Asheville Cardiology Associates

Feline bordetellosis is a respiratory disease caused by Bordetella bronchiseptica, a primary pathogen in domestic cats, dogs, and other species, particularly in densely housed populations. This case report outlines the management of an outbreak of B. bronchiseptica in cats in a suburban, limited-admission animal shelter in the Southeastern United States in October 2023. A group of 43 cats were managed, with 93% (40/43) morbidity and 100% (43/43) live outcomes (adoption) for treated cats. Outbreak management included recognition, case identification, risk assessment, diagnosis and treatment, decontamination, population management, documentation, and communication. The establishment of an offsite isolation facility and targeted treatment based on diagnostic testing were key to timely resolution. With proactive management and in collaboration with shelter medicine specialists, resolution of this outbreak occurred in 45 days.

There is a paucity of data regarding the longer-term durability of transcatheter heart valves. This analysis aimed to describe the 5-year clinical outcomes and valve durability for patients treated with the Portico transcatheter heart valves across 3 studies harmonized in their prospective enrollment, inclusion/exclusion criteria, centralized independent core laboratory echocardiographic analysis, and independent clinical events committee adjudication. Patient-level data from the PORTICO IDE randomized controlled trial, the PORTICO I postmarket study, and the PORTICO continued access protocol were pooled using a random-effects meta-analysis model. All 3 studies collected follow-up data at discharge, 30 days, and annually through 5 years. Adverse events and pooled echocardiographic data were assessed using Valve Academic Research Consortium-2 definitions. Durability definitions were adapted from Valve Academic Research Consortium-3 and European Association of Percutaneous Cardiovascular Interventions/European Society of Cardiology/European Association for Cardio-Thoracic Surgery consensus guidelines. A total of 1464 patients with severe symptomatic aortic stenosis and high or extreme surgical risk were included. Median age was 83 years, 61.7% were women, and the median Society of Thoracic Surgeons score was 4.9%. At 5 years, all-cause mortality and stroke rates were 49.4% and 12.3%, respectively. Transvalvular gradient and effective orifice area at 5 years were 6.2 mm Hg and 1.83 cm2, respectively, with paravalvular leak ≥moderate severity occurring in 1.9%. The 5-year bioprosthetic valve failure rate was 2.7%, including a 0.7% valve-related death rate and a 2.0% valve reintervention rate, but no patients with severe hemodynamic structural valve deterioration. Moderate hemodynamic structural valve deterioration occurred in 0.9% of the patients at 5 years. Hemodynamic performance and transcatheter heart valve durability remained stable irrespective of annular size. The use of the Portico transcatheter heart valve system in patients at high or extreme surgical risk demonstrated favorable clinical outcomes and hemodynamic performance with low transvalvular gradients and greater than mild paravalvular leak. Furthermore, bioprosthetic valve failure rates were low with no incidence of severe hemodynamic structural valve deterioration at 5 years, irrespective of annular size. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02000115 and NCT01802788.

ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease. Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use. Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography. Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

We introduce the SPRIG (Smart Proofs via Recursive Information Gathering) protocol. SPRIG allows agents to propose, question, and defend mathematical proofs in a decentralized fashion. A structure of stakes and bounties aims at producing debates in good faith and if those persist, they must go down to machine-level details, where they can be settled automatically. This combination of economic incentives and an oracle is designed to promote succinct and informative proofs. SPRIG can run autonomously as a smart contract on a blockchain platform, and hence it does not rely on a central trusted institution. We translate SPRIG into a general game-theoretic model and prove that the protocol satisfies two desirable properties: no spamming and monotonicity. We then characterize analytically the equilibrium of a simple two-player specification of the model: this provides important insights into the impact of the protocol’s parameters on the probabilities that it induces type I/II errors. We conclude by discussing the main attacks SPRIG’s designers will need to take into account.

A 30-year-old woman with a history of anorexia nervosa was admitted with weight loss, hypoglycaemia and electrolyte disturbances. During her admission, transaminases peaked at ALP 457 U/l, AST 817 U/l and ALT 1066 U/l. Imaging and laboratory findings were unrevealing, and she declined liver biopsy. Nutrition was introduced via a nasogastric tube and she demonstrated improvement in her laboratory values over several weeks. Her transaminitis was determined to be secondary to severe malnutrition, which has been previously described, but cases with such profound transaminitis are less common. Studies have demonstrated hepatic autophagocytosis as the likely cause.LEARNING POINTSAnorexia nervosa can cause severe liver injury as manifested in AST and ALT levels in the thousands.The slow reintroduction of enteral feeding can reverse liver injury.The mechanism is unclear but autophagocytosis of liver cells likely contributes to this phenomenon.

Abstract Background The optimal treatment target for ulcerative colitis (UC) is uncertain. The VERDICT trial in moderate to severe UC aims to determine if a treatment target of corticosteroid (CS)-free symptomatic + endoscopic + histologic remission is superior to CS-free symptomatic remission alone. Trial progress and the study cohort to date are described herein. Methods Our aim is to enrol 660 patients with moderately to severely active UC (Mayo rectal bleeding subscore [RBS] ≥1; Mayo endoscopic score [MES] ≥2). Patients are randomised to 3 treatment targets (2:3:5 ratio): CS-free symptomatic remission (Mayo RBS = 0) (Group 1); CS-free endoscopic remission (MES ≤1) + symptomatic remission (Group 2); or CS-free histologic remission (Geboes score &amp;lt;2B.0) + endoscopic + symptomatic remission (Group 3). Therapy is administered according to a treatment algorithm that is dependent upon each patient’s UC treatment at screening. Early introduction of vedolizumab (VDZ) and dose escalation up to 300 mg every 4 weeks until the target is met are central to each algorithm. Up to 3 opportunities to achieve the assigned target were prespecified in the algorithms (weeks 16, 32, or 48). Patients and central readers for endoscopy/histopathology are blinded to group allocation, and investigators are unblinded. Results As of 2 November 2022, 331 patients were enrolled at 55 sites across 10 North American and European countries. Mean (SD) baseline characteristics (Table) include a UC duration of 8.6 (8.3) years, Mayo Clinic score of 8.7 (1.7), C-reactive protein level of 13.3 (15.6) mg/dL, and a faecal calprotectin level of 1462.3 (1481.3) mg/kg. At baseline, 52% (172/331) and 11% (37/331) of patients were receiving concomitant CS and immunosuppressives, respectively, and 14% (47/331) had current/prior exposure to tumour necrosis factor antagonists. Most patients (85%) were receiving nonbiologic therapy. Of all randomised patients, 43/69 (Group 1), 65/98 (Group 2), and 115/164 patients (Group 3) have reached week 16; and 28 (65%), 25 (39%), and 42 (37%) met their target, respectively. After a median of 35 weeks (IQR 18-53), a total of 30 (Group 1), 32 (Group 2), and 50 patients (Group 3) have met their target and will be followed to relapse or study termination. The serious adverse event rate (8%; 36/483) was similar across groups. Conclusion VERDICT has randomised ~50% of its target enrolment. Enrolled patients represent a typical moderate to severe UC population and are primarily bionaive and receiving early VDZ initiation. Early results suggest the feasibility of achieving each treatment target, specifically histologic remission, and are consistent with expected values. No new VDZ safety signals were identified. Completion of enrolment is anticipated in late 2023.

When implementing interventions in primary care, tailoring implementation strategies to practice barriers can be effective, but additional work is needed to understand how to best select these strategies. This study sought to identify clinicians' contributions to the process of tailoring implementation strategies to barriers in clinical settings. We conducted a modified nominal group exercise involving 8 implementation scientists and 26 primary care clinicians in the WWAMI region Practice and Research Network. Each group identified implementation strategies it felt would best address barriers to using a cardiovascular disease (CVD) risk calculator previously identified across 44 primary care clinics from the Healthy Hearts Northwest pragmatic trial (2015 to 2018). These barriers had been mapped beforehand to the Consolidated Framework for Implementation Research (CFIR) domains. We examined similarities and differences in the strategies that 30% or more of each group identified (agreed-on strategies) for each barrier and for barriers in each CFIR domain. We used the results to demonstrate how strategies might be tailored to individual clinics. Clinicians selected 23 implementation strategies to address 1 or more of the 13 barriers; implementation scientists selected 35. The 2 groups agreed on at least 1 strategy for barriers in each CFIR domain: Inner Setting, Outer Setting, Intervention Characteristics, Characteristics of Individuals, and Process. Conducting local needs assessment and assessing for readiness/identifying barriers and facilitators were the 2 most common implementation strategies chosen only by clinicians. Clinician stakeholders identified implementation strategies that augmented those chosen by implementation scientists, suggesting that codesign of implementation processes between implementation scientists and clinicians may strengthen the process of tailoring strategies to overcome implementation barriers.