Diagnostic and public health investigation of Mycobacterium tuberculosis infection in a dog in Ontario, Canada.

A 4-y-old, female mixed-breed dog was presented to the Ontario Veterinary College for further evaluation of multiple pulmonary and hepatic masses, intrathoracic lymphadenitis, and recent development of a pyogranulomatous pleural effusion. Along with other comprehensive tests, a thoracic lymph node biopsy was performed, and Mycobacterium tuberculosis complex infection was confirmed by real-time PCR. The dog's condition declined post-operatively, and euthanasia was elected. Postmortem examination confirmed severe granulomatous pneumonia, hepatitis, intrathoracic and intraabdominal lymphadenitis, omentitis, and nephritis. Line-probe assays performed on samples collected postmortem confirmed the species as M. tuberculosis. 24-loci MIRU-VNTR genotyping, spoligotyping, and whole-genome sequencing revealed relations to known human isolates, but no epidemiologic link to these cases was investigated. Given the concern for potential human exposure during this animal's disease course, a public health investigation was initiated; 45 individuals were tested for M. tuberculosis exposure, and no subsequent human infections related to this animal were identified. Our case highlights the need for more readily available, minimally invasive testing for the diagnosis of canine mycobacteriosis, and highlights the ability of canid species to act as potential contributors to the epidemiology of M. tuberculosis infections.

Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease-Evidence to Inform Policy.

PURPOSE: Low socioeconomic status, race, ethnicity, and rural/remote populations are all associated with disparities in access, care, and outcomes for chronic kidney disease (CKD). There have been different interventions supported by Canadian renal programs to address these disparities. This article reviews the evidence for impact of strategies to reduce inequities experienced by vulnerable populations living with or at risk of CKD and to collate and share interprovincial targeted interventions through the newly formed "Canadian Senior Renal Leaders Community of Practice" focused on translating evidence into clinical practice and policy. SOURCE OF INFORMATION: A literature search of Medline, CINAHL, PubMed, and Google Scholar from 2008 to 2018 identified 13 reports of processes and interventions that have been implemented in Australia, Canada, and the United States to reduce inequities in CKD care and can be categorized into 3 broad areas: (1) early screening and prevention, (2) disease management and dialysis, and (3) pretransplant. Web sites from each Canadian jurisdiction and from Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network were used to assess the current state of Canadian initiatives. METHODS: Reviews were completed to gather information on renal initiatives for vulnerable populations, including (1) identification of populations that experience disparities in access to care or in outcomes in the context of CKD prevention and treatment and (2) interventions that have been implemented to reduce disparities in access, care, and outcomes for vulnerable populations with CKD. A current state summary of Canadian initiatives related to vulnerable populations was conducted through a review of publicly available information, including a review of renal program Web sites and a review of current projects related to vulnerable populations that are part of Can-SOLVE CKD. Can-SOLVE CKD is a Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR-SPOR) funded research network to transform the care of people affected by kidney disease. KEY FINDINGS: Interventions to improve inequities in access to CKD screening, disease management, and care are successful when developed with community engagement, provided to the patient in their own environment, and tailored to specific populations. Many provincial renal programs have implemented initiatives to support vulnerable populations with or at risk of CKD. Current projects funded through CIHR SPOR focus on underserved populations and involve partnerships with Indigenous populations. Many renal programs in Canada had or were in the process of implementing interventions to support vulnerable populations with CKD; however, information about the initiatives were not readily available online despite a strong interest and opportunity to support interprovincial knowledge sharing. Despite this common interest, little information is systematically shared between Canadian jurisdictions to support interprovincial sharing to promote evidence-informed policy and program development. Efforts will be made through the newly formed Canadian Senior Renal Leaders Community of Practice to collaborate and share learnings to inform future program and policy development, implementation, and evaluation. LIMITATIONS: As this was not a systematic review, literature search only encompassed studies published in English between 2008 and 2018. It is possible that populations and interventions were overlooked during the search and through the screening process. Furthermore, the controversial definition of "vulnerable" and literature that only came from Canada, the United States, and Australia limits the generalizability of this review.

CONTEXTE ET OBJECTIFS: En contexte d'insuffisance rénale chronique (IRC), le faible statut socioéconomique du patient, sa race, son origine ethnique et le fait d'habiter une région rurale/éloignée sont associés à des iniquités dans l'accès et la qualité des soins et dans les résultats de santé. Ces disparités ont d'ailleurs fait l'objet de différentes interventions de la part des programmes rénaux canadiens. Cet article explore les données probantes sur l'effet de ces stratégies de réduction des inégalités subies par les populations vulnérables atteintes ou susceptibles de développer une néphropathie chronique. L'article vise également à colliger et à partager les interventions ciblées entre les provinces par le biais de la toute nouvelle « Communauté de pratique des hauts dirigeants en néphrologie au Canada ¼, laquelle est axée sur la transposition des données probantes en politiques et pratiques cliniques. SOURCES: Une recherche sur Medline, CINAHL, PubMed et Google Scholar de la littérature publiée entre 2008 et 2018 a permis de répertorier 13 rapports faisant état d'interventions mises en œuvre en Australie, au Canada et aux États-Unis pour réduire les iniquités de soins en IRC. Ces interventions ont été classées selon trois thèmes: 1) prévention et dépistage précoce, 2) prise en charge et dialyse, et 3) pré-transplantation. Les sites Web du réseau Can-SOLVE CKD (Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease) et de chaque province et territoire canadiens ont été consultés pour dresser l'état actuel des stratégies canadiennes. MÉTHODOLOGIE: La revue de la littérature a permis de recenser les populations subissant des inégalités quant à l'accès aux soins ou aux résultats en contexte de prévention et de traitement de l'IRC, et de recueillir de l'information sur les interventions mises en œuvre pour réduire ces inégalités pour les populations vulnérables atteintes d'IRC. Un résumé des stratégies canadiennes actuelles a été rédigé à partir des informations accessibles au public sur les sites Web des différents programmes rénaux et des projets de Can-SOLVE CKD visant les populations vulnérables. Can-SOLVE CKD est un réseau de recherche financé par la Stratégie de recherche axée sur le patient des Instituts de recherche en santé du Canada (SRAP-IRSC) dont l'objectif est de transformer les soins destinés aux personnes atteintes de néphropathie. PRINCIPAUX RÉSULTATS: Les interventions visant à réduire les iniquités dans l'accès au dépistage, à la prise en charge et aux soins en IRC sont efficaces lorsqu'elles sont élaborées avec la participation de la communauté, prodiguées au patient dans son milieu de vie et adaptées en fonction de la population visée. Plusieurs programmes rénaux provinciaux ont déployé des stratégies pour venir en aide aux populations vulnérables atteintes ou susceptibles de développer une IRC. Les projets actuels financés par la SRAP-IRSC se concentrent sur les populations mal desservies et impliquent des partenariats avec les communautés autochtones. Plusieurs programmes rénaux canadiens disposent ou s'affairent à implanter des stratégies pour aider les populations vulnérables atteintes d'IRC. Par contre, malgré un grand intérêt et la possibilité de soutenir un partage interprovincial des connaissances, l'information concernant ces initiatives demeure difficilement accessible en ligne. De même, malgré l'intérêt, peu d'information est partagée systématiquement entre les provinces canadiennes pour soutenir l'élaboration de politiques et de programmes fondés sur les données probantes. La toute nouvelle « Communauté de pratique des hauts dirigeants canadiens en néphrologie ¼ s'efforcera donc de collaborer et de partager l'information afin d'éclairer l'élaboration, la mise en œuvre et l'évaluation des futurs programmes et politiques. LIMITES: Cette étude n'est pas une revue systématique; elle ne visait que les articles publiés en anglais entre 2008 et 2018. Ainsi, certaines populations ou interventions pourraient avoir été mises de côté lors de la recherche et de la sélection des articles. De plus, la définition controversée du terme « vulnérable ¼ et le fait que les articles retenus ne provenaient que du Canada, des États-Unis et de l'Australie rendent nos résultats difficilement généralisables.

Pleural epithelioid hemangioendothelioma: literature summary and novel case report.

Epithelioid hemangioendothelioma (EHE) is a rare malignant cancer of vascular origin that can affect multiple and varied tissue sites. A subtype of EHE, pulmonary epithelioid hemangioendothelioma (PHE), is more unusual with only 200 reported cases. Of these, only 27 have been classified as pleural in origin. Based on available literature, the average age of presentation of pleural PHE is 45.7 years with a male preponderance of 2.375. A summary of all published case reports reveals significant heterogeneity both in presentation and management. Here we add to this knowledge-base with a report of an unusual case of pleural PHE in a 36-year-old female who presented with a 6-week history of chest pain and breathlessness. Significant challenges in the diagnosis and management of patients with pleural PHE exist, including a wide initial differential diagnosis and difficulties in obtaining tissue specimens, coupled with relatively limited treatment options. Early referral to a cardiothoracic center for video-assisted thoracoscopic biopsy is crucial in facilitating a diagnosis and allowing adequate pleural drainage for symptomatic relief.

Transformation of oncology inpatients: effects on length of stay and patient satisfaction.

The oncology department at Imperial College Healthcare Trust ranked last in the National Cancer Patient Experience Survey in 2011/12 and 2012/13. Length of stay (LOS) was above national average. General Medical Council surveys of junior doctors highlighted significant issues with lack of senior review, education and working hours. Inpatient surveys echoed this with poor patient experience, and major complaints exposed lack of joint nursing and medical care. Restructuring the inpatient care pathway began in 2012 and centred around four target areas: 1) introduction of a ward based consultant; 2) defined admission criteria; 3) development of a cancer assessment unit; and 4) designated elective beds. Restructuring had a rapid effect on the service: total admissions per month declined from 246 in March 2013 to 183 in May 2014 and median LOS fell from 4.3 to 2 days over the same period (p<0.001). Complaints and serious incidents also fell and junior doctor satisfaction improved.

Right ventricular dysfunction is a predictor of non-response and clinical outcome following cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an established treatment in advanced heart failure (HF). However, an important subset does not derive a significant benefit. Despite an established predictive role in HF, the significance of right ventricular (RV) dysfunction in predicting clinical benefit from CRT remains unclear. We investigated the role of RV function, assessed by cardiovascular magnetic resonance (CMR), in predicting response to and major adverse clinical events in HF patients undergoing CRT. METHODS: Sixty consecutive patients were evaluated with CMR prior to CRT implantation in a tertiary cardiac centre. The primary end-point was a composite of death from any cause or unplanned hospitalization for a major cardiovascular event. The secondary end-point was response to therapy, defined as improvement in left ventricular ejection fraction ≥ 5% on echocardiography at one year. RESULTS: Eighteen patients (30%) met the primary end-point over a median follow-up period of 26 months, and 27 out of 56 patients (48%) were considered responders to CRT. On time-to-event analysis, only atrial fibrillation (HR 2.6, 95% CI 1.02-6.84, p = 0.047) and RV dysfunction, either by a reduced right ventricular ejection fraction-RVEF (HR 0.96, 95% CI 0.94-0.99, p = 0.006) or tricuspid annular plane systolic excursion-TAPSE (HR 0.88, 95% CI, 0.80-0.96, p = 0.006), were significant predictors of adverse events. On logistic regression analysis, preserved RVEF (OR 1.05, 95% CI 1.01-1.09, p = 0.01) and myocardial scar burden (OR 0.90, 95% CI 0.83-0.96, p = 0.004) were the sole independent predictors of response to CRT. Patients with marked RV dysfunction (RVEF < 30%) had a particularly low response rate (18.2%) to CRT. CONCLUSIONS: Right ventricular function is an important predictor of both response to CRT and long-term clinical outcome. Routine assessment of the right ventricle should be considered in the evaluation of patients for CRT.

Intimate partner violence in rural women.

In conclusion it can be said that domestic violence in rural populations is a very complex situation in which many rural women find themselves. The nurse or other healthcare provider, in the rural setting, has to recognize the prevalence of intimate partner violence in their aggregate and find ways to not only screen these women, but also assist them in their plight for freedom from abuse. It is not only a part of the job of nurses and healthcare providers, but an ethical obligation to empower our clients to leave abusive situations for themselves and their family.