BACKGROUND: Utilization management ensures the appropriateness of laboratory testing by reducing the performance of tests which can be reasonably avoided with no adverse effects for the patient. Electronic gatekeeping, a utilization management tool, was introduced at Groote Schuur in 2010. Criteria were based on the minimum retesting interval, healthcare location, level of experience and discipline of the requesting clinician and specific ICD-10 codes. METHODS: A retrospective observational study assessing the effectiveness of electronic gatekeeping at Groote Schuur Hospital (Cape Town, South Africa), by comparing the test request volumes by using absolute test numbers and pre-defined ratios in the year prior to gatekeeping, to the two years following implementation. A secondary aim is to apply selected ratios to the other national academic hospitals to determine the potential for cost saving. RESULTS: At the medical wards of Groote Schuur Hospital there was an overall decrease in number and cost of tests of 24% per inpatient day for 2011. The most dramatic difference in cost is seen for chloride (91%) followed by HbA1c (90%), FT3 (89%) and CRP (82%). The application of ratios to Groote Schuur Hospital show a decrease in 2011 in all ratios apart from PCT: FBC+WCC (0.003 vs 0.002) and Mg: Ca (0.86 vs 0.84). AST: ALT remained the same at 0.55. This suggests overall effectiveness of the eGK rules although there is ongoing panel requesting. If the GSH eGK rules were to be applied at all other national academic hospitals, it could translate into a potential cost saving of $13 411 873.96 (R103 196 838.80) per annum. CONCLUSIONS: Electronic gatekeeping is an effective utilization management tool at Groote Schuur Hospital. It is relatively easy to implement and manage, and when combined with additional tools has the potential to result in larger reductions of unnecessary tests, cost savings and improved patient outcome.

Background: Chloride and adenosine deaminase measurements in cerebrospinal fluid are still sporadically requested as part of tuberculous meningitis work-up. In the literature, evidence is contradictory and opinion is divided on their utility in clinical practice. The accuracy of both for the early presumptive diagnosis of tuberculous meningitis was investigated in patients in a region with high prevalence of tuberculosis and HIV infection in order to inform a decision on whether to continue offering these tests to clinicians. Methods: A retrospective descriptive study of diagnostic accuracy was conducted at the National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa. Data were collected on all cerebrospinal fluid specimens submitted for tuberculosis culture between 1 January 2012 and 31 December 2014. Chloride and adenosine deaminase concentrations were compared with automated liquid culture for Mycobacterium tuberculosis as the reference standard. Findings: There were 2531 cerebrospinal fluid specimens submitted for tuberculosis culture during the study period; exclusion of duplicates yielded 2081 specimens. Chloride was requested on 711 (34·2%) specimens; 44 (6·2%) were tuberculosis culture-positive. Adenosine deaminase was requested on 152 (7·3%) specimens; 20 (13·2%) were culture-positive. Chloride sensitivity (<120 mmol/L) for the detection of tuberculous meningitis was 93·2% (95% confidence interval 81·3-98·6), with specificity 62·4% (58·6-66·1), positive predictive value 14% (10·3-18·6), negative predictive value 99·3% (97·9-99·9), positive likelihood ratio 2·48 (2·18-2·81), and negative likelihood ratio 0·109 (0·037-0·326). Adenosine deaminase sensitivity (>6 U/L) was 70% (45·7-88·1), specificity 89·4% (82·8-94·1), positive predictive value 50% (30·6-69·4), negative predictive value 95·2% (89·8-98·2), positive likelihood ratio 6·6 (3·72-11·7), and negative likelihood ratio 0·336 (0·171-0·657). Interpretation: In this patient population chloride and adenosine deaminase showed at best only modest performance as markers of tuberculous meningitis. However, very good negative predictive values could serve to identify patients highly unlikely to have the disease.

Includes bibliographical references (leaves 171-184). / Affected members of the family investigated in this dissertation presented with photosensitivity and raised red cell protoporphyrin concentrations, indicative of protoporphyria. Further examination of this family revealed features that were atypical of erythropoietic protoporphyria. These included a highly penetrant disease, disease severity as expressed by more prevalent hepatic complications, a preponderance of protoporphyrin in its zinc chelated form, a therapeutic response to iron supplementation, and an absence of mutations in the ferrochelatase gene or haplotype markers associated with erythropoietic protoporphyria. We have reviewed clinical data from this family, established a ferrochelatase enzyme assay in our laboratory, and shown normal ferrochelatase enzyme activity in affected subjects.

No description available.

For more than a decade, community groups, scientific organizations and government agencies have collaborated to repopulate the endangered western barred bandicoot (Perameles bougainville). While initially successful, the unexpected discovery of a papillomatosis and carcinomatosis syndrome in captive and wild populations of P. bougainville exposed a dearth of knowledge regarding their diseases. This dissertation addresses this issue through study of the clinical pathology, immunology, parasitology, and virology of P. bougainville. To facilitate the detection and understanding of diseases in P. bougainville, guidelines for interpreting haematology and clinical chemistry results were developed, including calculated species-specific reference intervals for plasma aspartate transaminase activity (20–283 U/L), haemoglobin (122-165 g/L), haematocrit (0.36-0.49 L/L), total leukocytes (2.9-14.9 x10^9/L), monocytes (0-0.6 x10^9/L), eosinophils (0-0.9 x10^9/L) and total protein (47-63 g/L) estimated by refractometry. P. bougainville immunoglobulin was also fractionated from plasma and inoculated into sheep to derive antiserum for serological screening assays. Arthropods, helminths and protozoa parasitic on P. bougainville were catalogued and Eimeria kanyana n. sp. was formally described. The pathogenic and zoonotic potential of bacteria detected in ticks parasitic on P. bougainville was also considered. The association between bandicoot papillomatosis carcinomatosis virus type 1 (BPCV1) and the western barred bandicoot papillomatosis and carcinomatosis syndrome was investigated using PCR, in situ hybridization and virus isolation. Optimized in situ hybridization techniques demonstrated BPCV1 DNA within keratinocyte and sebocyte nuclei, and BPCV1 mRNA within the cytoplasm. BPCV1 virions were isolated by ultracentrifugation and visualized with negative stain transmission electron microscopy revealing icosahedral, non-enveloped viral capsids ~47 nm in diameter, comparable to viruses classified within Papillomaviridae and Polyomaviridae. A novel virus, tentatively named bandicoot papillomatosis carcinomatosis virus type 2 (BPCV2) was discovered in papillomatous lesions from a southern brown bandicoot (Isoodon obesulus). It had a circular double-stranded DNA genome of 7277 bp, and encoded two papillomavirus-like structural proteins, L1 and L2, and two polyomavirus-like putative transforming proteins, large T antigen and small t antigen. DNA and RNA in situ hybridization confirmed the presence of BPCV2 nucleic acids within lesion biopsies. The discovery of the bandicoot papillomatosis carcinomatosis viruses has provoked reassessment of the established virus taxonomy paradigm, theories of virus-host co-speciation and bandicoot population management strategies.

The field of medical informatics comprises many subdisciplines, united by a common interest in the establishment of standards to facilitate the sharing, reuse, and understanding of information. This work depends in large part on the ability of controlled medical terminologies to represent relevant concepts. This work augments a controlled terminology to provide not only standardized content, but also standardized explanatory knowledge for use in expert systems. This experiment consisted of four phases centered on the use of the controlled terminology-- Systemized Nomenclature of Medicine (SNOMED). The first phase evaluated SNOMED's ability to express explanatory knowledge for clinical pathology. The second developed the Normalized Medical Explanation (NORMEX) syntax for expressing and storing pathways of causal reasoning in the domain of clinical pathology. The third segment examined SNOMED's capacity to represent concepts used in the NORMEX model of clinical pathology. The final phase incorporated NORMEX-based pathways of influence in a Bayesian network to assess ability to predict causal mechanisms as implied by serum analyte results. Findings from this work suggest that SNOMED's capacity to represent explanatory information parallels its coverage of clinical pathology findings. However, SNOMED currently lacks much of the content necessary for both of these purposes. Additional explanatory content was created with an ontology-modeling tool. The NORMEX syntax was defined by SNOMED hierarchy names. Complex sequences of explanations were created using the NORMEX syntax. In addition, medical explanatory knowledge represented in the NORMEX format could be stored in an architectural framework consistent with that used by a controlled terminology such as SNOMED. Once stored, such knowledge could be retrieved from storage without loss of meaning or introduction of errors. Lastly, a Bayesian network constructed from the retrieved NORMEX knowledge produced a network whose prediction performance equaled or exceeded that of a network produced by more traditional means. / Ph. D.

Submitted by Erika Demachki (erikademachki@gmail.com) on 2014-10-14T17:05:51Z No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2014-10-16T18:46:31Z (GMT) No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-10-16T18:46:31Z (GMT). No. of bitstreams: 2 Dissertação - Thaís Domingos Meneses - 2013.pdf: 1894235 bytes, checksum: 41d8ee83924f2c998abe4f713c7f8f16 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-10-15 / Studies have shown that periodontal disease affects approximately 85 % of dogs older than three years of age, being responsible for inflammation and destruction of the tooth supporting tissues. This study aimed at evaluating the relationship between periodontal disease and glomerulonephritis in dogs. We evaluated and classified 61 dogs with periodontal disease into groups according to the severity of the case. Clinical evaluation consisted of complete blood count, serum biochemistry (urea, creatinine, total protein, albumin, cholesterol and phosphorus), blood pressure measurement, urinalysis and urinary biochemistry (GGT, ALP, protein and creatinine), and determination of urine protein:creatinine ratio. Of the 14 dogs with glomerulonephritis compatible alterations at the first exam, nine were submitted to a second laboratory evaluation, after periodontal treatment, in order to verify if they continued with persistent proteinuria associated with inactive urinary sediment. Of these, eight dogs continued to show abnormalities suggestive of glomerulonephritis, even after periodontal treatment. The diagnostic tools used in this study allowed to identify and characterize both glomerulonephritis secondary to periodontal disease, establishing a relationship between them and tubular damage and urinary tract infections that occur concurrently with periodontal disease. These findings help to establish the use of early markers of kidney injury in clinical laboratory tests, in order to prevent the process evolution, promoting animal welfare and contributing to increase longevity of dogs. / Estudos mostram que a doença periodontal acomete cerca de 85% de cães acima dos três anos de idade, sendo responsável pela inflamação e destruição dos tecidos de sustentação do dente. Este estudo teve como objetivo avaliar a relação existente entre a doença periodontal e a glomerulonefrite em cães. Sessenta e um cães com doença periodontal foram avaliados e classificados em grupos, conforme a gravidade, além da avaliação clínica foram realizados hemograma, bioquímica sérica (ureia, creatinina, proteínas totais, albumina, colesterol e fósforo), mensuração da pressão arterial, urinálise e bioquímica urinária (GGT, ALP, proteína e creatinina), com determinação da razão proteína:creatinina urinária. Dos 14 cães com alterações compatíveis para glomerulonefrite neste primeiro exame, após o tratamento periodontal, nove deles foram submetidos a uma segunda avaliação laboratorial, com o intuito de verificar se continuavam com a proteinúria persistente associado ao sedimento urinário inativo. Destes, oito cães continuaram apresentando alteração sugestiva de glomerulonefrite, mesmo após a realização do tratamento periodontal. As ferramentas de diagnóstico utilizadas em conjunto neste estudo permitiram identificar e caracterizar a glomerulonefrite secundária à doença periodontal, estabelecendo uma relação entre elas, além dos danos tubulares e infecções do trato urinário que ocorrem concomitantemente à doença periodontal. Esse conhecimento auxilia na instituição do uso de marcadores precoces de lesão renal na prática clínica de exames laboratoriais, com a finalidade de impedir a evolução do processo, promovendo bem-estar animal e contribuindo para o aumentando da longevidade dos cães.

A significant growth of rhea breeding has been happening in the last years, but there is still a lack of information about this specie. Thus, this study had the objectives of determining rheas reference range of electrophoresis, to verify differences due to age. Some parameters were evaluated in 45 rheas, grouped into four categories: G1 (n=10), animals with 15 days of age; G2 (n=10), animals with 30 days of age; G3 (n=10), animals with 45 days of age and G4 (n=15), animals with 1 year of age. Were verified homogeneity in the electrophoresis parameters analyzed in the birds inside of each age group. Differences were verified among groups of age in PPT, albumin, globulins and relationship albumin/globulin values. Also difference among groups for the α1, α2, β and γ fractions. Comparison among studied parameters with other avian species observed in the literature demonstrated that most values are not similar and they may not be used as pattern to this specie. / A criação de emas vem crescendo em todo Brasil nos últimos anos, porém ainda há uma escassez de informações sobre esta espécie. O presente trabalho teve como objetivos determinar os valores de referência da eletroforese em emas e verificar as diferenças existentes entre as faixas etárias. Tais parâmetros foram analizados em 45 emas, divididos em quatro grupos: grupo 1 (n=10), animais com 15 dias de idade; grupo 2 (n=10), animais com 30 dias de idade; grupo 3 (n=10), animais com 45 dias de idade e grupo 4 (n=15), animais com 1 ano de idade. Verificaram-se homogeneidade nos parâmetros de eletroforese analisados nas aves dentro de cada faixa etária. Houve diferença entre grupos etários em valores de PPT, albumina, globulinas e relação albumina/globulinas. Também houve diferença entre grupos para as frações α1, α2, β e γ. A comparação dos parâmetros estudados com os de outras espécies aviárias, compilados na literatura, indicou que a maioria dos parâmetros são distintos, não devendo ser utilizados, os valores da literatura, como padrões para emas.

Submitted by (edna.saturno@ufrpe.br) on 2016-10-14T15:16:10Z No. of bitstreams: 1 Kilder Henrique Guimaraes Alves.pdf: 610195 bytes, checksum: f77f942b9f6fec9c41704abdd022e4a2 (MD5) / Made available in DSpace on 2016-10-14T15:16:11Z (GMT). No. of bitstreams: 1 Kilder Henrique Guimaraes Alves.pdf: 610195 bytes, checksum: f77f942b9f6fec9c41704abdd022e4a2 (MD5) Previous issue date: 2008-10-08 / Ten Santa Inês lambs were used to study the effects of cumulative copper poisoning and the treatment with ammonium tetrathiomolybdate (TTM) on clinical profile, blood gas and oxidative metabolism. The lambs were drenched with increasing doses of copper sulfate until the onset of macroscopic hemoglobinuria. So the lambs were randomly distributed in two groups of five sheep each and treated (TTM) or not (C) with tetrathiomolybdate (3.4 mg/kg BW/ per day, for four days). All sheep C succumbed in four days of hemoglobinuria, while only one lamb died in the other group. The poisoning caused a typical clinical picture, creating major changes in various clinical parameters, together with determination of metabolic disorder, characterized by respiratory acidosis and metabolic alkalosis. With regard to the framework toxic oxidative metabolism caused intense formation of free radicals, showing a high serum malondialdehyde, reduction in the level of erythrocyte glutathione reduced, and increased the capacity anti-oxidant in plasma. High copper concentration in blood resulted in larger lipoperoxidation. The appropriate use of TTM in this status provided reduction in the formation of free radicals, increased the concentration of reduced erythrocyte glutathione, and also promoted gradual improvement of the clinical signs, clinical and gasometrical profile. / Para avaliar a influência da intoxicação cúprica cumulativa e do seu tratamento com tetratiomolibdato de amônia (TTM) no perfil clínico, hemogasométrico e metabolismo oxidativo, foram utilizados 10 cordeiros da raça Santa Inês que receberam doses crescentes de sulfato de cobre, até o surgimento de hemoglobinúria macroscópica. Neste momento foram distribuídos ao acaso cinco ovinos para cada um dos dois grupos; o primeiro foi mantido como controle (C) e o grupo subseqüente (TTM) tratado diariamente, no decorrer de quatro dias, com 3,4 mg TTM por kg de peso vivo. Todos os ovinos do grupo C sucumbiram no decorrer de quatro dias, enquanto que tal fato só ocorreu em um animal tratado com TTM. A intoxicação provocou um quadro clínico típico, gerando grandes alterações em diferentes parâmetros físicos, concomitantemente com determinação de distúrbio metabólico, caracterizado por acidose respiratória e alcalose metabólica. No tocante ao metabolismo oxidativo o quadro tóxico provocou intensa formação de radicais livres, representada por elevada concentração sérica de malondialdeído, redução no teor de glutationa reduzida eritrocitária, embora tenha aumentado a capacidade antioxidante no plasma. Quanto maior foi à concentração de cobre livre no sangue maior foi a lipoperoxidação. O uso adequado de TTM na intoxicação cúprica cumulativa em ovinos propiciou redução na formação de radicais livres, aumento da glutationa reduzida eritrocitária, melhora gradual do quadro clínico e dos sinais clínicos e hemogasométrico.

Veterinary students face the difficult task of learning to classify clinical laboratory data. In an effort to make this task easier, a computer and web based tool known as the Problem List Generator (PLG) was designed based on current literature dealing with learning theory and medical education which are reviewed in chapter 1. Chapter 2 describes the design and the development process for the PLG. The PLG allows the students to access any number of cases (determined by the professor) of increasing complexity which provide signalment, history, physical exam, and laboratory data for a number of patients. Using the PLG, students analyze the data, identify data abnormalities and mechanisms, arrange them in a problem list, diagnose the problem, and compare their problem list and diagnosis to an expert problem list and diagnosis. The PLG was evaluated using a four step evaluation process involving an expert review, one-to-one evaluations, small group evaluations, and a two-part field trial, and was evaluated in terms of clarity, feasibility, and impact. The PLG is usable, in terms of clarity and feasibility, though fixes are recommended. There is no evidence to infer, statistically, that the PLG has any effect on learning outcomes. However, trends in the quantitative data and logical inference based on the context of the evaluation suggest that the PLG might help students, particularly those of low and average ability to produce more accurate problem lists. / Ph. D.