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This report is of an osseous metaplasia of the transverse humeral ligament and secondary bicipital tenosynovitis in a 10-year-old Bengal cat. Computed tomography revealed the presence of an osseous bridge enclosing the bicipital groove, with ultrasonography confirming partial tear and inflammation of the bicipital tendon. Initial conservative management with intra-articular long-acting steroids failed to provide long-term improvement of clinical signs. Surgical excision of the osseous lesion resulted in complete resolution of lameness after surgery, confirmed by a 1-year follow-up. Histopathology of this lesion confirmed a well-differentiated osseous metaplasia of the transverse humeral ligament.

To report outcomes and complications associated with total hip replacements (THR) using a multiuser canine hip registry (CHR) and owner-administered questionnaire.Prospective longitudinal clinical study.Dogs (n = 1852).Total hip replacement cases submitted to a CHR were reviewed. An online questionnaire including an adapted "Liverpool Osteoarthritis in Dogs" (LOAD) score was e-mailed to owners. Data were analyzed to determine associations between clinical variables and the agreement by veterinary surgeons and owners for complications.A group of 1329 (72%) dogs had unilateral THRs and another group of 523 (28%) dogs had bilateral THRs, resulting in 2375 THRs. Indications included hip dysplasia and osteoarthritis (n = 2028/2375, 85%). Implants were manufactured by Kyon (n = 1087, 46%), BioMedtrix CFX (n = 514, 22%), BioMedtrix hybrid (n = 264, 11%), BioMedtrix BFX (n = 221, 9%), and Helica (n = 107, 4.5%). Median veterinary surgeon and owner follow up were 1328 and 900 days respectively. Postoperative LOAD scores (21 ± 9) reported by 461 owners improved compared to preoperative scores (11 ± 9) (P .001). Veterinary surgeons reported complications in 201/2375 (8.5%) THRs and owners in 107/461 (23%) THRs, with moderate agreement (weighted kappa = 0.44). No associations were identified between complications and weight, age, sex, or breed. BioMedtrix BFX and Helica implants were associated with increased complications (P = .031) when used for revisions of femoral head and neck excisions.Excellent outcomes, including improved canine mobility, were reported after THRs. Complications were underreported by veterinary surgeons compared to owners in this first multiuser CHR.Canine THRs are safe, effective procedures but THR implants should be carefully selected when revising femoral head and neck excisions.

ObjectiveTo develop and evaluate a modified version of the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire, for use in sedentary patients with Achilles tendinopathy, using the Consensus-based Standards for the selection of health Measurement Instruments recommendations.MethodsTwenty-two sedentary patients with Achilles tendinopathy completed the VISA-A and provided feedback regarding the relevance, comprehensiveness and comprehensibility of each item, response options and instructions. Patient and professional feedback was used to develop the VISA-A (sedentary) questionnaire. Reliability, validity and responsiveness of the VISA-A (sedentary) was evaluated in 51 sedentary patients with Achilles tendinopathy: 47.1% women, mean age 64.8 (SD 11.24).ResultsFactor analysis identified two dimensions (symptoms and activity) for the VISA-A (sedentary). Test–retest reliability was excellent for symptoms (intraclass correlation coefficient, ICC=0.991) and activity (ICC=0.999). Repeatability was 1.647 for symptoms and 0.549 for activity. There was a significant difference between the VISA-A and VISA-A (sedentary) scores both pretreatment and post-treatment. There was stronger correlation between the pretreatment to post-treatment change in the VISA-A (sedentary) scores (r=0.420 for symptoms, r=0.407 for activity) and the global rating of change than the VISA-A scores (r=0.253 for symptoms, r=0.186 for activity).ConclusionThe VISA-A (sedentary) demonstrates adequate reliability, validity and responsiveness in sedentary patients with Achilles tendinopathy. The VISA-A (sedentary) is a more appropriate measure than the VISA-A for this cohort and is recommended for clinical and research purposes.

To compare the ease of endoscopic duodenal intubation (EDI) in dogs during maintenance of general anaesthesia with isoflurane or propofol infusion.Prospective, randomized, partially blinded clinical trial.A total of 22 dogs undergoing upper gastrointestinal tract endoscopy to include EDI were recruited.Dogs were randomly assigned isoflurane (ISO; n = 10) or propofol (PROP; n = 11) for maintenance of general anaesthesia. Following anaesthetic premedication with intramuscular medetomidine (0.005 mg kgThere were no significant differences between groups for EDI score [median (interquartile range): 2 (3) ISO, 2 (3) PROP] or time to achieve EDI [mean ± standard deviation: 52.50 ± 107.00 seconds (ISO), 70.00 ± 196.00 seconds (PROP)]. Significantly more dogs responded to passage of the endoscope into the oesophagus in group PROP compared with group ISO (p = 0.01).Maintenance of general anaesthesia with either isoflurane or propofol did not affect EDI score or time to achieve EDI.

Objectives The aim of this study was to determine if epaxial muscle height (EMH) could be reliably incorporated into annual routine wellness screenings, and also determine its relationship to age, body condition score (BCS), subjective muscle assessment (SMA), breed and sex in mature cats. Methods EMH was determined independently by three observers from ultrasonographic examinations – collected by an additional trained individual – of cats enrolled at the Feline Healthy Ageing Clinic, University of Liverpool, UK. Age, body weight, BCS and SMA data were also collected. Results A total of 92 cats were included, 35 of which had repeat ultrasonographic examinations 12 months apart. Enrolled cats were a median age of 8 years and 9 months at the time of the first measurement. Variation in the quality of ultrasonographic images collected did not affect muscle depth measurements ( P = 0.974). Further, there was good intra- and inter-observer repeatability for all observations (intraclass correlation range 0.97−0.99). There was a moderate positive association between EMH and body weight ( r = 0.49, P Conclusions and relevance The accuracy of EMH measurement using ultrasonographic imaging is good, irrespective of observer experience and provided that the ultrasonographer has some training. This suggests that ultrasonographic measurement of EMH could have a major practical impact as a non-invasive determination of muscle mass in pet cat populations. Further research is required to assess longitudinal changes in muscle mass over time in senior pet cats.

Background Heart failure remains a leading cause of mortality and a major driver of health care utilization. Despite numerous medical advances in heart failure, associated hospitalizations continue to increase, owing largely to suboptimal outpatient management. Remote patient monitoring (RPM) aims to further address this current need in heart failure care by providing data to clinical teams to act pre-emptively to address clinical decompensation. However, to date, RPM approaches using noninvasive home-based patient sensors have failed to demonstrate clinical efficacy. Objective The Novel Data Collection and Analytics Tools for Remote Patient Monitoring in Heart Failure (Nov-RPM-HF) Trial aims to address current noninvasive RPM limitations. Nov-RPM-HF will evaluate a clinician co-designed RPM platform using emerging data collection and presentation tools for heart failure management. These tools include a ballistocardiograph to monitor nocturnal patient biometrics, clinical alerts for abnormal biometrics, and longitudinal data presentation for clinician review. Methods Nov-RPM-HF is a 100-patient single-center prospective trial, evaluating patients over 6 months. The outcomes will include patient adherence to data collection, patient/clinician-perceived utility of the RPM platform, medication changes including the titration of guideline-directed medical therapy to target doses, heart failure symptoms/performance status, and unplanned heart failure hospitalizations or emergency department visits. Results This prospective trial began enrollment in March 2020 and anticipates enrollment completion by June 2022, with trial completion by December 2022. Conclusions This trial protocol aims to provide a systematic framework for the evaluation of heart failure RPM strategies, which are currently heavily used but seldom robustly studied. The trial results will help to inform the role of noninvasive RPM as a viable clinical management strategy in heart failure care. International Registered Report Identifier (IRRID) DERR1-10.2196/32873

BACKGROUND Heart failure remains a leading cause of mortality and a major driver of health care utilization. Despite numerous medical advances in heart failure, associated hospitalizations continue to increase, owing largely to suboptimal outpatient management. Remote patient monitoring (RPM) aims to further address this current need in heart failure care by providing data to clinical teams to act pre-emptively to address clinical decompensation. However, to date, RPM approaches using noninvasive home-based patient sensors have failed to demonstrate clinical efficacy. OBJECTIVE The Novel Data Collection and Analytics Tools for Remote Patient Monitoring in Heart Failure (Nov-RPM-HF) Trial aims to address current noninvasive RPM limitations. Nov-RPM-HF will evaluate a clinician co-designed RPM platform using emerging data collection and presentation tools for heart failure management. These tools include a ballistocardiograph to monitor nocturnal patient biometrics, clinical alerts for abnormal biometrics, and longitudinal data presentation for clinician review. METHODS Nov-RPM-HF is a 100-patient single-center prospective trial, evaluating patients over 6 months. The outcomes will include patient adherence to data collection, patient/clinician-perceived utility of the RPM platform, medication changes including the titration of guideline-directed medical therapy to target doses, heart failure symptoms/performance status, and unplanned heart failure hospitalizations or emergency department visits. RESULTS This prospective trial began enrollment in March 2020 and anticipates enrollment completion by June 2022, with trial completion by December 2022. CONCLUSIONS This trial protocol aims to provide a systematic framework for the evaluation of heart failure RPM strategies, which are currently heavily used but seldom robustly studied. The trial results will help to inform the role of noninvasive RPM as a viable clinical management strategy in heart failure care. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/32873

Coronary artery disease (CAD) is a leading cause of death, yet its genetic determinants are not fully elucidated. We report a multi-ethnic genome-wide association study of CAD involving nearly a quarter of a million cases, incorporating the largest cohorts to date of Whites, Blacks, and Hispanics from the Million Veteran Program with existing studies including CARDIoGRAMplusC4D, UK Biobank, and Biobank Japan. We verify substantial and nearly equivalent heritability of CAD across multiple ancestral groups, discover 107 novel loci including the first nine on the X-chromosome, identify the first eight genome-wide significant loci among Blacks and Hispanics, and demonstrate that two common haplotypes are largely responsible for the risk stratification at the well-known 9p21 locus in most populations except those of African origin where both haplotypes are virtually absent. We identify 15 loci for angiographically derived burden of coronary atherosclerosis, which robustly overlap with the strongest and earliest loci reported to date for clinical CAD. Phenome-wide association analyses of novel loci and externally validated polygenic risk scores (PRS) augment signals from the insulin resistance cluster of risk factors and consequences, extend previously established pleiotropic associations of loci with traditional risk factors to include smoking and family history, and confirm a substantially reduced transferability of existing PRS to Blacks. Downstream integrative genomic analyses reinforce the critical role of endothelial, fibroblast, and smooth muscle cells within the coronary vessel wall in CAD susceptibility. Our study highlights the value of a multi-ethnic design in efficiently characterizing the genetic architecture of CAD across all human populations.

Among patients with atrial fibrillation (AF), little is known about contemporary compliance with quality measures as outlined in the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter. Measures include appropriate oral anticoagulant

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide, and a leading cause of stroke. The International Collaborative Partnership for the Study of Atrial Fibrillation (INTERAF) is a prospective, global registry program designed to describe treatment patterns in patients with AF

Background: The 2013 ACC/AHA guideline, first published in 11/2013, recommends moderate to high intensity statin therapy in 4 specific patient groups (Table). Whether this guideline has impacted clinical practice is not known. Methods: We examined statin use and dose intensity before (9/2012-10/2013) and after (2/2014-3/2015) the guideline in the 4 specific groups from cardiology practices participating in the ACC NCDR®’s PINNACLE Registry after excluding practices with missing data from either period. To assess the guidelines’ effect on statin use, using a hierarchical logistic model, we examined interaction between guideline publication and time to allow different slopes and intercepts during the 2 periods. Results: There was a small increase in statin and a similar decrease in non-statin lipid lowering therapy use after the guideline in all 4 groups (overall change Conclusion: There is suboptimal implementation of the 2013 ACC/AHA cholesterol guidelines in cardiology practices. Most high-risk patients are not receiving high intensity statin therapy. More efforts are needed for effective guideline implementation.

The purpose of this study was to examine the influence of employee burnout syndrome on organizational dissent. Two hundred nine employees from various organizations in the midwestern United States participated. Results indicated employees who report high levels of emotional exhaustion, feelings of failure, and isolation from fellow workers report low levels of articulated dissent and avoid using latent dissent. Displaced dissent did not significantly contribute to the equation.

Background: In a significant update, the 2013 ACC/AHA cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend non-statin therapies or treatment to target LDL-C levels, limiting the need for repeated LDL-C testing. We examined the implications of these updated guidelines on current lipid treatment and testing patterns in a national registry of cardiology practices. Methods: Using NCDR® PINNACLE Registry® data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease (ASCVD), diabetes, off-treatment LDL-C ≥190mg/dL, or an estimated 10-year ASCVD risk ≥7.5%) were described. Results: Among a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190mg/dL, 1.9% estimated 10-year ASCVD risk ≥7.5%). 377,311 (32.4%) patients were not receiving statin therapy and 259,143 (22.6%) were receiving non-statin therapies. 20.8% patients had 2 or more LDL-C assessments during the study period, and 7.0% had more than 4 assessments. Conclusions: In U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving them. In addition, 22.6% were receiving non-statin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines would result in significant increases in statin use, as well as significant reductions in non-statin therapies and laboratory testing.

For accurate interpretation of magnetic resonance (MR) images of the equine brain, knowledge of the normal cross-sectional anatomy of the brain and associated structures (such as the cranial nerves) is essential. The purpose of this prospective cadaver study was to describe and compare MRI and computed tomography (CT) anatomy of cranial nerves' origins and associated skull foramina in a sample of five horses. All horses were presented for euthanasia for reasons unrelated to the head. Heads were collected posteuthanasia and T2-weighted MR images were obtained in the transverse, sagittal, and dorsal planes. Thin-slice MR sequences were also acquired using transverse 3D-CISS sequences that allowed mutliplanar reformatting. Transverse thin-slice CT images were acquired and multiplanar reformatting was used to create comparative images. Magnetic resonance imaging consistently allowed visualization of cranial nerves II, V, VII, VIII, and XII in all horses. The cranial nerves III, IV, and VI were identifiable as a group despite difficulties in identification of individual nerves. The group of cranial nerves IX, X, and XI were identified in 4/5 horses although the region where they exited the skull was identified in all cases. The course of nerves II and V could be followed on several slices and the main divisions of cranial nerve V could be distinguished in all cases. In conclusion, CT allowed clear visualization of the skull foramina and occasionally the nerves themselves, facilitating identification of the nerves for comparison with MRI images.

Background: Value in health care, defined as the health outcomes achieved per dollar spent, is emerging as a framework for improvement in health care delivery. We sought to describe facility-level variation in 30-day PCI mortality, readmission and costs. Methods: Using national data from the VA CART Program, we evaluated all patients who had PCI from 2008 to 2010. 30-day total patient costs, readmission, and mortality were attributed to the hospital where the PCI was performed. Risk standardized costs and outcomes were calculated using standardized covariates, adjusting for cardiac and non-cardiac comorbidities. Results: There were 60 hospitals (21,173 patients) that performed more than 20 PCIs during the study period with a mean of 353 PCIs. The unadjusted mean mortality rate was 2.5%, with no significant variation in facility-level risk standardized mortality. The unadjusted mean readmission rate was 10.6%. The risk standardized readmission rate ranged from 0.8 to 1.58 times the average, with 2 hospitals significantly below and 8 hospitals significantly above the risk standardized average. The facility-level median per patient total costs was $26,491 (IQR $20,943 to $31,866). The index hospitalization accounted for 42.4% of 30-day total costs, and readmission accounted for 5.6% of the 30-day total costs at the facility-level. Comparison of risk standardized costs identified 17 hospitals with lower than expected costs and 15 hospitals with higher than expected costs. Facilities with low readmission rates were not overrepresented among low cost facilities, suggesting readmissions are not a major contributor to facility-level 30-day cost (Figure). Conclusion: We observed no variation in facility-level 30-day PCI mortality despite large variation in cost. Although readmission rates varied, readmission accounted for less than 6% of 30-day cost and was not related to facility-level costs. Further studies are needed to determine factors associated with high-value PCI care, defined by low morbidity and mortality despite similar or lower costs.

Background: Studies suggest HIV infected (HIV+) people have similar rates of major adverse cardiovascular events (MACE) after AMI and/or after percutaneous coronary interventions (PCI) compared to uninfected (HIV-) people. However, these studies were limited by a lack of CD4 cell count and/or stent type data. Low CD4 cell count and bare metal stents (BMS) are associated with higher MACE rates than high CD4 cell count and drug eluding stents (DES), respectively. Our study compared the rates and risk of MACE and mortality after PCI between HIV+ and HIV- stratified by stent type and CD4 cell count. Methods: We included 611 HIV+ and 1,564 HIV- from the Veterans Aging Cohort Study Virtual Cohort, a prospective, longitudinal, observational study of HIV+ and 1:2 matched HIV- who underwent PCI with stent placement between 1/2002-1/2010. 1-year incidence rates (IR) per 1000 person years and 95% confidence intervals (CI) for MACE and mortality were calculated by HIV and CD4 ( Results: There were 594 MACE including 108 deaths after PCI. Percent receiving DES was similar by HIV status (57% in HIV+ vs. 56% in HIV-). MACE rates were higher among those who received BMS (429.0, 95% CI 383.8-479.5) compared to DES (318.7, 95% CI 285.5-355.9), p=0.004 and the pattern is similar by HIV status. MACE rates were similar between HIV+ with CD4≥200 and HIV- (p=0.8), but higher for HIV+ with CD4 Conclusion: Stent type received did not vary by HIV status. HIV+ with CD4

Background: Previous research demonstrates an association between higher surgical volume and improved outcomes; however, there has been limited literature evaluating the association between volume and quality of care in cardiovascular patients. We examined the relationship between volume and compliance with selected outpatient quality measures for coronary artery disease (CAD). Methods: Using a contemporary cohort from the PINNACLE Registry ® (2009-2012), average monthly provider and practice volumes were calculated for CAD encounters. Performance for four American Heart Association (AHA) CAD measures (antiplatelets, beta blockers, ACE inhibitor/ARBs, lipid therapy) was assessed at the most recent encounter for each patient. The percentage of patients meeting 100% of quality measures was calculated for both providers and practices. We fit 3-level hierarchical logistic regression models to assess the relationship between provider and practice volume and performance on quality measures. Results: Data were available for 577,645 patients, representing 1,134 providers from 78 practices nationwide. Monthly practice volumes (median (IQR)) were 683 (251-1466) for CAD encounters and monthly provider volumes were 67 (33-119). Overall, 48% of patients met all CAD measures. The relationship between provider and practice volumes and adherence to performance measures varied significantly. Practice volume was not associated with adherence to performance measures (p = .49), however higher provider volume was positively associated with adherence to performance measures (p < 01) (See Figure 1 ). Conclusions: In the PINNACLE Registry ® performance on published quality measures for CAD was modest and variable. Higher provider volume was positively associated with adherence to performance measures, but there was no association between practice volume and performance.

Patients with prior coronary artery bypass graft (CABG) surgery often undergo percutaneous coronary intervention (PCI), yet the association between PCI target vessel on short- and long-term outcomes has received limited study. We sought to examine the frequency, associations and outcomes of native

Background: Blood pressure (BP) control among coronary artery disease (CAD) patients is sub-optimal in clinical practice and may be due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships are limited. Methods: We assessed BP trajectories among managed care patients with hypertension and incident CAD. Patients were stratified by target BP goal ( Results: 2763 patients had a Conclusions: In this managed care patient population, treatment intensification and medication adherence significantly affect BP trajectories in the year following CAD diagnosis.

To describe incidence and type of postoperative complications in the surgical management of incomplete ossification of the humeral condyle (IOHC) and identify any risk factors associated with development of these complications.Case series.Clinical records of dogs (n=57) that had prophylactic transcondylar screw insertion for treatment of IOHC (79 elbows) at 6 UK referral centers were reviewed. Signalment, presentation, surgical management, postoperative care, and complications were recorded. Postoperative complications were divided into seroma, surgical site infections (SSI) and implant complications.Spaniel breeds and entire males were overrepresented. The overall complication rate was 59.5%. Seroma (n=25) and SSI (24) were the most commonly encountered complications. Implant failure occurred in 2 dogs. Labrador retrievers were at greater risk of developing a postoperative complication than other breeds (P=.03). Increasing bodyweight was a significant risk factor for development of a SSI (P=.03). Placement of the transcondylar screw in lag fashion rather than as a positional screw reduced the incidence of postoperative SSI (P=.007).Surgical management of IOHC is associated with a high rate of postoperative complications. Placement of the transcondylar screw in lag fashion may limit postoperative complications and warrants further consideration.