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Atrial septal defects have been well reported in humans and dogs and the principles of intervention have been well established. In contrast, there is very little information published about these congenital anomalies in horses. True ASDs are regarded as rare and little is known about the clinical significance of these defects in horses. An 11‐year‐old Thoroughbred gelding with a history of poor performance was diagnosed with an atrial septal defect, measuring approximately 2 cm in diameter, on 2D transthoracic echocardiography. Real‐time three‐dimensional (3D) echocardiography was used to map the structure of the defect and was useful in fully characterising the ASD in this case., Atrial septal defects (ASDs) are uncommon findings in the horse and are usually asymptomatic. This report documents an unusually large ASD that was characterised using real‐time 3D echocardiography.

AIM: To compare the prevalence of poor glycemic control in probability samples of Japanese and American adults, and to determine the association with their somatic phenotypes. MATERIAL AND METHODS: Blood samples and anthropometric measures were obtained from 382 Japanese, 32–79 years of age, randomly selected to reflect the 23 wards of Tokyo. HA1c values were compared to 1215 Americans, 35–86 years of age, from a national study across the 48 continental states, along with an over-sampling of African-Americans from one city (www.midus.wisc.edu). Body Mass Index (BMI) and Waist-hip ratio (WHR) were also assessed. RESULTS: Many Japanese now have high HA1c approaching Caucasian-American levels, although elevated HA1c (>6.5%, 48 mmol/mol) is not nearly as prevalent as among African-Americans. Significant age-related trends were evident in both countries, with poor glycemic control occurring at younger ages in males and rarely found until old age in Japanese women. Japanese had higher HA1c levels at BMIs of 23–25, in contrast to Americans with Type 2 diabetes who more typically had a BMI over 30. Central adiposity predicted HA1c levels better than BMI, a relationship also apparent at a smaller WHR in Japan. CONCLUSION: The prevalence of high HA1c in Tokyo almost rivals white Americans, but those statistics are dwarfed by the 37% of Afr-Amer adults identified with Type 2 diabetes. Elevated HA1c was more common in men, reflecting central adiposity, but poor glycemic control was also widespread among overweight Afr-Amer women. Type 2 diabetes was higher among older Japanese, when more women succumb. Overall, the findings highlight the societal and clinical challenges posed by demographic trends in both countries.

Current literature suggests that infant oral anatomy may impact breastfeeding outcomes. Our research seeks to evaluate superior labial frenulum (SLF) attachment site grade utilizing a modified existing system and investigate the correlation with breastfeeding outcomes.Two hundred and eight dyads were recruited from the nursery at Brooke Army Medical Center. The neonate's SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF grade. Breastfeeding mothers completed surveys on attitudes and associated pain with feedings 24 h postdelivery, at 2 weeks and at 2 months. Categorical data were analyzed using chi-squared tests or Fisher's exact tests. Means and standard deviations were analyzed using analysis of variance or Wilcoxon's test.At 2 weeks and 2 months, 86.8% and 72.8% were breastfeeding, respectively. At 2 months, SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects (p = 0.0384). At 2 weeks and 2 months, there was no difference between SLF groups with regard to maternal breastfeeding attitudes or pain scores. There was no significant difference in terms of weight, referrals, or lingual-labial frenulectomy between SLF groups.Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system.2 Oxford Center for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 Laryngoscope, 132:2498-2504, 2022.

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Background Ultrasonographic measurement of the vena cava and aorta (Ao) diameters and their ratios have been suggested to be a reliable way of quantifying hypovolemia. Objective To evaluate the feasibility and reliability of an ultrasonographic technique for measurement of Ao and caudal vena cava (CVC) and derived ratios using three different acoustic windows in a population of healthy neonatal foals. Correlation between Ao and CVC measurements and ratios and foals' age or bodyweight were also investigated. Methods In 14 healthy foals aged less than 7 days, the diameters of the Ao and of the CVC in long and short axis were measured by two observers from images obtained using three different ultrasonographic imaging planes (left dorsal, left ventral and right views). The Ao and CVC cross‐sectional area and the CVC/Ao diameter and area ratios were calculated. Image quality was subjectively assessed. Intraobserver and interobserver reliabilities for image quality scores and measurements were evaluated between the two observers. Simple linear regression models were used to identify correlations between the CVC/Ao measurements and ratios and the age and bodyweight of the foals. Results The left ventral view showed the highest reliability. A correlation between bodyweight and the short axis measurement of the CVC was found (R 2 = 0.385; p = 0.018). Age was positively correlated with the long axis of measurement of the CVC (R 2 = 0.426; p = 0.011) and CVC/Ao diameter ratio (R 2 = 0.625; p = 0.001). Conclusions The left ventral view allows the Ao and CVC cross sections to be easily visualized and measured in neonatal foals in right lateral recumbency., The present study evaluated the feasibility and reliability of an ultrasonographic technique for measurement of Ao and CVC and derived ratios using three different acoustic windows in a population of healthy neonatal foals. A left ventral view of the abdomen allowed for rapid imaging and measurement of the cross‐sectional diameter of both the aorta and the CVC in neonate foals in lateral recumbency, and might be a promising method to quantitatively assess the degree of hypovolemia.

Background:Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair.Hypothesis:A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury.Study Design:Cohort study; Level of evidence, 3.Methods:We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump.Results:At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, −3.9° (2.0); acute repair group, −3.7° (1.9) ( P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury.Conclusion:Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated

OBJECTIVE To review and discuss the use of hydroxyethyl starches (HES) in equine veterinary medicine, and to provide recommendations for its use. DATA SOURCES Veterinary and human peer-reviewed medical literature including scientific reviews, meta-analyses, and original research articles. HUMAN DATA SYNTHESIS Increasing evidences on adverse effects after HES use and decreasing support for beneficial effects with regards to volume expansion and colloid osmotic pressure (COP) support in critically ill subjects have led to a recent guideline to limit the use of HES in critically ill people. EQUINE VETERINARY DATA SYNTHESIS The rationale for HES use in horses is mainly extrapolated from human medicine, and very limited studies in horses are available. There is limited evidence suggesting a superiority of volume expansion effects of HES over crystalloids. The potential for HES to increase and maintain COP is well supported, but there is no evidence that maintaining or increasing plasma COP influences outcome, tissue edema formation, or rates of complications that potentially relate to edema formation. HES induce dose-dependent changes in coagulopathic parameters, but there is no evidence that HES causes clinical coagulopathies. Insufficient data are available on other adverse effects such as acute kidney injury, or mortality in horses. The use of HES should be restricted in septic patients, but may still have some use in cases of hemorrhagic shock resuscitation, hypoalbuminemia, or perioperative fluid replacement. CONCLUSION The evidence supporting the use of HES in horses is weak due to lack of species-specific investigations. Acknowledging species differences, the use of HES should be judicious, yet with some recognition of its benefits in particular cases. More research is necessary to improve knowledge on use of HES in horses and to establish better future recommendations.

Background: Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our “traditional” or a “slowed down” rehabilitation after percutaneous surgical repair. Methods: Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated. Results: At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one. Conclusion: Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study. Level of Evidence: Level II, prospective comparative study.

Background The medial patellofemoral ligament (MPFL) is always damaged after patellar dislocation. In selected patients, MPFL reconstruction is necessary to restore a correct patellar tracking. Despite the large number of different techniques reported to reconstruct the MPFL, there is no consensus concerning the optimal procedure, and debates is still ongoing. The present study analysed the results after isolated MPFL reconstruction in patients with patellofemoral instability. Furthermore, a subgroup analysis of patients presenting pathoanatomical risk factors was made. Methods In November 2020, the main electronic databases were accessed. All articles reporting the results of primary isolated MPFL reconstruction for recurrent patellofemoral instability were considered for inclusion. Only articles reporting a minimum 12-month follow-up were eligible. Results Data from a total of 1777 knees were collected. The mean age of the patients involved was 22.8 ± 3.4 years. The mean follow-up was 40.7 ± 25.8 months. Overall, the range of motion (+ 27.74; P < 0.0001) and all the other scores of interests improved at last follow-up: Kujala (+ 12.76; P = 0.0003), Lysholm (+ 15.69; P < 0.0001), Tegner score (+ 2.86; P = 0.006). Seventy-three of 1780 patients (4.1%) showed a positive apprehension test. Thirty of 1765 patients (1.7%) experienced re-dislocations, while 56 of 1778 patients (3.2%) showed persisting joint instability. Twenty-five of 1786 patients (1.4%) underwent revision surgeries. Conclusion Isolated MPFL reconstruction for recurrent patellofemoral instability provides reliable surgical outcomes. Patients with pathoanatomical predisposing factors reported worse surgical outcomes.

Background: Tendon injuries are commonly seen in sports medicine practice. Many elite players involved in high-impact activities develop patellar tendinopathy (PT) symptoms. Of them, a small percentage will develop refractory PT and need to undergo surgery. In some of these patients, surgery does not resolve these symptoms. Purpose: To report the clinical results in a cohort of athletes who underwent further surgery after failure of primary surgery for PT. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 athletes who had undergone revision surgery for failed surgical management of PT were enrolled in the present study. Symptom severity was assessed through the Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P) upon admission and at the final follow-up. Time to return to training, time to return to competition, and complications were also recorded. Results: The mean age of the athletes was 25.4 years, and the mean symptom duration from the index intervention was 15.3 months. At a mean follow-up of 30.0 ± 4.9 months, the VISA-P score improved 27.8 points ( P < .0001). The patients returned to training within a mean of 9.2 months. Fifteen patients (68.2%) returned to competition within a mean of 11.6 months. Of these 15 patients, a further 2 had decreased their performance, and 2 more had abandoned sports participation by the final follow-up. The overall rate of complications was 18.2%. One patient (4.5%) had a further revision procedure. Conclusion: Revision surgery was feasible and effective in patients in whom PT symptoms persisted after previous surgery for PT, achieving a statistically significant and clinically relevant improvement of the VISA-P score as well as an acceptable rate of return to sport at a follow-up of 30 months.

With the rise of online shopping during COVID-19 pandemic in the Philippines, it is important to understand the buying decision among Filipinos. The purpose of this study was to determine the factors affecting customer satisfaction in online shopping. A valid response of 251 Filipinos participated in the empirical study. Structural Equation Modeling (SEM) was used to validate the measurement model and to test the causal relationship in the model. The result revealed that products/services, pricing, consumer, and technological were significantly influenced the consumer buying decision which also affect customer satisfaction. Surprisingly, operational was found not significant as a predictor for buying decisions and customer satisfaction. The SEM derived from the study could be beneficial to e-commerce platforms and businesses which can contribute to a better understanding of the determinants that affect buying decision and customer satisfaction.

BACKGROUND Previous studies have demonstrated a poor response to healing of gastric glandular lesions with oral omeprazole and other medications. OBJECTIVES To evaluate the efficacy of two novel treatments (misoprostol [M] and combined omeprazole-sucralfate [OS]) in horses for gastric glandular disease. STUDY DESIGN Prospective, clinical study. METHODS Sixty-three sports horses with grade >1/4 glandular disease were identified by gastroscopy. Horses received either 5 μg/kg of misoprostol per os BID 1 h prior to feeding or a combination of 4 mg/kg enteric coated omeprazole per os SID and 12 mg/kg sucralfate per os BID where drugs were given 1 h prior to feeding and sucralfate given 60 min after omeprazole; allocation was dependent upon centre. Gastroscopy was repeated at 28-35 days. Evaluators of the gastroscopy images were blinded to the treatments the horses received and images were reviewed independently. RESULTS The most common presenting sign in both treatment groups was poor performance (Overall - 65.1%; M - 60.5% and OS - 75%). Overall healing (P

Objectives: Eudaimonic well-being (EWB), increasingly recognized as a critical component of health, typically declines in later life, and there are no existing programs to sustain or increase EWB in older adults. Lighten UP! is an 8-week program to promote EWB through facilitated group sessions in community settings and at-home practice. Building on earlier pilot research, the current study assessed the effect of the Lighten UP! Program using a longitudinal, multi-site design. Methods: Men and women (N=169) aged 60 and over were recruited from three Wisconsin communities. EWB, life satisfaction, depression, and diverse aspects of health were assessed before and after the program and at 6-month follow up. Results: Participants reported significantly increased EWB; these changes were maintained 6months later. The specific EWB domains of self-acceptance, positive relations, and personal growth showed the most robust gains. Participants also showed significant and sustained declines in depressive symptoms, anxiety, and hostility. Conclusions: Lighten UP! Program confirmed its positive effects for enhancing EWB in older adults living in multiple community settings. Clinical Implications: Programs that sustain or enhance EWB in older adults can be expected to yield improvements in diverse aspects of mental and physical health.

Cardiac murmurs are a common finding in the adult horse and the majority are physiological. However, it is necessary to be able to differentiate between variations of normal and abnormal to ensure that potential performance and safety limiting conditions are identified and appropriately evaluated. The most common murmurs vary depending on the predominant horse type and age that is being evaluated. Cardiac examinations, including cardiac auscultation, are a fundamental part of determining the likely diagnosis when a murmur is auscultated, and also form part of the decision-making process to identify what is likely to be significant. Loud (>3/6) and wide-radiating murmurs should undergo further evaluation in horses used for ridden exercise. Differentiation of diastolic from systolic murmurs is extremely important for decision-making. The most common left-sided systolic murmurs are associated with physiological aortic flow, mitral regurgitation, increased pulmonary flow secondary to a ventricular septal defect, and a ‘haemic’ murmur caused by changes in blood viscosity. The most common right-sided systolic murmurs are associated with tricuspid regurgitation and turbulent blood flow through the defect of a ventricular septal defect. Left- and right-sided diastolic murmurs are most commonly associated with aortic regurgitation, although in certain groups short, squeaky diastolic murmurs that are usually intermittent can be physiological in nature.

Recent publications have cast light on the marked differences between diseases in the squamous and glandular regions of the equine stomach. Until recently the focus regarding all aspects of gastric disease has been on disease of the squamous mucosa and findings have then been extrapolated to disease in the glandular region. Disease of the squamous mucosa is caused by acid and results in hyperkeratosis, erosions and ulceration. Many of the risks for development of squamous disease relate to factors that allow or promote a more acidic gastric pH or increase exposure of the squamous mucosa to this acid. We know that this is not the case for the glandular mucosa as the epithelial cells in this region in health have protective factors against acid. We now know that disease in the glandular region is inflammatory in origin and not ulcerative. It is proposed that the inciting cause to this lesion is reduced gastric glandular blood flow and it is speculated that it may be an extension of idiopathic inflammatory bowel disease; acid may then slow or inhibit healing. Lesions in the glandular mucosa vary in appearance and these differences may relate to differing aetiologies. Recommendations for management changes are different to squamous disease and primarily involve minimising stress. Treatment for glandular disease is more challenging, healing may take longer and requires alternative approaches to oral omeprazole monotherapy when compared with squamous disease.