Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease.

OBJECTIVE: Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. METHODS: Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. RESULTS: Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. CONCLUSIONS: Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.

White-nose syndrome-related changes to Mid-Atlantic bat communities across an urban-to-rural gradient.

BACKGROUND: White-nose Syndrome (WNS) has reduced the abundance of many bat species within the United States' Mid-Atlantic region. To determine changes within the National Park Service National Capital Region (NCR) bat communities, we surveyed the area with mist netting and active acoustic sampling (2016-2018) and compared findings to pre-WNS (2003-2004) data. RESULTS: The results indicated the continued presence of the threatened Myotis septentrionalis (Northern Long-eared bat) and species of conservation concern, including Perimyotis subflavus (Tri-colored bat), Myotis leibii (Eastern Small-footed bat) and Myotis lucifugus (Little Brown bat). However, we documented a significant reduction in the abundance and distribution of M. lucifugus and P. subflavus, a decrease in the distribution of M. septentrionalis, and an increase in the abundance of Eptesicus fuscus (Big Brown bat). CONCLUSIONS: Documented post-WNS M. septentrionalis recruitment suggests that portions of the NCR may be important bat conservation areas. Decreases in distribution and abundance of P. subflavus and M. lucifugus indicate probable extirpation from many previously occupied portions of the region.

Assessment of a Commercially Available Serum Pregnancy-specific Protein B Test in Free-ranging Elk (Cervus canadensis) in Pennsylvania, USA.

Uterine examinations provide an inexpensive and reliable postmortem alternative to monitor pregnancy rates in free-ranging elk (Cervus canadensis). However, this technique may be insensitive during early pregnancies (i.e., <20 d postconception), relies on proper collection of tissues, and may not be comparable to antemortem approaches used throughout the rest of the year. To circumvent some of these issues, the sensitivity and specificity of a commercially available serum pregnancy-specific protein B (PSPB) enzyme-linked immunosorbent assay (ELISA) was determined relative to uterine examination. From 2013 to 2017, paired serum samples and uteri were collected from 245 harvested free-ranging cow elk in Pennsylvania, US in November. Uteri were examined to determine whether the cow was pregnant, and, if so, gestation age was estimated based on embryo crown-rump (CR) length. The serum PSPB ELISA testing was then performed. Since harvested elk could not be retested, samples with optical densities close to the threshold for pregnancy determination (i.e., high-recheck samples) were considered as both not pregnant and pregnant, and analyses were performed separately under each scenario. Overall, the PSPB ELISA had a sensitivity of 95% (high-recheck considered pregnant) and 93% (high-recheck considered not pregnant), and a specificity of 91% (high-recheck considered pregnant) and 93% (high-recheck considered not pregnant) relative to uterine examinations. Based on CR length, gestation age was <14 to 55 d. Our results indicated the PSPB ELISA was an accurate serum-based pregnancy test for elk.

Evaluation of Cytology for Diagnosing Avian Pox in Wild Turkeys ( Meleagris gallopavo).

Avian pox virus is a common cause of proliferative skin disease in wild turkeys ( Meleagris gallopavo); however, other etiologies may produce grossly indistinguishable lesions. Common methods for diagnosing avian pox include histopathology, virus isolation, and PCR. While these methods are sufficient in most cases, each has their limitations. Cytology is a cost-effective and rapid approach that may be useful when traditional diagnostics are not feasible. The objective of this study was to evaluate the performance of cytology relative to histopathology and PCR for avian pox diagnosis in wild turkeys. Fifty wild turkeys were submitted for necropsy due to nodular skin lesions on unfeathered skin of the head. Of these, five had similar skin lesions on the unfeathered legs and 26 had plaques on the mucosa of the oropharynx or esophagus. Representative skin, oropharyngeal, and esophageal lesions from all birds were examined with cytology and histopathology. Skin lesions on the head of each bird were also tested for avian pox virus via PCR. Histopathology and PCR were equally sensitive in diagnosing avian pox from skin lesions on the head. There were no significant differences between cytologic and histopathologic diagnosis of avian pox from skin lesions on the head (sensitivity = 97.4%, specificity = 100.0%), legs (sensitivity = 75.0%, specificity = 100.0%), or from lesions in the oropharynx and esophagus (sensitivity of 62.5%). Similarly, there were no significant differences between PCR and cytology for diagnosis of pox viral skin lesions of the head. Relative to PCR detection of avian pox virus, cytology had a sensitivity of 90.0% and a specificity of 90.0%. These results suggest that cytology is a useful tool for diagnosis of avian pox in wild turkeys.

Geographic and temporal prevalence of Baylisascaris procyonis in raccoons (Procyon lotor) in Pennsylvania, USA.

In autumn of 2010 we collected fecal samples from the rectums of 89 trapped or road-killed Pennsylvania raccoons (Procyon lotor). Similar samples were collected in the summer and autumn of 2011 from 383 raccoons. Fecal samples were stored in 10% formalin until examined. Using saturated sugar flotation and a direct smear, we found Baylisascaris procyonis eggs in 38% of 2010 samples and 32.9% of 2011 samples. Prevalence in raccoons was greater in autumn than in summer and greater in juveniles than in adults; there was not a statistically significant difference between sexes. Infected raccoons were found in 54 of the 65 counties from which samples were recovered (a mean of 5.9 [range 1-12] raccoons were examined per county). The prevalences were similar in all regions of the state.

Association, roost use and simulated disruption of Myotis septentrionalis maternity colonies.

How wildlife social and resource networks are distributed on the landscape and how animals respond to resource loss are important aspects of behavioral ecology. For bats, understanding these responses may improve conservation efforts and provide insights into adaptations to environmental conditions. We tracked maternity colonies of northern bats (Myotis septentrionalis) at Fort Knox, Kentucky, USA to evaluate their social and resource networks and space use. Roost and social network structure differed between maternity colonies. Overall roost availability did not appear to be strongly related to network characteristics or space use. In simulations for our two largest networks, roost removal was related linearly to network fragmentation; despite this, networks were relatively robust, requiring removal of >20% of roosts to cause network fragmentation. Results from our analyses indicate that northern bat behavior and space use may differ among colonies and potentially across the maternity season. Simulation results suggest that colony social structure is robust to fragmentation caused by random loss of small numbers of roosts. Flexible social dynamics and tolerance of roost loss may be adaptive strategies for coping with ephemeral conditions in dynamic forest habitats.

Pretreatment imaging of peripheral vascular malformations.

Peripheral vascular malformations (VMs) are complex and diverse vascular lesions which require individualized pretreatment planning. Pretreatment imaging using various modalities, especially magnetic resonance imaging and time-resolved magnetic resonance angiography, is a valuable tool for classifying peripheral VMs to allow proper diagnosis, demonstrate complete extent, identify the nidus, and distinguish between low-flow and high-flow dynamics that determines the treatment approach. We discuss pretreatment imaging findings in four patients with peripheral VMs and how diagnostic imaging helped guide management.

Evidence supporting a zoonotic origin of human coronavirus strain NL63.

The relationship between bats and coronaviruses (CoVs) has received considerable attention since the severe acute respiratory syndrome (SARS)-like CoV was identified in the Chinese horseshoe bat (Rhinolophidae) in 2005. Since then, several bats throughout the world have been shown to shed CoV sequences, and presumably CoVs, in the feces; however, no bat CoVs have been isolated from nature. Moreover, there are very few bat cell lines or reagents available for investigating CoV replication in bat cells or for isolating bat CoVs adapted to specific bat species. Here, we show by molecular clock analysis that alphacoronavirus (α-CoV) sequences derived from the North American tricolored bat (Perimyotis subflavus) are predicted to share common ancestry with human CoV (HCoV)-NL63, with the most recent common ancestor between these viruses occurring approximately 563 to 822 years ago. Further, we developed immortalized bat cell lines from the lungs of this bat species to determine if these cells were capable of supporting infection with HCoVs. While SARS-CoV, mouse-adapted SARS-CoV (MA15), and chimeric SARS-CoVs bearing the spike genes of early human strains replicated inefficiently, HCoV-NL63 replicated for multiple passages in the immortalized lung cells from this bat species. These observations support the hypothesis that human CoVs are capable of establishing zoonotic-reverse zoonotic transmission cycles that may allow some CoVs to readily circulate and exchange genetic material between strains found in bats and other mammals, including humans.

Monitoring seasonal bat activity on a coastal barrier island in Maryland, USA.

Research on effects of wind turbines on bats has increased dramatically in recent years because of significant numbers of bats killed by rotating wind turbine blades. Whereas most research has focused on the Midwest and inland portions of eastern North America, bat activity and migration on the Atlantic Coast has largely been unexamined. We used three long-term acoustic monitoring stations to determine seasonal bat activity patterns on the Assateague Island National Seashore, a barrier island off the coast of Maryland, from 2005 to 2006. We recorded five species, including eastern red bats (Lasiurus borealis), big brown bats (Eptesicus fuscus), hoary bats (Lasiurus cinereus), tri-colored bats (Perimyotis subflavus), and silver-haired bats (Lasionycteris noctivagans). Seasonal bat activity (number of bat passes recorded) followed a cosine function and gradually increased beginning in April, peaked in August, and declined gradually until cessation in December. Based on autoregressive models, inter-night bat activity was autocorrelated for lags of seven nights or fewer but varied among acoustic monitoring stations. Higher nightly temperatures and lower wind speeds positively affected bat activity. When autoregressive model predictions were fitted to the observed nightly bat pass totals, model residuals>2 standard deviations from the mean existed only during migration periods, indicating that periodic increases in bat activity could not be accounted for by seasonal trends and weather variables alone. Rather, the additional bat passes were attributable to migrating bats. We conclude that bats, specifically eastern red, hoary, and silver-haired bats, use this barrier island during migration and that this phenomenon may have implications for the development of near and offshore wind energy.

Intracystic Papillary Carcinoma in a Man with Gynecomastia.

Male breast cancer is a rare disease in the male breast whereas gynecomastia is quite common. An elevation of the estrogen-to-androgen ratio increases the risk of both of these diseases. However, a connection between gynecomastia and subsequent breast cancer development is controversial and unclear. Imaging studies including mammography and ultrasound provide valuable information in leading to a correct diagnosis. Traditionally, intracystic papillary carcinoma, also known as encapsulated papillary carcinoma, has been considered a form of ductal carcinoma in situ. Recent immunohistochemical studies, demonstrating an absence of myothelium, in many cases would be more compatible with the diagnosis of invasive malignancy. However, intracystic papillary carcinoma holds a favorable prognosis with local therapy alone. We report a case of intracystic papillary carcinoma in a male patient with long-standing gynecomastia diagnosed eight years prior by mammography. The patient presented with a breast lump on both occasions. Current work-up consisted of both mammography and ultrasound. Ultrasound provided key information revealing a complex mass requiring further evaluation. Ultrasound-guided core needle biopsy revealed intracystic papillary carcinoma with confirmation upon surgical excision.