Toxicology and Analytical Chemistry.

Knowing how to effectively use veterinary diagnostic toxicology laboratories is key when navigating suspect toxicoses in ruminants. This begins with establishing a causal relationship between clinical signs and potential sources of exposure, followed by collecting the appropriate samples for toxicology testing. There are times in which a successful diagnosis is hindered by not obtaining a thorough case history and not knowing what specimens to collect, or how much specimen to submit, for toxicology testing. This article is intended to offer some guidance with respect to the effective use of veterinary toxicology/analytical chemistry laboratories when navigating suspect toxicology cases in ruminants.

Atrazine intoxication in cattle, confirmed by gas chromatography-mass spectrometry.

Ten of 40 cows died within 48 h of gaining access to a barn in which various chemicals were stored. Some of the surviving cows exhibited drooling, muscle tremors, and agitation. Postmortem examinations of 2 cows were performed in the field, and revealed nonspecific, moderate-to-severe pulmonary congestion. Liver and rumen contents, each from a different cow, were analyzed using a qualitative, multi-residue GC-MS method validated for the detection of pesticides and other chemical analytes. Using this method, extracts from the liver and rumen content samples were compared to atrazine (neat standard) and matrix-matched, control samples fortified with atrazine. GC-MS analysis detected atrazine at 215 m/z (NIST match >97%) with a retention time of ~13 min in liver and rumen content samples from our case. Detection of atrazine in the samples from the cows in this herd, combined with the clinical history, indicate that atrazine toxicity was the likely cause of clinical signs and death observed in this herd.

Chronic copper toxicosis in a crossbred heifer calf.

An 8-mo-old, crossbred, heifer calf was presented to the Heeke Animal Disease Diagnostic Laboratory with a history of ataxia and altered mentation. Grossly, the liver was diffusely yellow-orange, turgid, and exuded watery, thin blood on cut section. The cortex and medulla in both kidneys were diffusely and markedly dark brown to black. The urinary bladder was filled with dark red urine. Histologically, centrilobular hepatocellular degeneration was observed, but these sections lacked necrosis. In the kidney, numerous cortical tubules contained intraluminal bright eosinophilic fluid and red-orange granular casts that stained positive for hemoglobin with the Dunn-Thompson method. The gross and histologic lesions supported a high level of suspicion for copper toxicosis. Feed and water samples from the farm were submitted for mineral analysis. The copper concentration in the feed was 118 mg/kg, and the molybdenum concentration was 0.9 mg/kg. Chronic copper toxicosis is rarely reported in cattle. The gross lesions in our case are a departure from, although similar to, previously reported cases, including lack of histologic hepatocellular necrosis. Collectively, gross and histologic lesions were compatible with copper toxicosis in this calf, and copper concentrations in the feed samples suggest a feed-mixing error.

Filter Cone Spray Ionization Coupled to a Portable MS System: Application to On-Site Forensic Evidence and Environmental Sample Analysis.

The complexity of field-borne sample matrices and the instrumental constraints of portable mass spectrometers (MS) often necessitate that preparative steps are added prior to ambient MS methods when operated on-site, but the corresponding decrease in throughput and experimental simplicity can make field operation impractical. To this end, we report a modified ambient MS method, filter cone spray ionization (FCSI), specifically designed for simple, yet robust, processing of bulk forensic evidence and environmental samples using a fieldable MS system. This paper-crafted source utilizes low-cost laboratory consumables to produce a conical structure that serves as a disposable, spray-based ionization source. Integrated extraction and filtration capabilities mitigate sample heterogeneity and carryover concerns and expedite sample processing, as characterized through the analysis of a variety of authentic forensic evidence types (e.g., abused pharma tablets, counterfeit/adulterated tablets, crystal-based drugs, synthetic marijuana, toxicological specimens) and contaminated soil samples. The data presented herein suggests that the FCSI-MS design could prove robust to the rigors of field-borne, bulk sample screening, overcoming the inefficiencies of other ambient MS methods for these sample classes. Novel applications of FCSI-MS are also examined, such as the coupling to trace evidence vacuum filtration media.

Investigative Diagnostic Toxicology and the Role of the Veterinarian in Pet Food-Related Outbreaks: An Update.

Although most commercial pet foods are safe, there have been a few instances in which chemical or bacterial contamination have caused outbreaks of illness in animals. Because of concerns regarding cases of contaminated commercial pet food that have been reported over the past several years, some pet owners may be choosing to feed noncommercial, home-prepared diets. When pet food contamination is suspected, pet owners often seek advice from their veterinarian regarding its health impact and subsequent diagnosis. This article addresses the role of the veterinarians in pet food contamination and highlights recommended approaches to handling pet food outbreaks or recalls.

Prospective Bundled Payments in a Changing Environment: The Experience of a Self-Funded, State-Sponsored Plan.

BACKGROUND: Healthcare reimbursement, which has traditionally been based on the quantity of services delivered, is currently moving toward value-based reimbursement-a system that addresses the quantity, quality, and cost of services. One such arrangement has been the evolution of bundled payments for a specific procedure or for an episode of care, paid prospectively or through post-hoc reconciliation. OBJECTIVE: To evaluate the impact of instituting bundled payments that incorporate facility charges, physician fees, and all ancillary charges by the State of Oklahoma HealthChoice public employee insurance plan. METHOD: From January 1 through December 31, 2016, HealthChoice, a large, government-sponsored Oklahoma health plan, implemented a voluntary, prospective, bundled payment system with network facilities, called Select. The Select program allows members at the time of certification of the services to opt to use participating facilities for specified services at a bundled rate, with deductible and coinsurance covered by the health plan. That is, the program allows any plan member to choose either a participating Select facility with no out-of-pocket costs or standard benefits at a participating network facility. RESULTS: During 2016, more than 7900 procedures were performed for 5907 patients who chose the Select arrangement (also designated as the intervention group). The most common outpatient Select procedures were for cardiology, colonoscopy, and magnetic resonance imaging scans. The most common inpatient procedures for Select-covered patients were in 6 diagnosis-related groups covering spinal fusions, joint replacement surgeries, and percutaneous coronary artery stenting. The allowable costs were similar for bundled procedures at ambulatory surgery centers and at outpatient hospital facilities; the allowable costs for patients not in the Select program (mean, $813) were lower at ambulatory surgery centers than at outpatient hospital departments (mean, $3086) because of differences in case mix. Patients in the Select system who had outpatient procedures had significantly fewer subsequent claims than those who were not in Select for hospitalization (1.7% vs 2.5%, respectively) and emergency department visits (4.4% vs 11.5%, respectively) in the 30 days postprocedure. Quality measures (eg, wound infection and reoperation) were similar for patients who were and were not in the Select group and had procedures. Surgical complication (ie, return to surgery) rates were higher for the Select group. CONCLUSION: The Select program demonstrated promising results during its first year of operation, suggesting that prospective bundled payment arrangements can be implemented successfully. Further research on reimbursement mechanisms, that is, how to pay physicians and facilities, and quality of outcomes is needed, especially with respect to which procedures are most suitable for this payment arrangement.

Teaching by residents.

This paper stresses the importance to students and residents of committed and competent teaching by residents who nationwide provide 20% to 70% of the clinical teaching for medical students. The obstacles to teaching effectiveness by residents are the lack of: (1) sufficient role modeling by faculty; (2) time (and money); (3) knowledge of the principles of adult learning and teaching techniques; (4) service-specific learning objectives; (5) recognition of teaching efforts; and (6) resident interest in teaching. Overcoming these obstacles will require increased faculty commitment to teaching, compensation for structured educational activities, more effective use of potential teaching moments, teaching workshops for residents, development of service-specific educational objectives, and recognition of exemplary teaching by residents and faculty.

Clinical relevance of Mycobacterium tuberculosis plcD gene mutations.

To identify Mycobacterium tuberculosis virulence factors, we integrated comparative genomics and epidemiologic data analysis to investigate the relationship between certain genomic insertions and deletions in the phospholipase-C gene D (plcD) with the clinical presentation of tuberculosis (TB). Four hundred ninety-six well-characterized M. tuberculosis clinical isolates were studied. Approximately 30% (147) of the isolates had an interruption of the plcD gene. Patients infected with the plcD mutant were twice as likely to have extrathoracic disease as those infected by a strain without an interruption (adjusted odds ratio, 2.19; 95% confidence interval, 1.27, 3.76). When we limited the analysis to the 275 isolates with distinct DNA fingerprint patterns, we observed the same association (adjusted odds ratio, 2.74; 95% confidence interval, 1.35, 5.56). Furthermore, the magnitude of the association appeared to differ with the type of extrathoracic TB. Our findings suggest that the plcD gene of M. tuberculosis is potentially involved in the pathogenesis of TB, and the clinical presentation of the disease may be influenced by the genetic variability of the plcD region.

Identification of risk factors for extrapulmonary tuberculosis.

The proportion of extrapulmonary tuberculosis cases in the United States has increased from 16% of tuberculosis cases, in 1991, to 20%, in 2001. To determine associations between the demographic, clinical, and life style characteristics of patients with tuberculosis and the occurrence of extrapulmonary tuberculosis, a retrospective case-control study was conducted. This study included 705 patients with tuberculosis, representing 98% of the culture-proven cases of tuberculosis in Arkansas from 1 January 1996 through 31 December 2000. A comparison between 85 patients with extrapulmonary tuberculosis (case patients) and 620 patients with pulmonary tuberculosis (control patients) showed women (OR, 1.98; 95% CI, 1.25-3.13), non-Hispanic blacks (OR, 2.38; 95% CI, 1.42-3.97), and HIV-positive persons (OR, 4.93; 95% CI, 1.95-12.46) to have a significantly higher risk for extrapulmonary tuberculosis than men, non-Hispanic whites, and HIV-negative persons. This study expands the knowledge base regarding the epidemiology of extrapulmonary tuberculosis and enhances our understanding of the relative contribution of host-related factors to the pathogenesis of tuberculosis.

Patterns of care study: comparison of process of post-mastectomy radiotherapy (PMRT) in Japan and the USA.

BACKGROUND: The Patterns of Care Study (USPCS) by the American College of Radiology (ACR) has made significant contributions to improvements in the procedures of care for patients with breast cancer in the USA. The purpose of this study was to identify problems associated with the process of care for patients undergoing post-mastectomy radiotherapy (PMRT) in Japan compared with those in the USA. METHODS: The Japanese Patterns of Care Study Subgroup (JPCS) conducted a national survey in 1998-2000, involving 79 institutions and using two-stage cluster sampling of institutions and patients, which showed that between 1995 and 1997 PMRT was performed on 258 patients. The survey of the USPCS, involving 55 institutions, found that 407 patients received PMRT between 1998 and 1999. RESULTS: More than three axillary positive nodes were detected in 54% of the patients covered by the JPCS and in 46% of those covered by the USPCS. The clinical set-up of radiation treatment was planned without the aid of computed tomography or X-ray simulation for 25% of the JPCS patients and for 6% of the USPCS patients. The chest wall of 31% of the JPCS patients and of 98% of the USPCS patients was irradiated. The JPCS showed that inappropriate radiation techniques such as parallel opposed fields for chest wall irradiation were used for 3% of the patients in academic facilities, but for 25% of those in non-academic facilities (P = 0.0002). CONCLUSION: There is ample room for improvement in radiation treatment planning and chest wall irradiation techniques in Japan.

Transmission of Mycobacterium tuberculosis in a rural community, Arkansas, 1945-2000.

A cluster of tuberculosis cases in a rural community in Arkansas persisted from 1991 to 1999. The cluster had 13 members, 11 linked epidemiologically. Old records identified 24 additional patients for 40 linked cases during a 54-year period. Residents of this neighborhood represent a population at high risk who should be considered for tuberculin testing and treatment for latent tuberculosis infection.

Correlating selection criteria with subsequent performance as residents.

The objective of this study was to determine which criteria in the residency application had the highest correlation with subsequent performance of orthopaedic residents. Data collected from the application files of 58 residents included scores on standardized tests, number of honors grades in the basic and clinical years of medical school, election to Alpha Omega Alpha, numbers of research projects and publications, and numbers of extracurricular activities. Measures of performance included scores on the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery Part I Examination, and faculty evaluations of overall, cognitive, affective, and psychomotor performance. The number of honors grades on clinical rotations was the strongest predictor of performance, whereas election to Alpha Omega Alpha was second. The only other significant correlation was between the number of fine motor activities and psychomotor performance. None of the predictor variables had a significant correlation with Orthopaedic In-Training Examination or American Board of Orthopaedic Surgery Examination scores. Consistency between faculty rankings in each of the four categories was supported by regression analysis. From the results of this study, it appears that academic performance in clinical clerkships in medical school is the most predictive of resident performance. Range restriction in the data available for orthopaedic residency applicants, however, likely precludes the development of a reliable model to assist in the selection of orthopaedic residents.