Clinical features and risk factors of oedematous Mycobacterium ulcerans lesions in an Australian population: beware cellulitis in an endemic area

Introduction
Oedematous lesions are a less common but more severe form of Mycobacterium ulcerans disease. Misdiagnosis as bacterial cellulitis can lead to delays in treatment. We report the first comprehensive descriptions of the clinical features and risk factors of patients with oedematous disease from the Bellarine Peninsula of south-eastern Victoria, Australia.

Methods
Data on all confirmed Mycobacterium ulcerans cases managed at Barwon Health, Victoria, were collected from 1/1/1998–31/12/2012. A multivariate logistic regression model was used to assess associations with oedematous forms of Mycobacterium ulcerans disease.

Results
Seventeen of 238 (7%) patients had oedematous Mycobacterium ulcerans lesions. Their median age was 70 years (IQR 17–82 years) and 71% were male. Twenty-one percent of lesions were WHO category one, 35% category two and 41% category three. 16 (94%) patients were initially diagnosed with cellulitis and received a median 14 days (IQR 9–17 days) of antibiotics and 65% required hospitalization prior to Mycobacterium ulcerans diagnosis. Fever was present in 50% and pain in 87% of patients. The WCC, neutrophil count and CRP were elevated in 54%, 62% and 75% of cases respectively. The median duration of antibiotic treatment was 84 days (IQR 67–96) and 94% of cases required surgical intervention. On multivariable analysis, there was an increased likelihood of a lesion being oedematous if on the hand (OR 85.62, 95% CI 13.69–535.70; P<0.001), elbow (OR 7.83, 95% CI 1.39–43.96; p<0.001) or ankle (OR 7.92, 95% CI 1.28–49.16; p<0.001), or if the patient had diabetes mellitus (OR 9.42, 95% CI 1.62–54.74; p = 0.02).

Conclusions
In an Australian population, oedematous Mycobacterium ulcerans lesions present with similar symptoms, signs and investigation results to, and are commonly mistakenly diagnosed for, bacterial limb cellulitis. There is an increased likelihood of oedematous lesions affecting the hand, elbow or ankle, and in patients with diabetes.

Taking the sting out of darting : Risks, restraint drugs and procedures for the chemical restraint of Southern Hemisphere otariids

The need to manage otariid populations has necessitated the development of a wide range of capture methods. Chemical restraint by remote drug delivery (i.e., darting) is a highly selective method that can be used to facilitate otariid capture in a range of scenarios, when other methods may be impracticable. However, the risks associated with darting otariids are not widely known and guidelines necessary to promote and refine best practice do not exist. We review the risks associated with darting and in light of our findings, develop darting guidelines to help practitioners assess and minimize risks during capture, anesthesia and recovery. Published studies reveal that mortalities associated with darting predominantly result from complications during anesthetic maintenance (e.g., prolonged respiratory depression, apnea, or hyperthermia), rather than from complications during capture or recovery. In addition to monitoring vital signs and proper intervention, the risk of irreversible complications during anesthesia can be reduced by administering drug doses that are sufficient to enable the capture and masking of animals, after which anesthetic depth can be regulated using gas anesthesia.

Evaluation of nurses' perceptions of the impact of targeted depression education and a screening and referral tool in an acute cardiac setting.

AIMS AND OBJECTIVES: The aim of this study was to evaluate nurses' perceptions of an education programme and screening and referral tool designed for cardiac nurses to facilitate depression screening and referral procedures for patients with coronary heart disease. BACKGROUND: There is a high prevalence of depression in patients with coronary heart disease that is often undetected. It is important therefore that nurses working with cardiac patients are equipped with the knowledge and skills to recognise the signs and symptoms of depression and refer appropriately. DESIGN: A qualitative approach with purposive sampling and semi-structural interviews was implemented within the Donabedian 'Structure-Process-Outcome' evaluation framework. METHODS: Semi-structured interviews were conducted with 14 cardiac nurses working in a major metropolitan hospital six weeks post-attending an education programme on depression and coronary heart disease. Thematic data analysis was implemented, specifically adhering to Halcomb and Davidson's (2006) pragmatic data analysis, to examine nurse knowledge and experience of depression assessment and referral in an acute cardiac ward. RESULTS: The key findings of this study were that the education programme: (1) increased the knowledge base of nurses working with cardiac patients on comorbid depression and coronary heart disease, and (2) assisted in the identification of depression and the referral of 'at risk' patients. CONCLUSIONS: Emphasis was placed on the translational significance of educating cardiac nurses about depression via the introduction of a depression screening and referral instrument designed specifically for use in the cardiac ward. As a result, participants found they were better equipped to identify depressive symptoms and, guided by the screening instrument, to confidently instigate referral procedures. RELEVANCE TO CLINICAL PRACTICE: Much complexity lies in caring for cardiac patients with depression, including issues such as misdiagnosis. Targeted education, including use of appropriate instruments, has the potential to facilitate early recognition of the signs and symptoms of depression in the acute cardiac setting.

Foot-and-mouth disease in red deer - experimental infection and test methods performance

Summary: The aim of this study was to evaluate a number of foot-and-mouth disease (FMD) test methods for use in red deer. Ten animals were intranasally inoculated with the FMD virus (FMDV) O UKG 11/2001, monitored for clinical signs, and samples taken regularly (blood, serum, oral swabs, nasal swabs, probang samples and lesion swabs, if present) over a 4-week period. Only one animal, deer 1103, developed clinical signs (lesions under the tongue and at the coronary band of the right hind hoof). It tested positive by 3D and IRES real-time reverse transcription polymerase chain reaction (rRT-PCR) in various swabs, lesion materials and serum. In a non-structural protein (NSP) in-house ELISA (NSP-ELISA-IH), one commercial ELISA (NSP-ELISA-PR) and a commercial antibody NSP pen side test, only deer 1103 showed positive results from day post-inoculation (dpi) 14 onwards. Two other NSP-ELISAs detected anti-NSP serum antibodies with lower sensitivity. It also showed rising antibody levels in the virus neutralization test (VNT), the in-house SPO-ELISA-IH and the commercial SPO-ELISA-PR at dpi 9, and in another two commercial SPO-ELISAs at dpi 12 (SPO-ELISA-IV) and dpi 19 (SPO-ELISA-IZ), respectively. Six of the red deer that had been rRT-PCR and antibody negative were re-inoculated intramuscularly with the same O-serotype FMDV at dpi 14. None of these animals became rRT-PCR or NSP-ELISA positive, but all six animals became positive in the VNT, the in-house SPO-ELISA-IH and the commercial SPO-ELISA-PR. Two other commercial SPO-ELISAs were less sensitive or failed to detect animals as positive. The rRT-PCRs and the four most sensitive commercial ELISAs that had been used for the experimentally inoculated deer were further evaluated for diagnostic specificity (DSP) using 950 serum samples and 200 nasal swabs from non-infected animals. DSPs were 100% for the rRT-PCRs and between 99.8 and 100% for the ELISAs.

Muscle damage and inflammation during recovery from exercise

Unaccustomed exercise consisting of eccentric (i.e., lengthening) muscle contractions often results in muscle damage characterized by ultrastructural alterations in muscle tissue, clinical signs and symptoms (e.g., reduced muscle strength and range of motion, increased muscle soreness and swelling, efflux of myocellular proteins). The time course of recovery following exercise-induced muscle damage depends on the extent of initial muscle damage, which in turn is influenced by the intensity and duration of exercise, joint angle/muscle length and muscle groups used during exercise. The effects of these factors on muscle strength, soreness and swelling are well characterized. By contrast, much less is known about how they affect intramuscular inflammation and molecular aspects of muscle adaptation/remodeling. Although inflammation has historically been viewed as detrimental for recovery from exercise, it is now generally accepted that inflammatory responses-if tightly regulated-are integral to muscle repair and regeneration. Animal studies have revealed that other cell types including mast cells, eosinophils, CD8 and T regulatory lymphocytes, fibro-adipogenic progenitors and pericytes also help to facilitate muscle tissue regeneration. However, more research is required to determine whether these cells respond to exercise-induced muscle damage. A large body of research has investigated the efficacy of physicotherapeutic, pharmacological and nutritional interventions for reducing the signs and symptoms of exercise-induced muscle damage, with mixed results. More research is needed to examine if/how these treatments influence inflammation and muscle remodeling during recovery from exercise.