are thus considered vaccination failures rather than failure to vaccinate. The remaining eight were born abroad, had emigrated to Israel as children and were not immunized at birth. We estimate the rate of chronic hepatitis B virus infection for children born since 1998 to be 0.24/10,000 births. For all children resident in the subdistrict under the age of 12 years, the period prevalence is estimated to be 1.26/10,000. The rate of chronic infection in children younger than 12 years was significantly less than that of older cohorts and less than that of historical controls before the start of immunization. Although the reported rates are probable underestimates of actual rates, the fact that they are based on testing carried out in clinical settings increases the likelihood of positive findings and thus reduces the degree of error. The fact that most young carriers are foreign born points to the importance of timely catch-up programmes. In countries with low and intermediate rates of chronic infection, serosurveys of immunized children need to be large and are therefore costly. Monitoring HBsAg positive tests from routine testing carried out in clinical settings is an inexpensive way to monitor chronic infection rates.

Congestive heart failure caused by intracardiac tumours in two dogs.

Congestive heart failure is a common presentation in small animal practice. Cardiac tumours are an unusual cause of congestive heart failure and, when they occur, usually cause clinical signs associated with pericardial effusion and cardiac tamponade. This case report outlines the clinical and histological findings in two dogs presented with clinical signs of congestive heart failure caused by obstruction of blood flow by intracavitary cardiac tumours. Case 1 showed signs of left-sided heart failure caused by osteosarcoma within the left atrial lumen, and case 2 presented with clinical signs of right-sided heart failure due to haemangiosarcoma occupying the right atrial and ventricular lumens. This case report provides further evidence for the inclusion of intracardiac neoplasia in the differential diagnosis for dogs with clinical signs of congestive heart failure.

Hemangioma of the zygomatic bone.

Bony hemangiomas of the zygomatic bone are rare. This report represents the tenth citing in the literature. The most common signs and symptoms include swelling and pain or tenderness. Diagnosis can be made by plain radiographic studies followed by CT scanning or MRI. The treatment of choice is surgical excision with a rim of normal bone around the tumor. Malignant degeneration has not been reported unless radiotherapy had been used.

A critical analysis of immediate and delayed mandibular reconstruction using A-O plates.

Eleven patients who underwent mandibular reconstruction with A-O plates were followed up for as long as 40 months. The patients underwent either immediate or delayed mandibular reconstruction. Nine patients had free cortical bone grafts included in the reconstruction. Complications in patients who underwent immediate reconstruction included loss of the bone graft due to infection, external and intraoral exposure of the reconstruction plate, pain, and infection. In the patients with immediate reconstruction, more than 50% of the bone grafts resorbed. There were less complications and minimal bone graft resorption in patients who underwent delayed reconstruction. The cosmetic results were initially good in both immediate and delayed reconstruction but deteriorated as more surgery was required for management of complications. At 40 months, 7 of 11 patients (5 of 9 with immediate reconstruction) had died of local recurrence, distant metastasis, or another primary tumor. No patients were rehabilitated prosthetically. We conclude that while A-O plating is technically easy and has a low perioperative morbidity rate, the long-term morbidity rate is high. This must be weighed against the benefits of the procedure and the probability that the patients will have a poor functional outcome.

Upper airway obstruction secondary to warfarin-induced sublingual hematoma.

Sublingual hematoma is a rare but potentially fatal complication of oral warfarin sodium. Less than ten cases are reported in the English-language literature with only two of these appearing in the otolaryngologic literature. Spontaneous bleeding into the sublingual and submaxillary spaces creates a "pseudo-Ludwig's" phenomenon with elevation of the tongue and floor of mouth and subsequent airway compromise. Two new cases, along with a review of the literature are presented. Management is directed at prompt control of the airway and reversal of the coagulopathy. Sore throat is a uniform, early complaint that should be taken seriously in any patient receiving oral anticoagulation therapy.

Lack of association of Streptococcus bovis with noncolonic gastrointestinal carcinoma.

Since previous studies have shown an increased fecal carriage rate of Streptococcus bovis in patients with carcinoma of the colon, a study was undertaken to determine the fecal carriage rate of this organism in patients with gastrointestinal carcinoma of noncolonic origin. Organisms identified as S. bovis were isolated on fecal culture from 10 of 82 (12%) controls, 19 of 94 (20%) individuals with noncolonic gastrointestinal carcinoma, and 12 of 80 (15%) patients with other gastrointestinal disorders. Subjects with noncolonic gastrointestinal carcinoma did not have a fecal carriage rate of S. bovis significantly different from that in controls. A literature review of 251 patients with S. bovis septicemia identified at least 89 (35%) with neoplasms of the colon. Only nine patients (4%) with gastrointestinal neoplasms of other than colonic origin were noted. At present, the indication for an intensive evaluation of the upper gastrointestinal tract in individuals with S. bovis bacteremia is substantially less than that for the colon.

Preseptal cellulitis caused by Mycobacterium intracellulare.

A case of preseptal cellulitis caused by Mycobacterium intracellulare is presented. A 56-year-old white woman developed erythema, induration, and tenderness of the lids of her right eye after chalazion removal, which did not respond to three weeks of broad spectrum antibiotics. Incision and drainage with biopsy revealed granuloma, and acid-fast bacilli were seem. Mycobacterium intracellulare was isolated on culture, resistant to all the antimicrobials that the patient was given. Antimicrobial therapy was discontinued, and the infection resolved over 15 months.