Patient-on-Staff Assaults: Perspectives of Mental Health Staff at an Acute Inpatient Psychiatric Teaching Hospital in the United States.

INTRODUCTION: Physical assaults perpetrated by patients in psychiatric hospitals against mental health staff (MHS) is a serious concern facing psychiatric hospitals. Assaulted staff reports physical and psychological trauma that affects their personal and professional lives. There is a dearth of literature exploring this phenomenon. PURPOSE: To explore MHS perspectives of assault by psychiatric patients. METHODS: A transcendental phenomenological qualitative design was used to explore and analyze the perspectives of a purposeful sample of 120 MHS perspectives at an acute inpatient psychiatric hospital. Participants' age ranged from 22 to 63 years (mean age = 32.4). Moustakas' theoretical underpinnings guided the study. RESULTS: Two patterns, 8 themes, and 19 subthemes were identified: (a) Psychological impacts revealed four themes-increase of anxiety/fear level, helplessness and hopelessness, flashbacks/burnout, and doubting own competency. (b) Physiosocial impacts revealed four themes-unsupportive superiors, stigmatization of staff victim, failure to report the incident, and environmental safety. DISCUSSION: Participants verbalized that assaults by patients have instilled fear and trauma in them. Most of the assaults occurred when staff were performing their routine job functions and setting limits to patient's behavior. CONCLUSION: The study allowed MHS opportunities to narrate their lived experiences of being assaulted by patients and provided validation of their perspectives. Findings illuminated the phenomenon and may help to support policy changes in psychiatric hospitals.

Long-Term Impact of Arteriovenous Fistula Ligation on Cardiac Structure and Function in Kidney Transplant Recipients: A 5-Year Follow-Up Observational Cohort Study.

Background: The long-term effects of arteriovenous fistula (AVF) ligation on cardiovascular structure following kidney transplantation remain uncertain. A prospective randomized, controlled trial (RCT) examined the effect of AVF ligation at 6 months on cardiovascular magnetic resonance imaging (CMR)-derived parameters in 27 kidney transplant recipients compared with 27 controls. A mean decrease in left ventricular mass (LVM) of 22.1 g (95% CI, 15.0 to 29.1) was observed compared with an increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group (P<0.001). We conducted a long-term follow-up observational cohort study in the treated cohort to determine the evolution of CMR-derived parameters compared with those documented at 6 months post-AVF ligation. Methods: We performed CMR at long-term follow-up in the AVF ligation observational cohort from our original RCT published in 2019. Results were compared with CMR at 6 months postintervention. The coprimary end point was the change in CMR-derived LVM and LVM index at long-term follow-up from imaging at 6 months postindex procedure. Results: At a median of 5.1 years (interquartile range, 4.7-5.5 years), 17 patients in the AVF ligation group were studied with repeat CMR with a median duration to follow-up imaging of 5.1 years (IQR, 4.7-5.5 years). Statistically significant further reductions in LVM (-17.6±23.0 g, P=0.006) and LVM index (-10.0±13.0 g/m2, P=0.006) were documented. Conclusions: The benefit of AVF ligation on LVM and LVM index regression appears to persist long term. This has the potential to lead to a significant reduction in cardiovascular mortality.

Correlation between computed tomography volumetry and nuclear medicine split renal function in live kidney donation: a single-centre experience.

BACKGROUND: Potential live renal donors undergo both renal computed tomography angiogram (CTA) and nuclear imaging dimercaptosuccinic acid (DMSA) scans. Each kidney's renal function and vascular anatomy influences the choice of donor side. Although DMSA measures differential blood flow, it is a surrogate for renal function and nephron mass. Computed tomography techniques can provide volumetry information. The aim of this study was to determine the relationship between measured split renal volumes on computed tomography versus renal volumes derived from DMSA split function in live donors. METHODS: Prospective data of live kidney donors assessed at a single Australian centre from 2014 to 2017 were reviewed. All patients had pre-operative CTA and DMSA imaging. Renal volume was determined via semi-automated software calculation from CTA three-dimensional image reconstructions by one investigator. Measured split renal volume was compared against calculated renal volume using measured DMSA split function (percentage split function multiplied by total renal volume). RESULTS: Fifty-three patients were included in the study. Split renal volumes on three-dimensional CTA images correlate to calculated split volumes determined from DMSA (Pearson coefficient 0.95 for right renal volume, 0.95 for left). The decision of which kidney to remove can be achieved with CTA only. Omitting a DMSA scan would reduce the radiation load by 0.70 mSv (35 chest X-rays) and potential cost saving of AU$1062.00 per donor. CONCLUSION: CTA technology allows accurate assessment of renal volumes that correlate well with DMSA split function. Avoiding a DMSA scan results in cost and radiation reduction in the assessment of a live kidney donor.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation.

BACKGROUND: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. METHODS: A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. RESULTS: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. CONCLUSION: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Comparative micro-epidemiology of pathogenic avian influenza virus outbreaks in a wild bird population.

Understanding the epidemiological dynamics of highly pathogenic avian influenza virus (HPAIV) in wild birds is crucial for guiding effective surveillance and control measures. The spread of H5 HPAIV has been well characterized over large geographical and temporal scales. However, information about the detailed dynamics and demographics of individual outbreaks in wild birds is rare and important epidemiological parameters remain unknown. We present data from a wild population of long-lived birds (mute swans; Cygnus olor) that has experienced three outbreaks of related H5 HPAIVs in the past decade, specifically, H5N1 (2007), H5N8 (2016) and H5N6 (2017). Detailed demographic data were available and intense sampling was conducted before and after the outbreaks; hence the population is unusually suitable for exploring the natural epidemiology, evolution and ecology of HPAIV in wild birds. We show that key epidemiological features remain remarkably consistent across multiple outbreaks, including the timing of virus incursion and outbreak duration, and the presence of a strong age-structure in morbidity that likely arises from an equivalent age-structure in immunological responses. The predictability of these features across a series of outbreaks in a complex natural population is striking and contributes to our understanding of HPAIV in wild birds. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'. This issue is linked with the subsequent theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'.

Effects of Arteriovenous Fistula Ligation on Cardiac Structure and Function in Kidney Transplant Recipients.

BACKGROUND: Cardiovascular morbidity and mortality remain high in recipients of a kidney transplant. The persistence of a patent arteriovenous fistula (AVF) after transplantation may contribute to ongoing maladaptive cardiovascular remodeling. The ability to reverse this maladaptive remodeling by ligation of this AVF is unknown. We conducted the first randomized controlled trial to evaluate the effect of AVF ligation on cardiac structure and function in stable kidney transplant recipients. METHODS: In this randomized controlled trial, kidney transplant recipients (>12 months after transplantation with stable graft function) were randomized to AVF ligation or no intervention. All participants underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, left and right atrial areas, LV ejection fraction, NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, cardiac output/index, brachial flows (ipsilateral to AVF), and pulmonary artery velocity. RESULTS: A total of 93 patients were screened, of whom 64 met the inclusion criteria and were randomized to the AVF ligation (n=33) or control (n=31) group. Fifty-four participants completed the study: 27 in the AVF ligation group and 27 in the control group. On the second cardiac magnetic resonance scan, a mean decrease of 22.1 g (95% CI, 15.0-29.1) was observed in LV mass in the AVF ligation group compared with a small increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group ( P<0.001). Significant decreases in LV end-diastolic volumes, LV end-systolic volumes, cardiac output, cardiac index, atrial volumes, and NT-proBNP were also seen in the AVF closure group ( P<0.01). No significant changes were observed in LV ejection fraction ( P=0.93) and pulmonary artery velocity ( P=0.07). No significant complications were noted after AVF ligation. No changes in estimated glomerular filtration rate or systolic and diastolic blood pressures were observed between cardiac magnetic resonance scans. CONCLUSIONS: Elective ligation of patent AVF in adults with stable kidney transplant function resulted in clinically significant reduction of LV myocardial mass. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au . Unique Identifier: ACTRN12613001302741.

Proceedings Paper-Avian Diseases 10th AI Symposium Issue Development and Application of Real-Time PCR Assays for Specific Detection of Contemporary Avian Influenza Virus Subtypes N5, N6, N7, N8, and N9.

Previously published NA subtype-specific real-time reverse-transcriptase PCRs (RRT-PCRs) were further validated for the detection of five avian influenza virus (AIV) NA subtypes, namely N5, N6, N7, N8, and N9. Testing of 30 AIV isolates of all nine NA subtypes informed the assay assessments, with the N5 and N9 RRT-PCRs retained as the original published assays while the N7 and N8 assays were modified in the primer-probe sequences to optimize detection of current threats. The preferred N6 RRT-PCR was either the original or the modified variant, depending on the specific H5N6 lineage. Clinical specimen (n = 137) testing revealed the ability of selected N5, N6, and N8 RRT-PCRs to sensitively detect clade 2.3.4.4b highly pathogenic AIV (HPAIV) infections due to H5N5, H5N6, and H5N8 subtypes, respectively, all originating from European poultry and wild bird cases during 2016-2018. Similar testing (n = 32 clinical specimens) also showed the ability of N7 and N9 RRT-PCRs to sensitively detect European H7N7 HPAIV and China-origin H7N9 low pathogenicity AIV infections, respectively.

Desarrollo y aplicación de ensayos de PCR en tiempo real para la detección específica de subtipos contemporáneos de influenza aviar Virus N5, N6, N7, N8 y N9. Métodos de transcripción reversa y PCR en tiempo real (RRT) específicos para subtipo específico de NA que fueron publicados anteriormente se validaron completamente para la detección de cinco subtipos de NA del virus de la influenza aviar (AIV), incluyendo N5, N6, N7, N8 y N9. El análisis de 30 aislamientos del virus de la influenza aviar de los nueve subtipos de NA proporcionaron información acerca de las evaluaciones de los ensayos, con los métodos de RRT-PCR N5 y N9 evaluados de acuerdo a los ensayos originales, mientras que los métodos N7 y N8 se modificaron en las secuencias del iniciador y de la sonda para optimizar la detección de los virus que constituyen amenazas actuales. Los métodos de RRT-PCR para el subtipo N6 preferido fueron tanto el dirigido al virus original o el dirigido a la variante modificada, dependiendo del linaje específico de H5N6. Las pruebas de muestras clínicas (n=137) revelaron que los métodos RRT-PCR seleccionados para N5, N6 y N8 detectaron con sensibilidad los subtipos del clado 2.3.4.4b del virus de la influenza aviar altamente patógenos H5N5, H5N6 y H5N8, respectivamente, todos originados en Europa de casos en avicultura comercial y de aves silvestres durante el año 2016 al 2018. Estudios similares (muestras clínicas n = 32) también mostraron que los métodos de RRT-PCR para los subtipos N7 y N9 detectaron con sensibilidad las infecciones por el virus H7N7 de alta patogenicidad europeo y por el subtipo H7N9 de origen chino de baja patogenicidad, respectivamente.

Weekend effect on early allograft outcome after kidney transplantation- a multi-centre cohort study.

Weekend surgery may be associated with a higher risk of early complications, but the effect of the timing of kidney transplant surgery on early allograft outcome remains uncertain. The aim of this study is to evaluate whether the association between weekend transplant surgery and allograft failure was modified by prevalent vascular disease. Using data from the Australia and New Zealand Dialysis and Transplant registry, we examined the association between weekend status and 90-day and 1-year allograft failure in deceased donor transplant recipients between 1994-2012. Two-way interaction between vascular disease and weekend status was examined. Of 6622 recipients, 1868 (28.2%) received transplants during weekends. Compared with weekday transplants, weekend transplants were associated with an adjusted hazard ratio (HR) for 90-day and 1-year allograft failure of 0.99 (0.78-1.25; P = 0.917) and 0.93 (0.76-1.13, P = 0.468), respectively. There was a significant interaction between prevalent vascular disease and weekend status for 90-day allograft failure (Pinteraction = 0.008) but not at 1-year, such that patients with vascular disease were more likely to experience 90-day allograft failure if transplanted on weekend (versus weekdays), particularly failures secondary to vascular complications. Timing of transplantation does not impact on allograft outcome, although those with vascular disease may benefit from more intensive post-transplant follow-up for potential vascular complications.

Detection of non-notifiable H4N6 avian influenza virus in poultry in Great Britain.

A 12-month pilot project for notifiable avian disease (NAD) exclusion testing in chicken and turkey flocks in Great Britain (GB) offered, in partnership with industry, opportunities to carry out differential diagnosis in flocks where NAD was not suspected, and to identify undetected or undiagnosed infections. In May 2014, clinical samples received from a broiler breeder chicken premises that had been experiencing health and production problems for approximately one week tested positive by avian influenza (AI) real-time reverse transcription polymerase chain reaction (RRT-PCR). Following immediate escalation to an official, statutory investigation to rule out the presence of notifiable AI virus (AIV; H5 or H7 subtypes), a non-notifiable H4N6 low pathogenicity (LP) AIV was detected through virus isolation in embryonated specific pathogen free (SPF) fowls' eggs, neuraminidase inhibition test, cleavage site sequencing and AIV subtype H4-specific serology. Premises movement restrictions were lifted, and no further disease control measures were implemented as per the United Kingdom (UK) legislation. Phylogenetic analysis of the haemagglutinin and neuraminidase genes of the virus revealed closest relationships to viruses from Mallard ducks in Sweden during 2007 and 2009. In June 2014, clinical suspicion of NAD was reported in a flock of free-range laying chickens elsewhere in GB, due to increasing daily mortality and reduced egg production over a five-day period. An H4N6 LPAIV with an intravenous pathogenicity index of 0.50 was isolated. This virus was genetically highly similar, but not identical, to the virus detected during May 2014. Full viral genome analyses showed characteristics of a strain that had not recently transferred from wild birds, implying spread within the poultry sector had occurred. A stalk deletion in the neuraminidase gene sequence indicated an adaptation of the virus to poultry. Furthermore, there was unexpected evidence of systemic spread of the virus on post-mortem. No other cases were reported. Infection with LPAIVs often result in variable clinical presentation in poultry, making detection of disease more difficult.

Laparoscopic-assisted Ex Vivo Reconstruction of Renal Artery Aneurysm with Internal Iliac Artery and Auto-transplantation.

Renal artery aneurysms (RAA) represent a complex and an often incidentally found disease commonly treated with endovascular approaches. In cases where in situ approaches are unsuitable, laparoscopic-assisted ex vivo repairs offer significant advantages during and post-surgery. We present a case of a female patient who presented with a long-standing right-sided flank pain. She was diagnosed with bilateral asymptomatic RAAs positioned well into the hilum, therefore making in situ repair infeasible. A laparoscopic-assisted ex vivo repair of the renal artery was performed using a graft from the internal iliac artery, which is a novel approach.

Association of oesophageal radiation dose volume metrics, neutropenia and acute radiation oesophagitis in patients receiving chemoradiotherapy for non-small cell lung cancer.

INTRODUCTION: The relationship between oesophageal radiation dose volume metrics and dysphagia in patients having chemoradiation (CRT) for non-small cell lung cancer (NSCLC) is well established. There is also some evidence that neutropenia is a factor contributing to the severity of oesophagitis. We retrospectively analysed acute radiation oesophagitis (ARO) rates and severity in patients with NSCLC who received concurrent chemotherapy and high dose radiation therapy (CRT). We investigated if there was an association between grade of ARO, neutropenia and radiation dose volume metrics. MATERIAL AND METHODS: Patients with NSCLC having concurrent CRT who had RT dose and toxicity data available were eligible. Exclusion criteria included previous thoracic RT, treatment interruptions and non-standard dose regimens. RT dosimetrics included maximum and mean oesophageal dose, oesophagus dose volume and length data. RESULTS: Fifty four patients were eligible for analysis. 42 (78 %) patients received 60 Gy. Forty four (81 %) patients received carboplatin based chemotherapy. Forty eight (89 %) patients experienced ARO ≥ grade 1 (95 % CI: 78 % to 95 %). ARO grade was associated with mean dose (rs = 0.27, p = 0.049), V20 (rs = 0.31, p = 0.024) and whole oesophageal circumference receiving 20 Gy (rs = 0.32 p = 0.019). In patients who received these doses, V20 (n = 51, rs = 0.36, p = 0.011), V35 (n = 43, rs = 0.34, p = 0.027) and V60 (n = 25, rs = 0.59, P = 0.002) were associated with RO grade. Eleven of 25 (44 %) patients with ARO ≥ grade 2 also had ≥ grade 2 acute neutropenia compared with 5 of 29 (17 %) patients with RO grade 0 or 1 (p = 0.035). CONCLUSION: In addition to oesophageal dose-volume metrics, neutropenia may also be a risk factor for higher grades of ARO.

A Single Center Experience With Adult Dual Kidney Transplant.

OBJECTIVES: Our renal transplant center in South Australian has been at the forefront of dual kidney transplants in Australia. In this study, we reviewed the 17 adult dual kidney transplants performed at our center between 1998 and 2014. MATERIALS AND METHODS: We retrospectively reviewed the 17 adult dual kidney transplants performed at our center since 1998 and report data pertaining to donor demographics, preimplant function, and histology of donor kidneys, as well as postoperative outcomes of transplant recipients. RESULTS: The mean age of donors was 68.5 ± 7.27 years, with 47% presenting with comorbid disease adversely affecting renal function (diabetes or hypertension). Histologic sampling of donor kidneys showed high rates of glomerular obsolescence, scarring, and vascular sclerosis. The mean age of recipients was 57.18 ± 10.93 years, with 10 patients receiving kidneys that were implanted bilaterally in each iliac fossa and 7 patients having both kidneys implanted into 1 iliac fossa. Early surgical complications (within the first 2 wk) were found in 6 patients (4 bilateral, 2 unilateral). In patients with bilaterally placed grafts, 2 developed a urinary leak, 1 lost both grafts secondary to renal vein thrombosis, and 1 lost a single graft due to renal vein thrombosis. In patients with unilaterally placed grafts, 1 had wound infection and 1 had double graft loss related to renal vein thrombosis. CONCLUSIONS: Adult dual kidney transplants offer an alternative use of kidneys from marginal donors.

Reassortant Pandemic (H1N1) 2009 virus in pigs, United Kingdom.

Surveillance for influenza virus in pigs in the United Kingdom during spring 2010 detected a novel reassortant influenza virus. This virus had genes encoding internal proteins from pandemic (H1N1) 2009 virus and hemagglutinin and neuraminidase genes from swine influenza virus (H1N2). Our results demonstrate processes contributing to influenza virus heterogeneity.

Barriers to timely arteriovenous fistula creation: a study of providers and patients.

BACKGROUND: Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation. STUDY DESIGN: Multicenter cohort study using mixed methods; qualitative and quantitative analysis. SETTING & PARTICIPANTS: 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients. PREDICTOR: Identification of barriers and enablers to AVF placement. OUTCOMES: Type of vascular access used at the start of hemodialysis therapy. MEASUREMENTS: Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start. RESULTS: 319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71; P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios. LIMITATIONS: A limited number of patient-based barriers was assessed. Cross-sectional data only. CONCLUSIONS: A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.

Characterization of cardiac remodeling in a large animal "one-kidney, one-clip" hypertensive model.

OBJECTIVE: The aim of this study is to characterize cardiac remodeling in a large animal model of hypertension. METHODS: 23 sheep were subjected to unilateral nephrectomy followed by clamping of the remaining renal artery to 60% ("one kidney-one clip", 1K1C) 3 weeks later. Blood pressure (BP) was monitored invasively over 73+/-28 days. Cardiac function was assessed with magnetic resonance imaging and compared with 12 size-matched controls. Detailed atrial histopathological analysis was performed. RESULTS: In the 1K1C animals, BP rose from baseline to reach a plateau by 4 weeks (systolic BP: 107+/-12 to 169+/-27, diastolic BP: 71+/-10 to 118+/-29 mmHg, both p< 0.0001); cardiac hypertrophy was significant when compared with controls with increased left ventricular weight [left ventricular (LV)/body wt: 2.7+/-0.5 vs 2.1+/-0.2 g/kg, p=0.01] as well as bi-atrial enlargement (right atrial, RA: 22.9+/-4.9 vs 15.7+/-2.8g, p=0.003; left atrial, LA: 35.5+/-6.7 vs 20.9+/-4.1g, p=0.0003); cardiac magnetic imaging demonstrated significantly increased LA volumes (end-diastolic volume: 42.9+/-6.8 vs 28.7+/-6.3 ml, p< 0.0001) and reduced LA ejection fraction (24.1+/-3.6 vs 31.6+/-3.0%, p=0.001) while LV function was relatively preserved (42.3+/-4.7 vs 46.4+/-4.1%, p=0.1); degeneration and necrosis of atrial myocytes were evident with increased atrial lymphocytic infiltration and interstitial fibrosis. CONCLUSIONS: The ovine 1K1C model produces reliable and reproducible hypertension with demonstrable cardiac end-organ damage.

The effect of age on the pathogenesis of a highly pathogenic avian influenza (HPAI) H5N1 virus in Pekin ducks (Anas platyrhynchos) infected experimentally.

BACKGROUND: Highly pathogenic avian influenza (HPAI) H5N1 viruses have recently displayed increased virulence for wild waterfowl. OBJECTIVES: To study the effect of host age on the shedding and tissue dissemination of a HPAI H5N1 virus in infected Pekin ducks. METHODS: Pekin ducks in two age-matched groups (n = 18), 8 and 12 weeks old (wo) were each infected with 10(6) EID(50)/0.1 ml of HPAI A/turkey/Turkey/1/05 (H5N1, clade 2.2). Each day for 5 days, birds were monitored clinically, and cloacal and oropharyngeal swabs collected, before three birds from each group were selected randomly for post-mortem examination. Tissue samples were collected for examination by real-time RT-PCR, histopathology and immunohistochemistry (IHC). RESULTS: Severe clinical signs, including incoordination and torticollis were observed in the 8 wo group resulting in 100% mortality by 4 dpi. Mild clinical signs were observed in the 12 wo group with no mortality. Real-time RT-PCR and IHC results demonstrated the systemic spread of H5N1 virus in birds of both age groups. Higher levels of virus shedding were detected in oropharyngeal swabs than in cloacal swabs, with similar levels of shedding detected in both age groups. Variations in level and temporal dissemination of virus within tissues of older ducks, and the presence of the virus in brain and heart were observed, which coincided with the appearance of clinical signs preceding death in younger birds. CONCLUSIONS: These results are consistent with reports of natural infections of wild waterfowl and poultry possibly indicating an age-related association with dissemination and clinical outcome in ducks following infection with H5N1 HPAI virus.

Transection of the renal pelvis by endocatch bag during laparoscopic donor nephrectomy.

A case of inadvertent transection of the renal pelvis by the Endocatch bag during laparoscopic donor nephrectomy is reported. This is the second reported injury resulting from the Endocatch bag. We have successfully managed the injury with continuing good renal function after 3 years. The aim of this report is to increase the awareness of this potential complication and how it can be prevented.