Clinical epidemiology

Rational clinical practice requires deductive particularization of diagnostic findings, prognoses, and therapeutic responses from groups of animals (herds) to the individual animal (herd) under consideration This process utilizes concepts, skills, and methods of epidemiology, as they relate to the study of the distribution and determinants of health and disease in populations, and casts them in a clinical perspective.

We briefly outline diagnostic strategies and introduce a measure of agreement, called kappa, between clinical diagnoses. This statistic is useful not only as a measure of diagnostic accuracy, but also as a means of quantifying and understanding disagreement between diagnosticians. It is disconcerting to many, clinicians included, that given a general deficit of data on sensitivity and specificity, the level of agreement between many clinical diagnoses is only moderate at best with kappa values of 0.3 to 0.6.

Sensitivity, specificity, pretest odds, and posttest probability of disease are defined and related to the interpretation of clinical findings and ancillary diagnostic test results. An understanding of these features and how they relate to ruling-in or ruling-out a diagnosis, or minimizzing diagnostic errors will greatly enhance the diagnostic accuracy of the practitioner, and reduce the frequency of clinical disagreement. The approach of running multiple tests on every patient is not only wasteful and expensive, it is unlikely to improve the ability of the clinician to establish the correct diagnosis.

We conclude with a discussion of how to decide on the best therapy, a discussion which centers on, and outlines the key features of, the well designed clinical trial. Like a diagnosis, the results from a clinical trial may not always be definitive, nonetheless it is the best available method of gleaning information about treatment efficacy.

     

Blood chemistry for the diagnosis of hepatobiliary disease in birds. A review

Summary

A review is presented of current knowledge with regard to blood chemistry for the diagnosis of hepatobiliary disease in birds. Straightforward conclusions are difficult, because research on this subject has been limited.

Jaundice caused by hyperbilirubinaemia occurs infrequently in birds, because the main bile pigment is biliverdin and not bilirubin. A yellow discolouration of avian plasma is often caused by the presence of carotenoids. The diagnostic value of plasma ALAT concentrations is controversial. Although ASAT and LD are not specific for the liver they appear to be sensitive enzymes to detect liver cell damage.

GLDH is liver specific in a number of animal species (including birds) and might prove to be a useful enzyme for diagnostic purposes. AP and GGT seem less useful. Little information is available on the diagnostic value of plasma bile acids and plasma dye clearance tests.     

Perceived Usefulness of the Collection of Subclinical and other Disease Entities Detected at Slaughter

Based on a survey of 1820 Ontario pork producers and 16 veterinary members of the Ontario Swine Practitioners Association, condemnation/demerit data, while viewed as potentially valuable, are seldom, if ever, utilized in the provision of herd health programs. We found, however, that: 1) 89.4 percent (SD 1.04 percent) of producers and all veterinarians would use the disease information made available by a computerized system that would collect and report on subclinical and other disease entities detected during the slaughter of hogs; 2) Iesion diagnosis should be as detailed as possible and report on severity of disease; and 3) with the exception of those producers who ship larger numbers of hogs to market for which reports were wanted for each kill, monthly reports would be adequate.

Written comments by producers expressed concerns about confidentiality of individual herd data, costs for the information/service, and veterinary expertise in the interpretation of findings.

     

Equine tapeworm infections: Disease,diagnosis and control

Equine tapeworm infection has gained increasing attention over the past few decades and a number of research studies have already been published. These focus primarily on the most common of the 3 tapeworm species, Anoplocephala perfoliata, although some new information has also been generated for the other two species, Anoplocephala magna and Anoplocephaloides mamillana. The preponderance of research studies have focused on development and validation of diagnostic techniques for tapeworm detection and the role of these parasites in equine gastrointestinal disease. Several diagnostic techniques have been found useful for diagnosis of A. perfoliata but each has its strengths and weaknesses. Egg counting techniques have been modified to achieve acceptable to good diagnostic performance but the trade‐off is often a more time‐consuming method. Validation studies indicate that these methods can reliably detect tapeworm burdens above 10 worms. Several enzyme‐linked immunosorbent assays (ELISAs) have been developed and made commercially available. These can generate useful information about tapeworm exposure on the herd level but are less reliable for individual diagnosis. Unfortunately, none of the available diagnostic techniques are useful for evaluating anthelmintic treatment efficacy. Coproantigen testing may find use as a future diagnostic modality but further characterisation is required. The large body of scientific evidence supports an association between A. perfoliata infection and certain types of equine colic, although some discrepancy exists between studies. Tapeworm surveillance and control should be considered as part of the overall parasite control strategy. When properly used, the currently available diagnostic tools can guide the veterinarian to make strategic decisions regarding tapeworm control.     

Roquefortine in the stomach contents of dogs suspected of strychnine poisoning in Alberta

From April to September 1990, submissions in Alberta veterinary diagnostic laboratories for which strychnine analysis was requested were tested retrospectively for roquefortine, a diketopiperazine alkaloidal tremorgenic mycotoxin. Roquefortine was found only in strychnine-negative samples. The specific origins of the fungal-contaminated specimens could not be determined. Of the six roquefortine-positive cases, four dogs that vomited prior to treatment recovered. Two dogs which died had significant amounts of stomach contents present at the time of postmortem.

At the present time only one veterinary laboratory in Canada is routinely testing for roquefortine when samples are negative for strychnine. It appears that a low diagnostic rate for this type of poisoning may be occurring due to incomplete testing. The inability to differentiate between roquefortine and strychnine poisoning on a clinical basis in five of our six cases emphasizes that an accurate causative diagnosis requires laboratory examination.

Research in rats and sheep has shown that the tremorgenic mycotoxins penitrem A and roquefortine are excreted through bile. Although further research is required, the submission of bile and intestinal contents is recommended if stomach contents or vomitus are not available for laboratory testing. Both of these mycotoxins should be tested for when strychnine analysis is negative as fungi may produce both toxins at the same time. In this study we were unsure if roquefortine alone or in combination with other toxins was responsible for our findings.

     

Canine congenital aortic stenosis: A review of the literature and commentary

Congenital aortic stenosis usually affects the subvalvular region, and occurs mainly in Newfoundland, Golden Retriever, German Shepherd, and Boxer dogs. The disorder is inherited as a dominant trait with variable penetrance in Newfoundland dogs.

The prevalence of subaortic stenosis-like heart murmurs in Golden Retriever dogs appears to be very much greater than previously suspected.

Most cases of aortic stenosis represent mild lesions, are detected as incidental findings, and result in no loss of longevity or quality of life. Moderate or severe stenosis may result in exertional weakness, syncope, or sudden death. Signs of congestive heart failure are rare unless mitral valve insufficiency is present.

Generally, electrocardiography and radiography are unrevealing in this disorder. Doppler echocardiography may be the best diagnostic tool to detect even mild cases of aortic stenosis.

At present, therapy is limited due to the technical expertise and expense required. The prognosis depends on the severity of the lesion.

     

Pig producer perspectives on the use of meat inspection as an animal health and welfare diagnostic tool in the Republic of Ireland and Northern Ireland

Background

Currently, there is growing interest in developing ante and post mortem meat inspection (MI) to incorporate measures of pig health and welfare for use as a diagnostic tool on pig farms. However, the success of the development of the MI process requires stakeholder engagement with the process. Knowledge gaps and issues of trust can undermine the effective exchange and utilisation of information across the supply chain. A social science research methodology was employed to establish stakeholder perspectives towards the development of MI to include measures of pig health and welfare. In this paper the findings of semi-structured telephone interviews with 18 pig producers from the Republic of Ireland and Northern Ireland are presented.

Results

Producers recognised the benefit of the utilisation of MI data as a health and welfare diagnostic tool. This acknowledgment, however, was undermined for some by dissatisfaction with the current system of MI information feedback, by trust and fairness concerns, and by concerns regarding the extent to which data would be used in the producers’ interests. Tolerance of certain animal welfare issues may also have a negative impact on how producers viewed the potential of MI data. The private veterinary practitioner was viewed as playing a vital role in assisting them with the interpretation of MI data for herd health planning.

Conclusions

The development of positive relationships based on trust, commitment and satisfaction across the supply chain may help build a positive environment for the effective utilisation of MI data in improving pig health and welfare. The utilisation of MI as a diagnostic tool would benefit from the development of a communication strategy aimed at building positive relationships between stakeholders in the pig industry.

     

Quantitative Polymerase Chain Reaction (PCR) for Detection of Aquatic Animal Pathogens in a Diagnostic Laboratory Setting

Abstract

Real-time, or quantitative, polymerase chain reaction (qPCR) is quickly supplanting other molecular methods for detecting the nucleic acids of human and other animal pathogens owing to the speed and robustness of the technology. As the aquatic animal health community moves toward implementing national diagnostic testing schemes, it will need to evaluate how qPCR technology should be employed. This review outlines the basic principles of qPCR technology, considerations for assay development, standards and controls, assay performance, diagnostic validation, implementation in the diagnostic laboratory, and quality assurance and control measures. These factors are fundamental for ensuring the validity of qPCR assay results obtained in the diagnostic laboratory setting.

Received March 30, 2011; accepted May 6, 2011     

Epizootic of Western Encephalomyelitis Virus Infection in Equines in Alberta in 1965

The epizootic of equine encephalomyelitis in 1965 in Alberta was proved to be due to Western Encephalomyelitis virus infection by serological findings and virus isolations.

Sixty-three horses of 88 tested, showed a diagnostic rise of CF antibodies to Western Encephalomyelitis virus.

Western Encephalomyelitis virus was isolated from 5 brains of horses. Homologous antibodies were shown in 3 of these animals, the only ones from which blood specimens were received.

For the first time virological evidence is given that Western Encephalomyelitis virus infection in horses is found in more areas of Alberta and in regions situated further North than those previously suspected.

     

Statistical Evaluation of Test Accuracy Studies for Toxoplasma gondii in Food Animal Intermediate Hosts

The availability of accurate diagnostic tests is essential for the detection and control of Toxoplasma gondii infections in both definitive and intermediate hosts. Sensitivity, specificity and the area under the receiver‐operating characteristic (ROC) curve are commonly used measures of test accuracy for infectious diseases such as toxoplasmosis. These test performance characteristics are important considerations when selecting from among a group of tests for a specific testing purpose. In this study, we reviewed statistical approaches to evaluation of tests for toxoplasmosis with and without a gold‐standard (reference) test, including use of ROC analysis and likelihood ratios which retain the diagnostic information inherent in a quantitative test result. We use previously published data from a comparison of the accuracy of serological tests for swine toxoplasmosis to demonstrate suggested methods of data analysis. We make recommendations for statistical analysis and reporting of test evaluation studies for T. gondii in food animals based on our own experiences and those of others.     

Blood thiamine levels in clinically normal goats and goats with suspected polioencephalomalacia

Abstract

AIMS: To identify and describe culture and antimicrobial resistance (AMR) patterns in bacteria isolated from canine urinary samples submitted to a New Zealand veterinary diagnostic laboratory.

METHODS: Records from a veterinary diagnostic laboratory were examined for bacterial isolates cultured from canine urine samples between January 2005 and December 2012. Culture and susceptibility results were compiled with information on the age, sex and breed of dog. Repeat submissions were removed. Susceptibility was assessed using results of the Kirby-Bauer disk diffusion method, for a standard panel including amoxicillin-clavulanic acid (AMC), cefovecin (from 2010–2012), cephalothin, clindamycin, enrofloxacin and trimethoprim-sulphonamide (TMS).

RESULTS: A total of 5,786 urine samples were submitted for analysis, and 3,135 bacterial isolates were cultured from 2,184 samples. Of these 3,135 isolates, 1,104 (35.2%) were Escherichia coli, 442 (14.1%) were Staphylococcus spp., 357 (11.4%) Proteus mirabilis and 276 (8.8%) were Enterococcus spp. The frequency of culture-positive samples increased with increasing age in both female and male dogs (p<0.001). The percentage of E. coli isolates resistant to AMC and cephalothin increased between 2005 and 2012 (p<0.001), as did resistance to enrofloxacin (p=0.022), but there was no change in resistance to TMS (p=0.696). Enrofloxacin was the antimicrobial with the least resistance shown by the four most common bacteria isolated during the course of the study.

CONCLUSIONS AND CLINICAL RELEVANCE: The results of this study provide important regional information regarding the prevalence of bacterial uropathogens and their susceptibility patterns. There was an increase in resistance to some commonly used antimicrobials in the treatment of urinary tract infections. Having access to regional antimicrobial susceptibility results is crucial when forming guidelines for the use of antimicrobials for the treatment of urinary tract infections. Given changes in practising habits and antimicrobial usage over time, ongoing monitoring and surveillance of resistance in pathogens is needed.     

Protection of piglets against a virulent New Zealand isolate of Aujeszky's disease virus by vaccination with a novel genetically-engineered vaccine

Abstract

AIMS: To modify and validate an existing swine erysipelas ELISA for use with poultry serum and to assess the safety of a swine erysipelas vaccine for use in New Zealand layer birds.

METHODS: An existing swine erysipelas ELISA was modified for use in domestic poultry and was validated using sera from birds injected with either 2 mL of a commercially available killed swine erysipelas vaccine (low-dose; n=12 birds), 4 mL of vaccine (high-dose; n=11 birds), or 2 mL saline (control; n=11 birds) on Day 0 and again on Day 21. Blood samples were collected on Days 0, 21, 42, and 63, and safety of the vaccine for use in layer birds was determined by assessing cloacal temperature and injection site reactions in birds at 0, 4, 24, 48, 72 and 96 h post-vaccination.

RESULTS: The ELISA that was developed had a diagnostic sensitivity and specificity of 93% and 98%, respectively, after being optimised for a positive cut-off at an optical density (OD) ≥1.50 read at 450-nm wavelength. OD readings were higher on Days 21, 42, and 63 than Day 0 in both the low-dose and high-dose groups (p<0.05), and differed amongst the three groups on Days 21, 42, and 63 (p<0.05), suggesting that vaccination using either dose induced detectable levels of antibody, even after a single dose. In addition, the high-dose protocol induced higher levels of antibody production than the low-dose protocol. No local or systemic reactions to the vaccine were observed and cloacal temperatures remained in the normal biological range after vaccination.

CONCLUSIONS: The ELISA that was developed had satisfactory diagnostic performance characteristics and the vaccine appeared to be safe for use in layer birds. However, the study design did not permit an assessment of the vaccine's efficacy to protect birds from clinical erysipelas.

CLINICAL RELEVANCE: A diagnostic ELISA has been developed for determining the exposure of layer birds to E. rhusiopathiae. The test will be useful for monitoring flock-level erysipelas, response to vaccination, and in epidemiological studies designed to identify risk factors for exposure to the disease.     

Pathology of gastritis and gastric ulceration in the horse. Part 2: A scoring system

Reasons for performing study: High numbers of racehorses in training are reported to have gastric ulceration. Gross lesion scoring systems exist, but there is no fixed protocol with which to record gastric microscopic findings. In man, the histological classification of stomach lesions helps in the identification of recognised and emerging aetiologies of gastric disease and aids accurate comparison of findings between studies. In horses, the development of such a system would therefore be of benefit. Objectives: To develop a pathological scoring system that can be applied to examine samples of the equine stomach at biopsy and post mortem. Methods and results: The equine gastritis grading (EGG) system was developed initially using horse stomachs at post mortem. The protocol involved sampling tissue from 5 fixed locations within the squamous and glandular regions. Histological examination recorded both type and degree of inflammatory infiltrate and the presence of erosions, ulceration or any other reactive change in each slide. These results were combined and an overall diagnosis of gastritis type given for each stomach. Conclusions and potential relevance: This is the first example of a complete pathological scoring system developed specifically for recording gastric lesions in the horse. It provides a thorough and repeatable method with which to examine the equine stomach in microscopic detail. It can be used in diagnostic or research situations and the consistency of the information gathered will enable accurate comparison of data between different studies. It aims to give an indication as to the currently undetermined pathological variations seen in the stomach of healthy and diseased horses, as well as increasing the understanding of the pathogenesis of gastritis and gastric ulceration. Using this information, interpretation of biopsy samples is improved.     

Keeshonds: a genetic study of epilepsy and EEG readings

Data are presented from some 321 Keeshond dogs attending a clinic for electroencephalographic records, and their 108 close ancestors. They are examined to see whether the EEG readings are diagnostic of a tendency to epileptiform fits, and what hereditary basis there is, if any, for both the readings and the fits. The evidence does not support the idea of a diagnostic value; finds no hereditary basis for the readings; and, as far as the limited information about dogs which have had fits allows, slightly favours some hereditary component in the aetiology of epilepsy. These findings are discussed in relation to those concerning hereditary epilepsy in other breeds.     

Use of information from Pig finishing herds for meat inspection purposes

Summary

In a field trial on Integrated Quality Control of finishing pigs we evaluated information written on Quality Information Cards (QUIC) for meat inspection purposes. These cards were sent with 3747 shipments of pigs going from the finishing herd to the slaughterhouse. Pig suppliers answered five questions dealing with health problems and the use of drugs during the finishing period By comparing QUIC answers to recorded post‐mortem abnormalities, we found that the information on the QUIC had some, albeit low, predictive value with respect to the abnormalities ‘arthritis’, ‘condemned liver’ and lung lesions. Shipments without a QUIC or with a faulty QUIC were considered ‘suspect’ because higher levels of abnormalities were found in these shipments. These results indicate the potential use of a QUIC.     

A physiological approach to research in pasture utilization

A study of species selection by cattle under a system of controlled selective grazing using wheel‐point surveys and fistulated animals has demonstrated that both techniques provide valuable information on the preference shown for such species as Andropogon amplectens, Eulalia villosa, Themeda triandra, Trachypogon spicatus, Tristachya hispida and Monocymbium ceresiiforme.

The wheel‐point survey, which presents information on the degree of utilization of different species over the entire grazing period, is complemented by the more detailed information obtained by identifying grass species from oesophageal fistula samples obtained at specific times within the grazing period.

Preference for species does not appear to be markedly affected by their relative contribution to basal cover, but apparently is subject to seasonal variations.     

Cystourethroscopy in the dog

Summary

The cystourethroscopic examination with cold light cystoscopes forms an essential part of a complete urological examination and is useful for diagnostic as well as surgical procedures. The fast and non‐invasive character of the procedure limits the inconvenience to the patient.

With the rigid non‐flexible scope its use is, however, limited to female dogs, unless in the male dog a urethro(s)tomy is performed.     

Comparison of first-opinion and second-opinion histopathology from dogs and cats with cancer: 430 cases (2001–2008)

Second-opinion histopathology is intended to detect clinically significant discrepancies that have a direct impact on patient care. We sought to determine if this practice at our institution affected patient management and prognosis. First- and second-opinion histopathology reports from cases were retrospectively reviewed. Reports were considered to be in diagnostic agreement, partial diagnostic disagreement or complete diagnostic disagreement. Four hundred and thirty cases were studied. In 70% of cases there was a diagnostic agreement. In 20% of cases, there was partial diagnostic disagreement, where diagnoses were the same but information such as grade or lymphatic and/or vascular invasion was changed. In 10% of cases, complete diagnostic disagreement resulted from a change in degree of malignancy (malignant to benign, or converse; 7%) or a change in cell type (3%). In 17% of the cases evaluated, the histopathology review prompted a change in treatment or prognosis. These findings support the use of second-opinion histopathology as an important part of patient care.     

Endoscopy in birds

Summary

Endoscopic examination is described as a valuable diagnostic method in birds. In the introduction, reference is made to the literature on this subject. Apart from the classical approaches, alternative sites to enter the thoraco‐abdominal cavity in birds are discussed. The basic equipment for endoscopy in birds is described and a new biopsy forceps which makes a secundary puncture redundant is introduced.

After a discussion of the indications and complications, the value of the endoscopic examination is compared with other diagnostic methods for the diagnosis of avian tuberculosis in birds.     

Recent advances in reproductive endocrinology of the mare

The recent development of radioimmunoassay techniques to determine changes in blood hormone levels has increased our understanding of the endocrinology of the oestrous cycle and pregnancy in the mare. This review describes recent findings concerning the endocrine basis and treatment of some common types of infertility.

Further evidence supporting the concept that prostaglandin F2∝ is the uterine luteolysin in the mare is discussed. Persistent corpus luteum is now recognized as an important cause of infertility, which may be treated by uterine distension or prostaglandin; recommendations for avoiding treatment failures are presented.

The clinical significance of recent findings on the effectiveness of HCG in hastening ovulation, and on the increase in anti-HCG antibodies after repeated injections of this hormone are also discussed.

Although antibiotics successfully control the specific pathogen causing contagious equine metritis, the treatment of common opportunistic organisms with antibiotics appears to give indifferent results. The increased understanding of the role of sex steroids in susceptibility to uterine infection seems likely to lead to improved methods of control.

Although stimulation of folliculogenesis and ovulation in seasonally acyclic mares is possible using extracts of equine pituitary glands, this treatment is impractical on a clinical scale. Gonadotrophin-releasing-hormone provides a more physiological method of stimulation, and results of recent experiments using this hormone are reviewed.

In the pregnant mare, recent studies have shown that the “pregnancy signal” to the mare may be the production of oestrogens from the developing blastocyst from Day 14. Measurement of PMSG as an aid to pregnancy diagnosis is evaluated, and the use of progesterone supplementation to prevent abortion is discussed.