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This study was carried out in order to identify acanthocephalan species complexes, based on morphological variability, infecting Barbonymus schwanenfeldii from Lake Kenyir, Terengganu, Malaysia. Acanthocephala were fixed in ethanol, stained with aceto-carmine and studied morphologically by using a light microscope. Variation in morphological traits such as proboscis, proboscis receptacle, egg, testes shape and location, number of hooks and cement gland has been traditionally used to diagnose the acanthocephalans species but the delimitations between closely related species are still confusing and are always questionable among taxonomists. Molecular analysis was used for support the identification. Morphological variability prospecting reveals the presence of three different new species complexes from the subgenus Acanthosentis by referring published taxonomic keys. These new species may be distinguished from the other 46 described species of Acanthosentis by having six unique structures: the presence of an anterior parareceptacle structure (PRS); vaginal sleeve structure; a paired lateral, cone-shaped, muscular jacket surrounding the vagina; alternating pattern and size of proboscis hooks, variation in proboscis size and shape; the presence of the circular collar ring around the neck between the proboscis and trunk and lastly the presence of a muscular-like structure attached to the collar ring on the proboscis. These acanthocephalans found in the intestine of B. schwanenfeldii in Kenyir Lake Malaysia represent new species, named Acanthogyrus ( Acanthosentis) kenyirensis n.sp., A. ( A.) terengganuensis n.sp. and A. ( A.) tembatensis n. sp.

ObjectiveAdvances in medical discoveries have bolstered expectations of precise and complete care, but delivering on such a promise for complex, chronic neurologic care delivery requires solving last-mile challenges. We describe the iterative human-centered design and pilot process for multiple sclerosis (MS) NeuroShare, a digital health solution that brings practical information to the point of care so that clinicians and patients with MS can view, discuss, and make informed decisions together.MethodsWe initiated a comprehensive human-centered process to iteratively design, develop, and implement a digital health solution for managing MS in the routine outpatient setting of the nonprofit Sutter Health system in Northern California. The human-centered codesign process included 3 phases: discovery and design, development, and implementation and pilot. Stakeholders included Sutter Health's Research Development and Dissemination team, academic domain experts, neurologists, patients with MS, and an advisory group.ResultsMS NeuroShare went live in November 2018. It included a patient- and clinician-facing web application that launches from the electronic health record, visually displays a patient's data relevant to MS, and prompts the clinician to comprehensively evaluate and treat the patient. Both patients and clinicians valued the ability to jointly view patient-generated and other data. Preliminary results suggest that MS NeuroShare promotes patient-clinician communication and more active patient participation in decision-making.ConclusionsLessons learned in the design and implementation of MS NeuroShare are broadly applicable to the design and implementation of digital tools aiming to improve the experience of delivering and receiving high-quality care for complex, neurologic conditions across large health systems.

IN BRIEF Chronic conditions such as diabetes are largely managed by primary care providers (PCPs), with significant patient self-management. This article describes the development, pilot testing, and fine-tuning of a Web-based digital health solution to help PCPs manage patients with cardiometabolic diseases during routine office encounters. It shows that such products can be successfully integrated into primary care settings when they address important unmet needs and are developed with input from end-users.

Epizootic ulcerative syndrome (EUS), caused by the water mould (Oomycota) Aphanomyces invadans, has spread throughout the world’s major continents over the last 50 years, with the apparent exception of South and Central America. With over 160 susceptible fish species representing 54 families and 16 orders recorded to date, EUS is of international concern and infection with A. invadans is a World Organisation for Animal Health (OIE) listed disease. This paper examines what little has been reported on the impacts of EUS on subsistence fisheries and wildlife, or what can be deduced about those impacts, and concludes that there is a need for systematic data collection on the size and socio-economic importance of subsistence fisheries. Such fisheries are often relied upon by the poorest communities, thus food and nutrition security impacts can be significant. Similarly, impacts on wildlife are poorly documented, emphasising the lack of, and the need for, research on and modelling of the ecosystem-level impacts of EUS and other aquatic animal diseases. The history of EUS and several other aquatic animal diseases also brings into question the effectiveness of current measures for controlling the international spread of aquatic animal diseases and calls for a re-think on how best to meet this ongoing challenge.

The endemic green-lipped mussel (GLM) Perna canaliculus is a key cultural and economic species for New Zealand. Unlike other cultured shellfish species, GLMs have experienced relatively few disease issues. The apparent absence of diseases in both wild and farmed GLM populations does not preclude risks from environmental changes or from the introduction of overseas mussel pathogens and parasites. Potential for disease exchange between the GLM and other mytilid species present in New Zealand has yet to be elucidated. After reviewing and discussing relevant scientific literature, we present an initial assessment of GLM vulnerability to disease threats and the potential risk pathways for mussel pathogens and parasites into New Zealand and highlight a number of challenges. These include knowledge gaps relevant to GLM susceptibility to exotic pathogens and parasites, risk pathways into New Zealand and biosecurity risk associated with domestic pathways. Considerations and findings could potentially apply to other farmed aquatic species with limited distribution range and/or low disease exposure.

Farmed New Zealand Chinook salmon Oncorhynchus tshawytscha Walbaum have been found to be infected by rickettsia-like organisms (NZ-RLO). While these Gram-negative intra-cellular bacteria are closely related to Piscirickettsia salmonis, a significant pathogen for farmed salmon globally, the pathogenicity of NZ-RLO is unknown. The aim of the present study was to determine if one strain, NZ-RLO2, causes disease in Chinook salmon. Post-smolt salmon were inoculated with NZ-RLO2 by intraperitoneal injection at high, medium and low doses and observed for 30 d. All fish in the high and medium dosed groups died by the end of the study and 63% of the low dose group died within 30 d of inoculation. Necropsy revealed the fish inoculated with NZ-RLO2 had internal multifocal haemorrhages. The most consistent histological finding in fish inoculated with NZ-RLO2 was neutrophilic and necrotizing pancreatitis and steatitis with intra-cytoplasmic organisms often visible within areas of inflammation. Other histological lesions included multifocal hepatic necrosis, haematopoietic cell necrosis and splenic and renal lymphoid depletion. The presence of NZ-RLO2 within the inoculated fish was confirmed by replication in cell culture and qPCR. The results suggest NZ-RLO2 can cause disease in Chinook salmon and therefore could be a significant pathogen in farmed Chinook salmon.

With the growing importance of aquaculture worldwide, characterization of the microbiota of high-value aquaculture species and identification of their shifts induced by changes in fish physiology or nutrition is of special interest. Here we report the first 16S rRNA gene metabarcoding survey of the mid-intestinal bacteria of Chinook salmon (Oncorhynchus tshawytscha), an economically important aquacultured species. The microbiota of 30 farmed Chinook salmon from a single cohort was surveyed using metabarcode profiling of the V3-V4 hypervariable region of the bacterial 16S rRNA gene. Seawater, feed and mid-intestinal samples and controls were sequenced in quadruplicate to assess both biological and technical variation in the microbial profiles. Over 1000 operational taxonomic units were identified within the cohort, providing a first glimpse into the mid-intestinal microbiota of farmed Chinook salmon. The taxonomic distribution of the salmon microbiota was reasonably stable, with around two thirds of individuals dominated by members of the family Vibrionaceae. We anticipate that the workflow presented in this paper could be applied in other aquacultured fish species to capture variation or dysbiosis occurring as a result of changes in feed, health or environmental conditions.

From 2011, lamprey (Geotria australis) populations in Southland, New Zealand have been affected by reddening along the length of the body and increased mortalities, termed lamprey reddening syndrome (LRS). Molecular testing, bacteriology, histopathology and epidemiology were used to determine if an infectious agent was present and to increase the understanding of this syndrome. An atypical Aeromonas salmonicida was detected from affected lamprey in 2011. This organism has not previously been reported from New Zealand. Investigative molecular testing indicated the organism was an uncharacterised, unculturable, atypical A. salmonicida and a likely incidental finding. Histopathology did not indicate an infectious process was involved, but suggested the reddening may be due to blunt trauma. Epidemiological investigation found the Mokoreta River had a significantly higher prevalence of LRS than others in the Southland region, but there was no clear reason why. To date, no infectious aetiology for this syndrome has been identified.

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC B Y. Published by BMJ.

A total of 777 fish from three growing regions of New Zealand Chinook salmon farms comprising of five sites were tested. Quantitative PCR was used to determine the distribution of New Zealand rickettsia-like organism and Tenacibaculum maritimum. Genetic information from these bacteria were then compared with strains reported worldwide. Using this information, suggested associations of pathogens with clinically affected fish were made. NZ-RLO was detected in two of the three regions, and T. maritimum was detected in all regions. Three strains of NZ-RLO were identified during this study. Based on analysis of the ITS rRNA gene, NZ-RLO1 appears to be part of an Australasian grouping sharing high similarity with the Tasmanian RLO, NZ-RLO2 was shown to be the same as an Irish strain, and NZ-RLO3 was shown be closely related to two strains from Chile. Based on multi-locus sequence typing, the New Zealand T. maritimum was the same as Australian strains. NZ-RLOs were detected more frequently in fish with skin ulcers than fish without skin ulcers. While additional research is required to investigate the pathogenicity of these organisms, this is the first time that NZ-RLOs have been associated with the development of clinical infections in farmed Chinook salmon.

Context Both adherence and outcomes are more difficult to measure in patients with multiple sclerosis (MS) than in patients with diseases such as hypertension, for which most medications are taken orally and surrogate outcomes (eg, blood pressure) are routinely collected. Objectives To characterize the adherence and outcomes of patients with MS within a large integrated health system and to assess the relationship between adherence and outcomes. Study Design Retrospective review of adherence and health care utilization outcomes via electronic health records and claims (2004-2013) combined with a prospective survey regarding adherence and functional outcomes (2012-2013). Methods Retrospectively, medication possession ratios were calculated, and adherence groups were compared regarding health care utilization and costs. Prospectively, patients were recruited to complete questionnaires to measure self-reported adherence (SRA) and MS-specific outcomes, including the Multiple Sclerosis Impact Scale (MSIS), the Kurtzke Expanded Disability Status Scale (EDSS), and the Treatment Satisfaction Questionnaire for Medication (TSQM). Regression was used to statistically test for differences in these outcomes among adherence groups. Results A total of 681 patients were studied. Most patients (307 of 375 [82%] in the retrospective cohort and 244 of 306 [89%] in the prospective cohort) had greater that 80% adherence to their MS medications. Mean inpatient days per patient for MS-related admissions was highest for high-adherence than for intermediate and low-adherence patients (0.52 vs 0.23 and 0.34, respectively; PPPP Conclusions The findings of this study indicate that patients with MS are mostly adherent to their existing treatments. Patients with greater medication adherence may have increased cost, but their physical outcomes are better. This finding may shed light on other chronic disease entities and how we view the success of treatments.

Gas bubble disease (GBD) is a non‐infectious condition in aquatic organisms caused by supersaturated levels of total dissolved gas (TDG) in water (Bouck, 1980). GBD is analogous to “the bends” (decompression sickness) in human scuba divers (Barratt, Harch, & Van Meter, 2002). In fish, the disease can manifest externally as bubbles on the eyes, opercula, fins, body and mouth regions, and internally as bubbles in the blood and on gill arches (Espmark, Hjelde, & Baeverfjord, 2010). GBD has also been reported in invertebrates, including in shrimp, blue crab, oysters and clams (Johnson, 1976; Lightner, Salser, & Wheeler, 1985; Malouf, Keck, Maurer, & Epifanio, 1972). The effects of GBD can range from mild to lethal depending on the level of TDG supersaturation, the species affected, life history stage, animal health, depth distribution and water temperature (Beeman et al., 2003; Johnson, 1976; Smiley, Drawbridge, Okihiro, & Kaufmann, 2011)...

An investigation was conducted to identify the cause of mortalities in freshwater reared Chinook salmon (Oncorhynchus tshawytscha). Mortalities occurred in juvenile salmon, at a salmon rearing facility in the South Island of New Zealand. The affected fish were from a pen inside the facility with no surrounding pens or other year classes affected.Clinically affected fish presented with skin lesions. The majority of skin lesions were unruptured, boil-like, raised circular masses up to 4 cm in diameter, particularly on the dorsolateral aspects and the flank. A number of fish presented with large ulcers resulting from rupturing of the raised lesions described above. This clinical presentation showed similarities to that of furunculosis caused by typical Aeromonas salmonicida, a bacterium exotic to New Zealand.Samples were taken from two representative fish in the field for histopathology, bacterial culture and molecular testing. Histopathological findings included granulomatous lesions in the kidney, liver, spleen and muscle. When stained with Fite-Faraco modified acid fast stain filamentous branching rods were identified within these granulomas. Following bacterial culture of kidney swabs pure growth of small white matt adherent colonies was observed. This isolate was identified as a Nocardia species by biochemical testing and nucleotide sequencing of the partial 16S rRNA gene. All samples were negative for A. salmonicida based on bacterial culture and PCR testing.Nocardiosis caused by a Nocardia species.Nocardiosis in these fish was caused by a previously undescribed Nocardia species that differs from the species known to be pathogenic to fish: N. asteroides, N. salmonicida and N. seriole. This bacterium is likely to be a new or unnamed environmental species of Nocardia that has the potential to cause disease in Chinook salmon under certain conditions. The clinical presentation of this Nocardia species manifested as raised, boil-like skin lesions which has similarities to the presentation of furunculosis caused by the bacterium typical A. salmonicida, a species exotic to New Zealand.

In the summer months of 2015 Chinook salmon, Oncorhynchus tshawytscha (Walbaum), were submitted to the New Zealand Ministry for Primary Industries (MPI) for disease investigation. Gross examination of 10 moribund fish revealed multiple areas of ulceration over all areas of the body including fins and mouth in eight of the 10 fish. Pale livers (n = 4), mottled appearance of the kidney (n = 5) and reddening of the distal intestines (n = 5) were also observed. As these fish presented with skin lesions, Piscirickettsia salmonis was included as a differential diagnosis. Testing for this agent was conducted and a rickettsia-like organism (RLO) was detected by histopathology in seven fish and by molecular methods in three fish. Nucleic acid sequencing revealed that this organism had highest similarity to a piscirickettsia-like organism with a 19 base pair (bp) deletion in the internal transcribed spacer (ITS) region of the rDNA operon when compared to the reference strain P. salmonis, LF-89 (ATCC VR-1361...

Objective: We describe how electronic health record (EHR) audit files can be used to understand how time is spent in primary care (PC). Materials/methods: We used audit file data from the Geisinger Clinic to quantify elements of the clinical workflow and to determine how these times vary by patient and encounter factors. We randomly selected audit file records representing 36 437 PC encounters across 26 clinic locations. Audit file data were used to estimate duration and variance of: (1) time in the waiting room, (2) nurse time with the patient, (3) time in the exam room without a nurse or physician, and (4) physician time with the patient. Multivariate modeling was used to test for differences by patient and by encounter features. Results: On average, a PC encounter took 54.6 minutes, with 5 minutes of nurse time, 15.5 minutes of physician time, and the remaining 62% of the time spent waiting to see a clinician or check out. Older age, female sex, and chronic disease were associated with longer wait times and longer time with clinicians. Level of service and numbers of medications, procedures, and lab orders were associated with longer time with clinicians. Late check-in and same-day visits were associated with shorter wait time and clinician time. Conclusions: This study provides insights on uses of audit file data for workflow analysis during PC encounters. Discussion: Scalable ways to quantify clinical encounter workflow elements may provide the means to develop more efficient approaches to care and improve the patient experience.

Background Activity or audit log data are required for EHR privacy and security management but may also be useful for understanding desktop workflow. Objective We determined if the EHR audit log file, a rich source of complex time-stamped data on desktop activities, could be processed to derive primary care provider (PCP) level workflow measures. Methods We analyzed audit log data on 876 PCPs across 17,455 ambulatory care encounters that generated 578,394 time-stamped records. Each individual record represents a user interaction (e.g., point and click) that reflects all or part of a specific activity (e.g., order entry access). No dictionary exists to define how to combine clusters of sequential audit log records to represent identifiable PCP tasks. We determined if PARAFAC2 tensor factorization could: (1) learn to identify audit log record clusters that specifically represent defined PCP tasks; and (2) identify variation in how tasks are completed without the need for ground-truth labels. To interpret the result, we used the following PARAFAC2 factors: a matrix representing the task definitions and a matrix containing the frequency measure of each task for each encounter. Results PARAFAC2 automatically identified 4 clusters of audit log records that represent 4 common clinical encounter tasks: (1) medications’ access, (2) notes’ access, (3) order entry access, and (4) diagnosis modification. PARAFAC2 also identified the most common variants in how PCPs accomplish these tasks. It discovered variation in how the notes’ access task was done, including identification of 9 distinct variants of notes access that explained 77% of the input data variation for notes. The discovered variants mapped to two known workflows for notes’ access and to two distinct PCP user groups who accessed notes by either using the Visit Navigator or the Wrap-Up option. Conclusions Our results demonstrate that EHR audit log data can be rapidly processed to create higher-level constructed features that represent time-stamped PCP tasks.

With the growing importance of aquaculture worldwide, characterisation of the microbial flora of high-value aquaculture species and identification of gut flora shifts induced by changes in fish physiology or nutrition is of special interest.Here we report the first metabarcoding survey of the intestinal bacteria of Chinook salmon (Oncorhynchus tshawytscha), an economically important aquacultured species. The microbiota of 30 farmed Chinook salmon from a single cohort was surveyed using metabarcode profiling of the V3-V4 hypervariable region of the bacterial 16S rRNA gene. Seawater, feed and intestinal samples, and controls were sequenced in quadruplicate to assess both biological and technical variation in the microbial profiles.Over 1,000 operational taxonomic units (OTUs) were identified within the cohort, providing a first glimpse into the gut microbiota of farmed Chinook salmon. The taxonomic distribution of the salmon microbiota was reasonably stable, with around two thirds of individuals dominated by members of the familyVibrionaceae.This survey was performed amid a summer heat wave, during which the fish exhibited reduced feeding. Although the sampled fish appeared healthy, they had minimal intestinal content, and the observed intestinal flora may represent the microbiota of fasting and stressed fish. Limited comparison betweenMycoplasmaandVibriosequences from the Chinook salmon gut and published microbial sequences from the intestines of a variety of fish species (including Atlantic salmon) indicated that despite the starvation and temperature variations, the replacement ofVibriowithMycoplasmais occurring within expected ecological parameters and does not necessarily reflect colonisation by atypical microbes.DATA SUMMARYRaw sequences from Chinook salmon intestinal microbiome 16S survey generated on the Illumina platform are publically available through NCBI Sequence Read Archive (SRA) database:Bioproject PRJNA421844SRA study SRP134829https://www.ncbi.nlm.nih.gov/bioproject/PRJNA421844IMPACT STATEMENTAlthough 16S metabarcoding surveys are becoming routine, little is still known about the microbiota of fish. This is the first survey of the intestinal microbiota of Chinook salmon, a species native to the Pacific Northwest which is farmed in New Zealand and Chile. While most intestinal microbiota studies are performed on faecal material, we directly sampled the intestine epithelium and content.During the time of sampling, the farmed fish population was experiencing stress from a summer heat wave and had little intestinal content. Over 1,000 operational taxonomic units (OTUs) were identified within the intestines of the cohort, providing a first glimpse into the gut microbiota of farmed Chinook salmon.We believe this survey will be of interest not only to those interested in fish biology and aquaculture, but also as an addition to the ongoing debate in the literature on sampling and DNA extraction methods for challenging samples.

In November 2013 the Animal Health Laboratory, Ministry for Primary Industries, New Zealand, received a report of a grey mullet (Mugil cephalus) presenting reddish-white granular lesions across its body. Gross pathological examination revealed cyst-like lesions on the distal portion of the scales and proximal part of the fins. Giemsa-stained wet preparations of these lesions presumptively identified spores as Myxobolus sp. DNA sequencing of the 18S rRNA gene further identified these spores as Myxobolus episquamalis. This is the first report of Myxobolus episquamalis infecting M. cephalus from New Zealand.

While financial incentives to providers or patients are increasingly common as a quality improvement strategy, their impact on patient subgroups and health care disparities is unclear. To examine these patterns, we analyzed data from a randomized clinical trial of financial incentives to lower low-density lipoprotein (LDL) cholesterol levels in patients at risk for cardiovascular disease. Patients with higher baseline LDL experienced greater cholesterol reductions in the shared incentive arm (0.23 mg/dL per unit change in baseline LDL, 95% CI [−0.46, −0.00]) but were also less likely to have medication potency increases in the physician incentive arm ( OR = 0.98, 95% CI [0.97, 0.996]). Uninsured patients and those of race other than Black or White were less likely to have potency increases in the shared incentive arm ( OR = 0.15, 95% CI [0.03, 0.70] and OR = 0.09, 95% CI [0.01, 0.93], respectively). These findings suggest some differential response to incentives, particularly in the form of targeted medication changes.

This report documents an emerging trend of identification of Megalocytivirus-like inclusions in a range of ornamental fish species intercepted during quarantine detention at the Australian border. From September 2012 to February 2013, 5 species of fish that had suffered mortality levels in excess of 25% whilst in the post-entry quarantine and had Megalocytivirus-like inclusion bodies in histological sections were examined by PCR. The fish had been imported from Singapore, Malaysia and Sri Lanka. Ninety-seven of 111 individual fish from affected tanks of fish tested were positive for the presence of Megalocytivirus by PCR. Sequence analysis of representative PCR products revealed an identical sequence of 621 bp in all cases which was identical to a previously characterized Megalocytivirus (Sabah/RAA1/2012 strain BMGIV48). Phylogenetic analysis of available Megalocytivirus major capsid protein (MCP) sequences confirmed the existence of 3 major clades of Megalocytivirus. The virus detected in this study was identified as a member of Genotype II. The broad host range and pathogenicity of megalocytiviruses, coupled to the documented spread of ornamental fish into the environment, render this a significant and emerging biosecurity threat to Australia.

Streams are vital components of landscapes, serving as important ecosystems for nutrient processing, habitats of high biodiversity, and providing numerous ecosystem services. Streams, however, are being assaulted by numerous environmental changes. At the heart of furthering our understanding of the impacts of environmental change is advancing our conceptual and mathematical models of the hydrologic and geomorphic systems to incorporate the response to climate change and increasing water demands. The hydrologic and geomorphic systems, in turn, affect stream ecosystem functioning and rates of primary production, respiration, and solute transformation. Ultimately, streams are important components of the broader landscape, and impacted by changes such as conversion of land to agriculture, expansion of urban areas, and increased use of fertilizers, pesticides, and other contaminants. Collectively, these changes have the potential to produce long-lasting legacies, which may limit stream ecosystem resiliency, lead to regime shifts, and impact the ecosystem services provided by streams.

Mulloway Argyrosomus japonicus is a native fish species in Western Australia, for which aquaculture production has recently been developed. A single cohort was stocked in a cage offshore at Geraldton, Western Australia, at a water depth of 6 m. Fish appeared healthy before stocking. Routine histological analysis was carried out from 10 mo post stocking and until completion of harvest (about 2.5 yr post stocking). No gross pathology was evident. Microscopically, however, granulomatous lesions were present in the kidneys of almost 100% of the fish examined. Enclosed in the granuloma was an aggregate of organisms, 4.2 to 5.4 µm in diameter. Kidney granulomas appeared as multi-focal aggregates. Granulomas at different stages of formation and finally fibrosing granulomas were observed. Granulomas also appeared infrequently in other organs: a few granulomas were found in the liver and spleen and a single granuloma in the heart of one fish. Transmission electron microscopy (TEM) revealed that the organism was composed of 2 cells, an outer cell enclosing an inner cell. The inner cell was surrounded by a double membrane and the outer cell by a single membrane. Cellular material, presumably of parasitic nature, surrounded the outer cell. The organism contained primitive mitochondria and abundant free ribosomes. Small subunit ribosomal DNA (SSU rDNA) sequence obtained by PCR revealed an 84% sequence identity with the myxosporean Latyspora scomberomori. Based on TEM and preliminary molecular results, we suggest that the organism is the extrasporogonic developmental stage of a myxozoan parasite, which failed to form spores in the mulloway host.

Objective While questionnaires have been developed to capture patient-reported outcomes (PROs) in rheumatology practice, these instruments are not widely used. We developed a touchscreen interface designed to provide reliable and efficient data collection. Using the touchscreen to obtain PROs, we compared 2 different workflow models implemented separately in 2 rheumatology clinics. Methods The Plan-Do-Study-Act methodology was used in 2 cycles of workflow redesign. Cycle 1 relied on off-the-shelf questionnaire builder software, and cycle 2 relied on a custom programmed software solution. Results During cycle 1, clinic 1 (private practice model, resource replete, simple flow) demonstrated a high completion rate at the start, averaging between 74% and 92% for the first 12 weeks. Clinic 2 (academic model, resource deficient, complex flow) did not achieve a consistent completion rate above 60%. The revised cycle 2 implementation protocol incorporated a 15-minute “nurse visit,” an instant messaging system, and a streamlined authentication process, all of which contributed to substantial improvement in touchscreen questionnaire completion rates of ∼80% that were sustained without the need for any additional clinic staff support. Conclusion Process redesign techniques and touchscreen technology were used to develop a highly successful, efficient, and effective process for the routine collection of PROs in a busy, complex, and resource-depleted academic practice and in typical private practice. The successful implementation required both a touchscreen questionnaire, human behavioral redesign, and other technical solutions.

This is the first pathological description of ‘scale drop syndrome’ (SDS) in Asian seabass, Lates calcarifer Bloch. Cumulative mortality was estimated at 40–50%. The vasculitis in all major organs including the skin and associated tissue necrosis was distinctive. The dermis overlying scale beds was often necrotic and associated with scale loss. Necrosis of splenic ellipsoids, renal glomeruli and choroid rete glands of eye were further hallmarks of a disease with systemic vascular involvement. The brain was not spared vascular damage, and the resulting multifocal encephalomalacia probably accounts for the spiral swimming behaviour in some affected fish. Other lesions included accentuated hepatic lobulation and gastric gland necrosis. Nuclear chromatin margination and karyolysis in hepatocytes, renal tubular epithelium and gastric and intestinal epithelium suggest specific targeting of cells. Basophilic cytoplasmic inclusions were present in spleen, kidney, liver, heart and choroid rete, but they were not prominent. Using transmission electron microscopy, two morphological forms of virions were observed: single- and double-enveloped hexagonal virions. Based on size and morphology, these virions resemble iridovirus or herpesvirus. The cause of SDS is unknown, but the pathological changes, especially the vasculitis, suggest an infectious aetiology, possibly viral.

This is the first report of an intestinal Eimeria infection in Asian seabass (Lates calcarifer) at the histopathological and ultrastructural levels. The Eimeria infection was often associated with severe pathology and significant mortality in the absence of other pathogens. This showed that it is an important disease of juvenile L. calcarifer in small scale nurseries in Vietnam. Heavy infection and high prevalence levels of the Eimeria infection are suspected to be linked to the low daily water exchange rates practised in these nurseries. Although systemic iridovirus infection was concurrently observed in some of the fish examined, it was not as consistently present in diseased fish as the Eimeria infection.

Quantitative risk (QR) formulas have been developed for multiple conditions but are not routinely used in clinical practice. Tests were made of the feasibility of an automated clinical care process for using QR in routine primary care. Several modifications were made to the Framingham Risk Score (FRS) and it was applied to routine care in three areas: (1) for risk-stratification, (2) patient education about care options, and (3) guidance on optimizing choice of care options. Evidence-based methods were used to convert the smoking status variable from a binary- to a continuous-scale format and to add variables for alcohol use and HbA1c. An automated protocol tested in 2008-2010 was successful for all three applications. At-risk patients (defined according to criteria from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC]-7 or the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [adult treatment panel/ATP-III]) were automatically identified during routine encounters. Patient-reported data were obtained (n = 1826) by touchscreen questionnaire and automatically used with electronic health record (EHR) data to calculate risks on 1068 patients who had complete data. Patients were risk-stratified. Higher-risk patients viewed an interactive web-based tool and chose options to modify risk factors. Feasibility was successful for use of the FRS in the interactive web tool.

In October 2006, severe mortalities (80 to 100%) were reported in pearl oyster Pinctada maxima production farms from Exmouth Gulf, Western Australia. Only P. maxima were affected; other bivalves including black pearl oysters P. margaratifera remained healthy. Initial investigations indicated that the mortality was due to an infectious process, although no disease agent has yet been identified. Gross appearance of affected oysters showed mild oedema, retraction of the mantle, weakness and death. Histology revealed no inflammatory response, but we did observe a subtle lesion involving tissue oedema and oedematous separation of epithelial tissues from underlying stroma. Oedema or a watery appearance is commonly reported in published descriptions of diseased molluscs, yet in many cases the terminology has been poorly characterised. The potential causes of oedema are reviewed; however, the question remains as to what might be the cause of oedema in molluscs that are normally iso-osmotic with seawater and have no power of anisosmotic extracellular osmotic regulation.

Objectives This study sought to investigate the efficacy and safety of clopidogrel in women and men. Background Previous analyses have shown sex-based differences in response to several antiplatelet medications. Little is known about the efficacy and safety of clopidogrel in women and men. Methods This study performed a meta-analysis of all blinded randomized clinical trials comparing clopidogrel and placebo (CURE [Clopidogrel in Unstable Angina to Prevent Recurrent Events], CREDO [Clopidogrel for the Reduction of Events During Observation], CLARITY–TIMI 28 [Clopidogrel as Adjunctive Reperfusion Therapy–Thrombolysis In Myocardial Infarction 28], COMMIT [Clopidogrel and Metoprolol in Myocardial Infarction Trial], and CHARISMA [Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance] trials), involving a total of 79,613 patients, of whom 30% were women. The relative efficacy and safety of clopidogrel at reducing cardiovascular events (cardiovascular death, myocardial infarction [MI], or stroke) in women and men was estimated using random-effects modeling. Results Overall, clopidogrel was associated with a highly significant 14% proportional reduction in the risk of cardiovascular events (odds ratio [OR]: 0.86; 95% confidence interval [CI]: 0.80 to 0.93), with no significant differences in treatment effect between women and men. Among the 23,533 women enrolled, there were fewer cardiovascular events in the clopidogrel group compared with the placebo group (11.0% vs. 11.8%; OR: 0.93; 95% CI: 0.86 to 1.01). In women the risk reduction with clopidogrel seemed to be greatest for MI (OR: 0.81; 95% CI: 0.70 to 0.93), with the effects on stroke (OR: 0.91; 95% CI: 0.69 to 1.21) or total death (OR: 0.99; 95% CI: 0.90 to 1.08) not statistically significant. Among the 56,091 men enrolled, there were fewer cardiovascular events in those receiving clopidogrel compared with placebo (7.8% vs. 9.0%; OR: 0.84; 95% CI: 0.78 to 0.91), and the risk reduction was significant for MI (OR: 0.83; 95% CI: 0.76 to 0.92), stroke (OR: 0.83; 95% CI: 0.71 to 0.96), and total death (OR: 0.91; 95% CI: 0.84 to 0.97). Clopidogrel increased the risk of major bleeding in both women (OR: 1.43; 95% CI: 1.15 to 1.79) and men (OR: 1.22; 95% CI: 1.05 to 1.42). Conclusions Clopidogrel reduces the risk of cardiovascular events in both women and men.

Objective To determine if juvenile pearl oysters (Pinctada maxima) infected with Haplosporidium hinei are also infected with another haplosporidian parasite, Minchinia occulta. Design Archived samples of pearl oysters infected with H. hinei were examined using polymerase chain reaction (PCR) assays and in situ hybridisation (ISH) to analyse and identify haplosporidians. A 144-bp and 220-bp region of Minchinia DNA were targeted by PCR and amplified DNA from formalin-fixed H. hinei-infected pearl oyster samples was sequenced. A 25-bp oligonucleotide probe targeting a variable section of the parasite's small subunit rRNA gene was used in ISH. Results The results of DNA-based diagnostic assays supported each other. The sequences obtained by PCR were found to be almost identical to M. occulta from rock oysters and the ISH assay demonstrated infection with M. occulta in affected pearl oysters. ISH indicated a prevalence of infection of 26.7% in one of the previous outbreaks. Conclusion Pearl oyster spat are susceptible to infection by a Minchinia parasite, most likely M. occulta, which was recently identified in rock oysters within the pearl-producing zones of Western Australia and is associated with mortalities of up to 80% in this species. The occurrence of haplosporidian co-infections in pearl oysters suggests the immunocompetence of juvenile oysters may be an important factor in preventing infection and therefore preventing mortalities such as those occurring in the recent outbreaks of pearl oyster oedema disease.

The pathology associated with an intracellular ciliate infection in the digestive gland of pearl oysters Pinctada maxima (Jameson, 1901) is described. Histopathological and transmission electron microscopic examination were used to characterise the organism and its location within host cells. The parasite is tear-drop shaped measuring 5.53 microm (range of 2.73-7.47 microm, n=9) in width and 11.15 microm (range of 9.02-16.2 microm) in length with a centrally located lobulated nucleus and a large nucleus:cytoplasmic ratio. The ciliate has nine evenly spaced rows of cilia running obliquely along the length of cell, converging on the pointed end. Infected digestive glands typically had a moderate to severe infiltration with mononuclear hemocyte. A strong correlation existed between the burden of ciliates and the host response; (p0.001, C=0.315 Pearson Correlation). The use of a single tissue section upon microscopic examination was found to detect only 38-50% of the infections. However, examination of serial haematoxylin and eosin stained sections improved the reliability of detecting infection.

Two epizootics affecting pilchards Sardinops sagax neopilchardus have been observed over their entire geographical range off the Australian coastline. The first occurred in 1995, involving high mortality (at least 10%) that devastated the pilchard population. The second occurred in 1998 and involved even higher mortality (70%). Both epizootics moved rapidly against the prevailing Leeuwin and East Australian currents from a defined point of origin. A herpesvirus, pilchard herpesvirus (PHV), was determined to be the cause of the epizootics, but the source of the virus remains unknown. In this research, in situ hybridization (ISH), polymerase chain reaction (PCR), and real-time PCR were compared for the detection of PHV in archived paraffin-embedded tissue and frozen tissue collected before, during, and after the 1995 epizootic. Results show that the conventional PCR failed to detect PHV in archived paraffin-embedded tissue, and that real-time PCR was the most sensitive of the 3 techniques and the best method for the detection of PHV.

SUMMARYA Minchinia sp. (Haplosporidia: Haplosporidiidae) parasite was identified infecting rock oysters and morphologically described by Hine and Thorne (2002) using light microscopy and transmission electron microscopy (TEM). The parasite was associated with up to 80% mortality in the host species and it is suspected that the parasite would be a major impediment to the development of a tropical rock oyster aquaculture industry in northern Western Australia. However, attempts to identify the parasite following the development of a specific probe for Haplosporidium nelsoni were unsuccessful. The SSU region of the parasite's rRNA gene was later characterized in our laboratory and an in situ hybridization assay for the parasite was developed. This study names the parasite as Minchinia occulta n sp. and morphologically describes the parasite using histology, scanning electron microscopy and transmission electron microscopy. The non-spore stages were unusual in that they consisted primarily of uninucleate stages reminiscent of Bonamia spp. The parasite's spores were ovoid to circular shaped and measured 4·5 μm–5·0 μm×3·5–4·1 μm in size. The nucleus of the sporoplasm measured 1·5–2·3 μm and was centrally located. The spores were covered in a branching network of microtubule-like structures that may degrade as the spore matures.

Compartmentalisation is a new tool for disease management within a country. In aquaculture, the successful application of compartmentalisation is largely dependent on the system of production and the epidemiology of the disease(s) for which the compartment is being defined. Therefore, compartmentalisation may not be universally applicable across all systems and diseases. The paper examines the implementation of the concept, providing examples of specific industries, and discusses the application of hazard analysis and critical control points (HACCP) to the biosecurity of the system. The role of compartmentalisation in the management of aquaculture disease emergencies is also discussed.

SUMMARYAn infection of pearl oysters, Pinctada maxima, attributed to a Haplosporidium sp. by Hine and Thorne (1998) has been detected on 3 occasions and is considered to represent a serious concern to the pearling industry in Australia. The spore ornamentation of the parasite was determined by scanning electron microscopy and transmission electron microscopy. Spores of the parasite were pleomorphic, or elongated 3·5–4 μm×2·5–3·0 μm in size. Two filaments were wound around the spore and originated from 2 ‘knob-like’ posterior thickenings. Both filaments passed up one side of the spore together until just below the operculum whereupon each split and passed obliquely under the lip of the opercula lid. Each filament wrapped around the spore 4 times. The posterior thickenings seem to appear late in the development of the spore and were composed of spore wall material. A second set of branching tubular filaments composed of a different material was observed on the spore body although not on mature spores possessing a ‘knob-like’ posterior thickening. The ornamentation on the spores of the pearl oyster parasite was unique amongst described haplosporidian species where spore ornamentation is known. The parasite is named in this manuscript as Haplosporidium hinei n. sp.

Mollusc culture, particularly the cultivation of pearl oysters, is an important component of the aquaculture industry in Western Australia. As a result, there has been a long-term investment in surveys of commercial mollusc species for potential diseases of concern. A number of pathogens, particularly haplosporidans, identified within wild-stock shellfish have the potential to adversely affect mollusc populations. Others pose risks for translocations associated with aquaculture. The microsporidan Steinhausia mytilovum (Field), found in ova of the blue mussel Mytilus galloprovincialis (Lamarck), poses intriguing questions about the origin and dispersal of its host.

Molluscs are known to be seriously affected by trace amounts of environmental pollutants such as tributyltin at concentrations in seawater that are below the level of detection by all but the most sensitive chemical analytical techniques. This extreme sensitivity by molluscs has led to use of both adults and larvae as biomonitors for environmental pollution. Mollusc aquaculture has led to an increasing demand for commercial hatcheries to supply seed stock, including selected genetic lines of spat and juveniles. It is becoming apparent that many of the unexplained “crashes”, ill thrift or failures of larvae to metamorphose in such hatcheries are primarily due to their being compromised for a range of reasons including traces of inhibitory or toxic substances in the water supply. Because dead and dying larvae are ideal substrates for bacterial and ciliate growth, such invaders are often assumed to be the primary cause of the problem and this hinders finding a solution. In addition, many of the toxins which may be implicated in crashes are sporadic in occurrence and are both difficult to detect and hard to remove from the water supply. This paper provides evidence for these toxic effects and suggests ways of reducing the problems.

In 1995, and again in 1998, high mortalities of pilchards Sardinops sagax neopilchardus were seen over their entire geographical range on the Australian coastline. A virus with typical herpesvirus morphology was identified as the causative agent, although the source of the virus remains unknown. At the time of the mortality events, the only available diagnostic test available for the detection of the virus was electron microscopy and hence, development of a rapid diagnostic test for detection and identification of the virus was required. Initial sequence data for Pilchard herpesvirus (PHV) was acquired by comparing the highly conserved region of the ORF 62 gene of other piscine herpesviruses (Ictalurid herpesvirus 1 [Channel catfish virus, CCV] and Salmonid herpesvirus 2 [Oncorhynchus masou virus, SaHV2, OMV]), and designing primers that successfully amplified a fragment of PHV. Here we describe the use of polymerase chain reaction (PCR) technology to detect PHV in infected tissues. Sequence analysis of amplified fragment resulting from this PCR is different from all known herpesviruses and can therefore distinguish PHV from all known viruses.

Haliotrema abaddon is a significant monogenean parasite of the gills of maricultured Western Australian dhufish, Glaucosoma hebraicum, and can cause severe gill pathology. A series of trials was undertaken using infested fish in 120-l glass aquaria to assess the safety and efficacy of some potential “in water” treatments, including trichlorphon, praziquantel, formalin, toltrazuril and a freshwater bath. Treatment efficacy was established by assessment of the number of parasites found in tank sediment immediately following treatment and by examination of gills for parasites using a gill biopsy technique. Praziquantel bathes, 2 mg l−1 of 30-h duration, were the most safe and effective treatment. Freshwater bathes of below 2‰ salinity for 90 min were effective but highly stressful for the fish. Trichlorphon 0.5 mg l−1 for 30 h was safe and relatively effective. Formalin, 25 ppm, and toltrazuril, 12.5 mg l−1, were safe but resulted in the removal of insufficient parasites to recommend it as a treatment for dhufish infested with H. abaddon.