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Background: The learning curve for new operators performing ultrasound-guided transfemoral access (TFA) remains uncertain., Methods: We performed a pooled analysis of the FAUST (Femoral Arterial Access With Ultrasound Trial) and UNIVERSAL (Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures) trials, both multicenter randomized controlled trials of 1:1 ultrasound-guided versus non-ultrasound-guided TFA for coronary procedures. Outcomes included the composite of major bleeding or vascular complications and successful common femoral artery cannulation. Participants were stratified by the operators' accrued case volume. We used adjusted repeated-measurement logistic regression, with random intercepts for operator clustering, for comparison against the non-ultrasound-guided TFA group and to model the learning curve., Results: The FAUST and UNIVERSAL trials randomized a total of 1624 patients, of which 810 were randomized to non-ultrasound-guided TFA and 814 to ultrasound-guided TFA (cases 1-10, 391; 11-20, 183; and >20, 240). Participants who had operators who performed >20 ultrasound-guided TFAs had a decreased risk for the primary end point (5/240 [2.1%] versus 64/810 [7.9%]; adjusted odds ratio, 0.26 [95% CI, 0.09-0.61]) compared with non-ultrasound-guided TFA. Operators who performed >20 ultrasound-guided procedures had increased odds of successfully cannulating the common femoral artery (224/246 [91.1%] versus 327/382 [85.6%]; adjusted odds ratio, 1.76 [95% CI, 1.08-2.89]) compared with non-ultrasound-guided TFA. The learning curve plots demonstrated growing competence with increasing accrued cases., Conclusions: New operators should perform at least 20 ultrasound-guided TFA to decrease access site complications and increase proper cannulation compared with non-ultrasound-guided TFA. Additional accrued cases may lead to increased proficiency. Training programs should consider these findings in the transradial era., Competing Interests: Dr d’Entremont is a Canadian Institutes of Health Research Canada Graduate Scholarship awardee. Dr Jolly reports receiving grants or contracts from Boston Scientific and payment or honoraria for lectures, presentations, speaker’s bureaus, article writing, or educational events from Penumbra, Teleflex, and Abiomed. Dr Seto reports receiving grants or contracts from Arena Medical, Philips, and ACIST; payment or honoraria for speaker’s bureaus from Janssen, Terumo, Gettinge, and GE Healthcare; consulting fees from Medtronic and Medicure; and reports having equity in Frond Medical. The other authors report no conflicts.

Background: Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results., Aims: We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis., Methods: We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days., Results: A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009)., Conclusions: In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.

Background: The optimal strategy to prevent no-reflow in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) is unknown., Aims: We aimed to examine the effect of thrombectomy on the outcome of no-reflow in key subgroups and the adverse clinical outcomes associated with no-reflow., Methods: We performed a post hoc analysis of the TOTAL Trial, a randomised trial of 10,732 patients comparing thrombectomy versus PCI alone. This analysis utilised the angiographic data of 1,800 randomly selected patients., Results: No-reflow was diagnosed in 196 of 1,800 eligible patients (10.9%). No-reflow occurred in 95/891 (10.7%) patients randomised to thrombectomy compared with 101/909 (11.1%) in the PCI-alone arm (odds ratio [OR] 0.95, 95% confidence interval [CI]: 0.71-1.28; p-value=0.76). In the subgroup of patients who underwent direct stenting, those randomised to thrombectomy compared with PCI alone experienced less no-reflow (19/371 [5.1%] vs 21/216 [9.7%], OR 0.50, 95% CI: 0.26-0.96). In patients who did not undergo direct stenting, there was no difference between the groups (64/504 [12.7%] vs 75/686 [10.9%)], OR 1.18, 95% CI: 0.82-1.69; interaction p-value=0.02). No-reflow patients had a significantly increased risk of experiencing the primary composite outcome (cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA Class IV heart failure) at 1 year (adjusted hazard ratio 1.70, 95% CI: 1.13-2.56; p-value=0.01)., Conclusions: In patients with STEMI treated by PCI, thrombectomy did not reduce no-reflow in all patients but may be synergistic with direct stenting. No-reflow is associated with increased adverse clinical outcomes.

Background: It remains unclear whether racial and ethnic disparities for atherosclerotic cardiovascular disease (ASCVD) persist within universal health care systems. We aimed to explore long-term ASCVD outcomes within a single-payer health care system with extensive drug coverage in Québec, Canada., Methods: CARTaGENE (CaG) is a population-based prospective cohort study of individuals aged 40 to 69 years. We included only participants without previous ASCVD. The primary composite endpoint was time to the first ASCVD event (cardiovascular death, acute coronary syndrome, ischemic stroke-transient ischemic attack, or peripheral arterial vascular event)., Results: The study cohort included 18,880 participants followed for a median of 6.6 years (2009 to 2016). The mean age was 52 years, and 52.4% were female. After further adjustment for socioeconomic and cardiovascular factors, the increase in ASCVD risk for South Asians (SAs) was attenuated (hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.75, 2.67), whereas Black participants' risk was lower (HR, 0.52; 95% CI, 0.29, 0.95) compared with White participants. After similar adjustments, there were no significant differences in ASCVD outcomes among the Middle Eastern, Hispanic, East-Southeast Asian, Indigenous, and mixed race-ethnicities participants and the White participants., Conclusions: After adjustment for CV risk factors, the risk of ASCVD was attenuated in the SA CaG participants. Intensive risk-factor modification may mitigate the ASCVD risk of the SAs. Within a universal health care context and comprehensive drug coverage, the ASCVD risk was lower among Black compared with White CaG participants. Future studies are needed to confirm whether universal and liberal access to health care and medications can reduce the rates of ASCVD among the Black population., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Four female Japanese macaques (Macaca fuscata) from the same group as well as Wolf's guenon (Cercopithecus wolfi) and a Western lowland gorilla (Gorilla gorilla gorilla) from a second institution presented with vaginal foreign bodies in parallel with diseases of the urogenital tract or with endocrine disorders. These foreign bodies were associated with a mild to marked, diffuse vaginitis in all cases. Underlying pathological conditions consisted of a cavernous uterine hemangioma in a 20-year-old macaque, diffuse endometritis in a 21-year-old macaque, an in situ endometrial carcinoma in a 24-year-old macaque, endometritis and an ovarian cyst-like structure in the 27-year-old Western lowland gorilla, chronic cystitis and chronic renal disease in a 24-year-old macaque, and a history of hypothyroidism with irregular reproductive cycles in the 12-year-old Wolf's guenon. Vaginal foreign bodies have been reported in nonhuman primates used in biomedical research, but their concurrence with underlying conditions has not been explored. In women, vaginal foreign bodies have been linked to serious underlying medical conditions. This case series emphasizes the recommendation to investigate this abnormal behavior for underlying medical or adverse psychosocial conditions in primates under human care., (© 2022 Wiley Periodicals LLC.)

In this case series, clinical investigations were pursued during a Synhimantus nasuta infection in a lorikeet ( Trichoglossus spp.) flock outbreak situation to better describe and document clinical presentations. In 11 lorikeets suspected to be infected with Synhimantus based on at least one abnormal finding on their physical examination (lethargy, feather-damaging behavior on the ventrum, weight loss, pale iris), the presence of five additional parameters was documented: anemia, relative eosinophilia, increased proventricular diameter-to-keel height ratio (PKR), proventricular barium filling defect, and positive fecal occult blood detection test. A total score (X of 9) was calculated by combining all these findings. Synhimantus nasuta infection was confirmed in four of these individuals by modified Wisconsin fecal examination. Suspected cases ( n = 7 of 11) presented only with low scores (1-3 of 9), whereas birds with confirmed infections ( n = 4 of 11) presented with both low (1-3 of 9, n = 2 of 4) and high (6-7 of 9, n = 2 of 4) total scores. High scores were associated with clinical anemia. Fecal occult blood was present in all confirmed cases and 4 of 7 suspected cases. An enlarged proventriculus was only observed in birds with active shedding ( n = 3 of 4). Follow-up evaluations after 6 mon of treatment with ivermectin and selamectin suggested complete recovery with lowered or normalized total scores. In conclusion, during an S. nasuta outbreak, a rapid physical examination helps to identify suspect cases, including individuals requiring immediate medical attention. In the absence of ova shedding, infection cannot be excluded on the basis of scarce clinical findings, but the detection of occult fecal blood and an increased PKR should raise the index of suspicion.

Background: The optimal method of coronary revascularization for diabetes mellitus (DM) patients with left main coronary artery disease (LMCAD) is controversial in the drug-eluting stent (DES) era., Methods: We performed a systematic review and meta-analysis comparing DES-based percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) for LMCAD in DM patients and tested for effect measure modification (EMM) by diabetes for adverse events. We included all randomized controlled trials (RCTs) and observational studies comparing CABG to DES-based PCI including DM patients with LMCAD published up to March 1, 2021. We completed separate random-effects meta-analyses for four RCTs (4356 patients, mean follow-up of 4.9 years) and six observational studies (9360 patients, mean follow-up of 5.2 years)., Results: In RCTs among DM patients, DES-based PCI, compared to CABG, was associated with a 30% increased relative risk (RR) (RR 1.30, 95% CI 1.09-1.56, I 2  = 0%), while among non-DM patients, there was a 25% increased relative risk (RR 1.25, 95% CI 1.07-1.44, I 2  = 0%) for the composite endpoint of all-cause mortality, myocardial infarction, stroke, and unplanned revascularization (MACCE). There was no evidence of EMM (p-value for interaction = 0.70). The mean weighted SYNTAX score was 25.7. In observational studies, there was no difference between DES-based PCI and CABG for all-cause mortality in patients with DM (RR 1.13, 95% CI 0.91-1.40, I 2  = 0%)., Conclusions: CABG was superior to PCI for LMCAD in RCTs in DM patients for MACCE. Heart teams may consider DM as one of the many components in the clinical decision-making process, but may not want to consider DM as a primary deciding factor between DES-based PCI and CABG for LMCAD with low to intermediate anatomical complexity in the other coronary arteries., Study Registration: CRD42021246931 (PROSPERO)., (© 2022. The Author(s).)

Background: Although prior studies have demonstrated racial disparities regarding acute coronary syndrome (ACS) care within private or mixed healthcare systems, few researchers have explored such disparities within universal healthcare systems. We aimed to evaluate the quality and outcomes of in-hospital ACS management for White patients vs patients of colour, within a universal healthcare context., Methods: We performed a post hoc analysis of the A cute  M yocardial  I nfarction - Knowledge Translation to  Optim ize  A dherence to Evidence-Based Therapy study, a cluster-randomized trial evaluating a knowledge-translation intervention at 24 hospitals in Quebec, Canada (years: 2009 and 2012). The primary endpoint was coronary catheterization. The secondary endpoints included in-hospital mortality, percutaneous and surgical coronary revascularization, major bleeding, total stroke, and discharge prescription of evidence-based medical therapy., Results: Of 3444 included patients, 2738 were White, and 706 were people of colour. The mean age was 68.2 years (33.3% women) among White patients and 69.5 years (36.0% women) among patients of colour. Patients of colour were less likely to undergo in-hospital coronary catheterization than were White patients (74.5% vs 80.3%, P  = 0.001). This difference was attenuated after adjusting for patient-level characteristics (odds ratio 0.89; 95% confidence interval 0.73-1.09), and it was eliminated after adjusting for hospital-level characteristics (odds ratio 1.04; 95% confidence interval 0.73-1.49)., Conclusions: Racial disparity in coronary catheterization for ACS persists within a universal healthcare context. Patients' comorbidities and hospital-level factors may be partially responsible for this inequality. Future research on cardiovascular healthcare in patients with diverse racial/ethnic backgrounds in universal healthcare systems is needed to remediate racial inequality in ACS management., (© 2021 The Authors.)

Background: Two-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD., Methods: We conducted a case-control study of all consecutive patients with abnormal ESE in 2018-2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13-17, segment 17, and segments 15-16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively., Results: We excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84, p = 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70, p = 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73, p = 0.11)., Conclusions: Two-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD., (© 2021. The Author(s).)

Objectives: To investigate the effects of early upstream antithrombotic therapy administration (ATTA) in ST-segment elevation myocardial infarction (STEMI) patients with prolonged transport times to primary percutaneous intervention (PPCI) on major clinical outcomes., Background: It remains unclear whether early upstream administration of aspirin, ticagrelor, and unfractionated heparin (UFH) confers additional benefits compared with in-hospital administration., Methods: Between 2015 and 2018, we performed PPCI in 709 included consecutive STEMI patients. We compared 482 STEMI patients who received aspirin, ticagrelor, and UFH loading in a non-PCI capable spoke hospital before transfer (NPHT) versus 227 prehospital triage setting (PTS) STEMI patients who received in-ambulance aspirin, followed by ticagrelor and UFH in the hub catheterization laboratory. The primary outcome was the presence of a pre-PPCI TIMI flow 2-3 in the infarct related artery (IRA). The secondary outcomes included definite acute stent thrombosis and hemorrhagic complications., Results: The median times from ticagrelor and heparin administration to angiography in the NPHT group and the PTS group were 80.5 min (Interquartile Range (IQR) 68.5-94) and 10 min (IQR 5-15) respectively (p < .0001). Using inverse probability of treatment weighting to minimize heterogeneity between groups, we showed significant differences for the primary outcome (44.6 versus 18.5%, p < .0001) and for definite acute stent thrombosis (0.6 versus 2.6%, p = .03), with no difference in the combined in-hospital BARC 2-5 bleeding events (1.9 versus 3.5%, p = .18) in the NPHT versus the PTS group, respectively., Conclusion: In this single-center retrospective cohort study, after adjusting for baseline covariates, early upstream ATTA with aspirin, ticagrelor, and UFH was associated with greater pre-PPCI TIMI flow and less definite acute stent thrombosis in STEMI patients, without increased bleeding risk., (© 2020 Wiley Periodicals LLC.)

Contraception is needed to prevent overpopulation and inbreeding in highly fecund captive bat colonies. Reports on surgical contraception in bats are limited. The objective of this study was to describe surgical castration techniques in a megachiropteran and a microchiropteran fruit bat species. Open orchiectomy by transfixing ligation of the spermatic cord was performed in 14 Ruwenzori long-haired fruit bats ( Rousettus lanosus ) (RL-LIG), and orchiectomy with radiosurgery alone was performed in 125 Jamaican fruit-eating bats ( Artibeus jamaicensis ) (AJ-RS) and one Ruwenzori bat (RL-RS). The surgical techniques were not compared in different species with the exception of the one Ruwenzori bat operated with RS. Anesthesia was induced and maintained with isoflurane in oxygen via facemask. Preoperatively, all bats received butorphanol and subcutaneous fluids. Meloxicam was administered postoperatively for the RL-LIG. For the RL-LIG, anesthesia lasted 49 ± 15 min (mean ± SD) with a total surgery time of 26 ± 12 min. In comparison, the RS was considerably shorter, lasting 10 ± 3 min for anesthesia and 5 ± 2 min for surgery. Complications were rare, with a morbidity rate of 6.7% with the RL-LIG (prolonged recovery [ n = 1]) and of 4.8% with the RS (dyspnea [ n = 3], hemorrhage [ n = 2], and prolonged recovery [ n = 1]). One of the cases of hemorrhage was in the single Ruwenzori bat castrated using the RS technique. Mortality rate was 1.6% ( n = 2) with the RS. No mortality occurred with the RL-LIG. In conclusion, using radiosurgery alone appears to be a safe and rapid surgical technique in smaller species of fruit bats. For larger species, such as the Ruwenzori fruit bats, ligation or use of an advanced vessel sealing system is recommended.

An onset of respiratory disease in a captive bachelor group ( n = 3) of western lowland gorillas ( Gorilla gorilla gorilla ) was concomitant with peak attendance of visitors at the institution and with unwanted occurrences of food items being thrown in the gorillas' enclosure. While the condition of two individuals improved with supportive therapy and antibiotics, the third gorilla died three days following initiation of treatment. A fatal bacterial pneumonia, secondary to an infection by a human parainfluenza virus 2 (HIPV-2), was considered to be the cause of death based on histopathology, lung cultures, and reverse transcription PCR. HPIV-2 activity in the human population of the province was detected for that period, including the same viral strain. This report confirms a HPIV-2 respiratory illness and associated death in a gorilla. Clinical presentation and context suggest conspecifics were also affected and that contaminated food thrown by visitors may have been the source of infection.

Objectives: To validate a thermal threshold (TT) nociceptive model in bearded dragons (Pogona vitticeps) and to document TT changes after administration of morphine., Study Design: A two-part randomized, blinded, controlled, experimental study., Animals: Five adult bearded dragons (242-396 g)., Methods: A TT device delivered a ramped nociceptive stimulus (0.6 °C second -1 ) to the medial thigh until a response (leg kick/escape behavior) was observed or maximum (cut-off) temperature of 62 °C was reached. In phase I, period 1, six TT readings were determined at 20 minute intervals for evaluation of repeatability. Two of these readings were randomly assigned to be sham to assess specificity of the behavioral response. The same experiment was repeated 2 weeks later (period 2) to test reproducibility. In phase II, animals were administered either intramuscular morphine (10 mg kg -1 ) or saline 0.9%. TTs (maximum 68 °C) were determined before and 2, 4, 8, 12 and 24 hours after treatment administration. Data were analyzed using one-way anova (temporal changes and repeatability) and paired t tests (reproducibility and treatment comparisons) using Bonferroni correction (p < 0.05)., Results: Mean TT values were 57.4 ± 3.8 °C and 57.3 ± 4.3 °C for periods 1 and 2, respectively. Data were repeatable within each period (p = 0.83 and p = 0.07, respectively). Reproducibility between periods was remarkable (p = 0.86). False-positive responses during sham testing were 10%. TTs were significantly increased after morphine administration at 2, 4 and 8 hours compared with baseline, and at 2 and 4 hours compared with saline 0.9%. The highest TT was 67.7 ± 0.7 °C at 4 hours after morphine administration., Conclusions and Clinical Relevance: Testing was repeatable, reproducible and well tolerated in bearded dragons. TT nociceptive testing detected morphine administration and may be suitable for studying opioid regimens in bearded dragons., (Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

A cutaneous mass was surgically excised in a 4-year-old African pygmy hedgehog (Atelerix albiventris). A squamous cell carcinoma was diagnosed based on histopathological examination and local recurrence following excision is strongly suspected. To the authors' knowledge, this is the first well-documented report of a cutaneous squamous cell carcinoma in this species.