Effect of Maternal Flavour Conditioning Combined with Organic and Inorganic Iron-Supplemented Creep Feed on Piglet Performance and Haemoglobin Status.

Iron injections are vital but imperfect against iron deficiency anaemia (IDA). This experiment explored the effects on piglets of maternal flavour conditioning and the voluntary intake of anise flavoured, iron-supplemented creep feed compared with iron injections. The experiment was a 2 × 2 factorial arrangement: ±maternal exposure to dietary anise flavour and ±intramuscular injections of piglets. Twenty-three sows and their litters (242 piglets) were randomly allocated to one of four treatments (n = 5 or 6 per treatment): no flavour plus no injection (NF + NI); no flavour plus iron injection (NF + I); flavour plus no injection (F + NI); and flavour plus iron injection (F + I). All piglets could access anise flavoured, iron-supplemented creep feed (organic and inorganic forms) from D2 of birth. Sow feed intake and milk anethole concentration, piglet body weight (BW) and average daily gain (ADG), creep feed disappearance, piglet behavioural time budgets, and piglet blood glucose and haemoglobin concentrations were determined. Over the four-week study, the only significant differences found were that iron-injected piglets had reduced blood glucose (p = 0.036) on D14 and that maternal flavour provision increased the frequency of piglet creep feed interaction (p = 0.023) and decreased the frequency of suckling events (p = 0.009). In summary, maternal flavour conditioning reduced piglet creep feed neophobia without influencing consumption. The supplementation of creep feed with iron and anise flavour to piglets under the conditions of this trial was effective in preventing IDA, regardless of exposure to maternal flavouring conditioning.

A comparison between veterinary small animal general practitioners and emergency practitioners in Australia. Part 1: demographic and work-related factors.

Occupational stressors are commonly encountered in small animal veterinary practice and have been associated with burnout. The working context of veterinarians differs by specialty, and this can potentially lead to variable exposures to risk factors for burnout. The aim of this study was to explore differences in demographic and working conditions of veterinary general practitioners (GPs) and emergency practitioners (EPs) to compare exposure to different potential stressors. An anonymous, online survey was administered to veterinary GPs and EPs practicing in metropolitan regions of Australia. In total, 320 participant responses were analyzed (n = 237, 74.2% GPs and n = 83, 25.9% EPs). Significant differences (P < 0.05) in the demographics and work-related exposures were found between the two groups. GPs were found to be older than EPs with a greater number of years of experience in their field (P < 0.001). Most veterinary GPs worked only day shifts (207/236, 87.7%); where EPs worked a greater variety of shift patterns, with "only day shifts" being the least common shift pattern (P < 0.001). Most GPs worked a set and predictable roster pattern (195/236, 83.6%), while most EPs did not (51/83, 61.5%). EPs worked more weekends and public holidays (P < 0.001). The EP group performed more hours of work each week but worked less overtime. The main contributing factors for overtime were scheduling factors for GPs and staffing issues for EPs. EPs were commonly not able to take meal-breaks and GPs' meal-breaks were commonly interrupted by work. EPs were more frequently exposed to patient death, euthanasia (including for financial reasons), emotionally distressed clients and delivering negative news (P < 0.001). Both groups indicated that most work environments were collegiate and supportive, and a minority reported toxic colleagues (11.8%) or management teams (26.9%). Just under one-half of respondents reported having witnessed or experienced workplace bullying. Of our respondent group, 52.0% (166/319) were not satisfied with their remuneration. Desire to leave their principal area of practice was prevalent among this survey group (192/319, 60.2%) with approximately one-third considering leaving the veterinary profession. We discuss the implications of these workplace factors, including mitigation strategies.

A comparison between veterinary small animal general practitioners and emergency practitioners in Australia. Part 2: client-related, work-related, and personal burnout.

Burnout is reported to be common among veterinarians. However, there is limited research investigating the relationship between specific types of veterinary practice and burnout. A previous study found significant differences in work exposures between veterinary general practitioners (GPs) and emergency practitioners (EPs). The primary aim of this study was to investigate whether Australian veterinary EPs suffer from a higher level of burnout compared to veterinary GPs. The secondary aim of this study was to explore if the previously reported differences between GP and EP groups were positively associated with burnout. An anonymous, online survey incorporating the Copenhagen Burnout Inventory (CBI) was administered to veterinary GPs and EPs practicing in metropolitan regions of Australia. In total, 320 responses were analysed (n = 237, 74.2% GPs and n = 83, 25.9% EPs). Both groups suffered from moderate levels of burnout, but there were no significant differences in the severity of CBI burnout scores between the two groups. From the multivariable analysis four investigated factors were found to be significantly associated (p < 0.05) with the work-related CBI subscale: frequency of finishing work on time; adequate staffing; work satisfaction and seriously considering leaving their principal area of practice. Five factors were significantly associated (p < 0.05) with the client-related CBI subscale: position in practice; frequency of client adherence; work satisfaction; frequency of interacting with emotionally distressed clients and seriously considering leaving their principal area of practice. Four factors were significantly associated (p < 0.05) with the personal burnout CBI subscale: gender; seriously considering leaving their principal area of practice; frequency of interacting with emotionally distressed clients and the workplace environment. The total burnout score was also significantly associated (p < 0.05) with four factors: position in practice, workplace environment, appropriate staffing in the past week and client adherence. Future studies should focus on investigating effective strategies to mitigate these risk factors for both GPs and EPs, to reduce career attrition.

Feline radial and ulnar diaphyseal fractures: a retrospective study of 49 cases comparing single bone fixation and dual bone fixation.

OBJECTIVES: The objectives of this study were to report the complications in radial and ulnar diaphyseal fractures in cats and to compare the differences in outcome between single and dual bone internal fixation. METHODS: Medical records between 2004 and 2022 were searched retrospectively for cats with antebrachial diaphyseal fractures treated with internal bone-plate fixation. In total, 49 cases were included from six referral hospitals, including one teaching hospital. Patient information was collated, including fracture configuration, location, repair method and clinical outcome as assessed by veterinary physical examination, radiography and owner questionnaire. RESULTS: A total of 47 cats (mean age 4.2 years) were included. Fractures were located distally (24/49, 49%), proximally (13/49, 26.5%) and mid-diaphyseally (12/49, 24.5%). Dual bone fixation was used in 13/49 (26.5%) cases, with only 1/13 (7.7%) having major complications. By comparison, 4/36 (11.1%) of single plated fractures had major complications. Single bone fixation was 14.25 times more likely (95% confidence interval [CI] 2.07-97.99) to have a successful outcome (veterinarian-assigned score of 0) compared with dual bone fixation (P = 0.007). When evaluating owner-assessed outcomes, single bone fixation was 9.4 times more likely (95% CI 1.4-61.96) to have a successful outcome (owner score of 0) compared with dual bone fixation (P = 0.019). CONCLUSIONS AND RELEVANCE: Fractures that were repaired with single bone fixation had a greater chance of a better outcome. Although the difference was not significant, there was a higher major complication rate and a lower minor complication rate for cases treated with single bone fixation compared with dual bone fixation. The majority of fractures were located in the distal diaphysis. Comminution of the fracture and concurrent orthopaedic issues did not significantly affect the outcome. Further prospective studies with standardised follow-up, radiographic assessment, surgeon and implants are required to truly assess the difference between dual and single bone fixation.

Outcomes of treatment of cats with feline infectious peritonitis using parenterally administered remdesivir, with or without transition to orally administered GS-441524.

BACKGROUND: Nucleoside analog GS-441524 is effective in treating cats with feline infectious peritonitis (FIP). Investigation into the use of parent nucleotide analog remdesivir (GS-5734) is needed. OBJECTIVES: To assess efficacy and tolerability of remdesivir with or without transition to GS-441524 in cats with FIP and document clinical and clinicopathologic progression over 6 months. ANIMALS: Twenty-eight client-owned cats with FIP. METHODS: Cats were prospectively recruited between May 2021 and May 2022. An induction dosage of remdesivir 10 to 15 mg/kg intravenously or subcutaneously q24h was utilized for 4 doses, with a maintenance dosage of remdesivir (6-15 mg/kg SC) or GS-441524 (10-15 mg/kg per os) every 24 hours continued for at least 84 days. Laboratory testing, veterinary, and owner assessments were recorded. RESULTS: Twenty-four cats survived to 6 months (86%). Three cats died within 48 hours. Excluding these, survival from 48 hours to 6 months was 96% (24/25). Remission was achieved by day 84 in 56% (14/25). Three cats required secondary treatment for re-emergent FIP. Remission was achieved in all 3 after higher dosing (15-20 mg/kg). Adverse reactions were occasional site discomfort and skin irritation with remdesivir injection. Markers of treatment success included resolution of pyrexia, effusions, and presenting signs of FIP in the first half of treatment and normalization of globulin concentration, and continued body weight gains in the latter half of the treatment period. CONCLUSIONS AND CLINICAL IMPORTANCE: Parenteral administration of remdesivir and oral administration of GS-441524 are effective and well-tolerated treatments for FIP. Early emphasis on clinical, and later emphasis on clinicopathologic response, appears prudent when monitoring treatment efficacy.

Medium-Term Outcomes of Conservative and Surgical Treatments for Stress Urinary Incontinence: A Medicare Claims Analysis: Developed by the AUGS Payment Reform Committee.

OBJECTIVE: This study aimed to evaluate the 3- to 5-year retreatment outcomes for conservatively and surgically treated urinary incontinence (UI) in a population of women 66 years and older. METHODS: This retrospective cohort study used 5% Medicare data to evaluate UI retreatment outcomes of women undergoing physical therapy (PT), pessary treatment, or sling surgery. The data set used inpatient, outpatient, and carrier claims from 2008 to 2016 in women 66 years and older with fee-for-service coverage. Treatment failure was defined as receiving another UI treatment (pessary, PT, sling, Burch urethropexy, or urethral bulking) or repeat sling. A secondary analysis was performed where additional treatment courses of PT or pessary were also considered a treatment failure. Survival analysis was used to evaluate the time from treatment initiation to retreatment. RESULTS: Between 2008 and 2013, 13,417 women were included with an index UI treatment, and follow-up continued through 2016. In this cohort, 41.4% received pessary treatment, 31.8% received PT, and 26.8% underwent sling surgery. In the primary analysis, pessaries had the lowest treatment failure rate compared with PT (P<0.001) and sling surgery (P<0.001; survival probability, 0.94 [pessary], 0.90 [PT], 0.88 [sling]). In the analysis where retreatment with PT or a pessary was considered a failure, sling surgery had the lowest retreatment rate (survival probability, 0.58 [pessary], 0.81 [PT], 0.88 [sling]; P<0.001 for all comparisons). CONCLUSIONS: In this administrative database analysis, there was a small but statistically significant difference in treatment failure among women undergoing sling surgery, PT, or pessary treatment, but pessary use was commonly associated with the need for repeat pessary fittings.

Partial validation of a TaqMan quantitative polymerase chain reaction for the detection of the three genotypes of Infectious spleen and kidney necrosis virus.

Megalocytiviruses (MCVs) are double-stranded DNA viruses known to infect important freshwater and marine fish species in the aquaculture, food, and ornamental fish industries worldwide. Infectious spleen and kidney necrosis virus (ISKNV) is the type species within the genus Megalocytivirus that causes red seabream iridoviral disease (RSIVD) which is a reportable disease to the World Animal Health Organization (WOAH). To better control the transboundary spread of this virus and support WOAH reporting requirements, we developed and partially validated a TaqMan real-time qPCR assay (ISKNV104R) to detect all three genotypes of ISKNV, including the two genotypes that cause RSIVD. Parameters averaged across 48 experiments used a 10-fold dilution series of linearized plasmid DNA (107-101 copies), carrying a fragment of the three-spot gourami iridovirus (TSGIV) hypothetical protein revealed that the assay was linear over 7 orders of magnitude (107-101), a mean efficiency of 99.97 ± 2.92%, a mean correlation coefficient of 1.000 ± 0.001, and a limit of detection (analytical sensitivity) of ≤10 copies of TSGIV DNA. The diagnostic sensitivity and specificity for the ISKNV104R qPCR assay was evaluated and compared to other published assays using a panel of 397 samples from 21 source populations with different prevalence of ISKNV infection (0-100%). The diagnostic sensitivity and specificity for the ISKNV104R qPCR assay was 91.99% (87.28-95.6; 95% CI) and 89.8% (83.53-94.84). The latent class analysis showed that the ISKNV104R qPCR assay had similar diagnostic sensitivities and specificities with overlapping confidence limits compared to a second TaqMan qPCR assay and a SYBR green assay. This newly developed TaqMan assay represents a partially validated qPCR assay for the detection of the three genotypes of the species ISKNV. The ISKNV104R qPCR assay once fully validated, will serve as an improved diagnostic tool that can be used for ISKNV surveillance efforts and diagnosis in subclinical fish to prevent further spread of MCVs throughout the aquaculture and ornamental fish industries.

Clinicopathological and Epidemiological Findings in Pet Cats Naturally Infected with Feline Immunodeficiency Virus (FIV) in Australia.

Feline immunodeficiency virus (FIV) infection in experimentally infected domestic cats produces characteristic clinical manifestations including hematological changes, neurological disease, neoplasia (most notably lymphoma) and lymphopenia-mediated immunodeficiency predisposing cats to a range of secondary infections. Conflicting reports exist, however, with regard to disease associations and survival time in naturally FIV-infected cats. The purpose of this retrospective case−control study was to investigate the effect of natural FIV infection on hematological, blood biochemical and urinalysis parameters and survival time in three cohorts of pet cats in Australia. Cohorts 1 and 2 were recruited from a large veterinary hospital in Melbourne, Victoria (n = 525 and 282), while a third cohort consisted of cats recruited from around Australia as part of a FIV field vaccine efficacy trial (n = 425). FIV-infected cats in cohorts 1, 2 and 3 were found to have 15/37 (41%), 13/39 (33%) and 2/13 (15%) clinicopathological parameters significantly different to FIV-uninfected cats, respectively. Two changes in FIV-infected cats in cohort 1, hypochromia (low hemoglobin) and hyperglobulinemia, were outside the supplied reference intervals and should serve as diagnostic triggers for FIV testing. Kaplan−Meier survival analysis of cats in cohorts 1 and 2 combined did not find any difference between FIV-infected and FIV-uninfected cats, however a confounding factor was a large euthanasia rate within the first 12 months in both groups. Three significant (p < 0.05) spatial clusters of FIV infection were identified in Melbourne. A possible relationship between FIV infection status and socioeconomic disadvantage was discovered, based on three government indices of socioeconomic status (p < 0.001). Until longitudinal field studies are performed in Australia to further investigate the long-term effects of natural FIV infection, Australian veterinarians should consider FIV to be an important infection of pet cats, and recommend measures to prevent FIV infection.

Influence of Screw-Hole Defect Size on the Biomechanical Properties of Feline Femora in an Ex Vivo Model.

OBJECTIVE: The study aims to evaluate the biomechanical properties of feline femora with craniocaudal screw-hole defects of increasing diameter, subjected to three-point bending and torsion to failure at two different loading rates. STUDY DESIGN: Eighty femoral pairs were harvested from adult cat cadavers. For each bending and torsional experiment, there were five groups (n = 8 pairs) of increasing craniocaudal screw-hole defects (intact, 1.5 mm, 2.0 mm, 2.4 mm, 2.7mm). Mid-diaphyseal bicortical defects were created with an appropriate pilot drill-hole and tapped accordingly. Left and right femora of each pair were randomly assigned to a destructive loading protocol at low (10 mm/min; 0.5 degrees/s) or high rates (3,000 mm/min; 90 degrees/s) respectively. Stiffness, load/torque-to-failure, energy-to-failure and fracture morphology were recorded. RESULTS: Defect size to bone diameter ratio was significantly different between defect groups within bending and torsional experiments respectively (intact [0%; 0%], 1.5 mm [17.8%; 17.1%], 2.0 mm [22.8%; 23.5%], 2.4 mm [27.8%; 27.6%], 2.7 mm [31.1%; 32.4%]) (p < 0.001). No significant differences in stiffness and load/torque-to-failure were noted with increasing deficit sizes in all loading conditions. Screw-hole (2.7 mm) defects up to 33% bone diameter had a maximum of 20% reduction in bending and torsional strength compared with intact bone at both loading rates. Stiffness and load/torque-to-failure in both bending and torsion were increased in bones subjected to higher loading rates (p < 0.001). CONCLUSION: Screw-hole defects up to 2.7 mm did not significantly reduce feline bone failure properties in this ex vivo femoral study. These findings support current screw-size selection guidelines of up to 33% bone diameter as appropriate for use in feline fracture osteosynthesis.

Evaluation of Electroencephalography, Behaviour and Eye Temperature in Response to Surgical Castration in Sheep.

Castration has been demonstrated to cause pain in sheep. However, it is routinely performed for management purposes. Electroencephalography (EEG) has been used successfully to measure pain in lambs in response to castration and other husbandry procedures in livestock. The aim of this study was to evaluate the use of EEG as a measure of pain and analgesia in conscious lambs undergoing castration on farm over a 24 h period. EEG responses were compared to behavioural observations and changes in ocular temperature via infrared thermography. Twenty-four merino ram lambs (18.63 ± 2.06 kg) were used in this study. Lambs were randomly allocated to one of the following treatment groups: (1) castration with pre-surgical administration of meloxicam (0.5 mg/kg Metacam 20 mg/mL injected subcutaneously into the skin of the neck 15 min prior to recording) and lignocaine (applied via intra-testicular injection five minutes prior to castration, 2 mL lignocaine hydrochloride 20 mg/mL, Troy/Ilium) (CML, n = 8); (2) castration only (C, n = 8); (3) sham castration, handling only (SC, n = 8). EEG was recorded for 5 mins pre-procedure (prior to any intervention), and for 5 mins post-procedure at 0, 1, 4 and 24 h. Behavioural reactions to the procedure were scored, and behaviours were scan sampled at 5 min intervals at the above time points, by blinded observers. Eye temperature was measured for five-minute intervals at each time point. EEG decreased from baseline to 0 h for CML and C groups (p < 0.001), C group values returned similar to baseline at 24 h. Eye temperature increased post-castration at 0 h for C group, no initial change was seen for CML or SC groups. CML and C groups were more likely to have higher reaction scores and showed more abnormal behaviours (p = 0.017). CML and C groups had similar results, indicating minimal effect of analgesic intervention. Lambs in SC group showed significant EEG changes, suggesting that stress from handling also impacted EEG results.

Anticholinergic prescribing pattern changes of urogynecology providers in response to evidence of potential dementia risk.

INTRODUCTION AND HYPOTHESIS: Recent publications show an association between exposure to anticholinergic medications and the risk of developing dementia. We hypothesized that urogynecology providers have changed their overactive bladder syndrome treatment as a result of this literature. METHODS: This was an anonymous, cross-sectional, web-based survey of American Urogynecologic Society members. Survey questions queried awareness of the referenced literature, prescribing practices, the impact of insurance on treatment plans, and demographics. Our primary outcome measured the change in prescribing practice in response to literature linking anticholinergic medications with the risk of dementia. Descriptive statistics were used. RESULTS: A total of 222 urogynecology providers completed the survey. Nearly all respondents (99.1%) were aware of the recent literature, and, as a result, 90.5% reported changing their practice. Prior to the publication of recent literature, a "non-CNS-sparing" anticholinergic (e.g., oxybutynin) was most commonly prescribed (64.4%), whereas after the literature was published, this shifted to ß3-adrenoceptor agonists (58.5%, p < 0.001). A majority of respondents (96.6%) reported that insurance restrictions led to a change in treatment for some patients, with 73.5% describing the prior-authorization process as difficult. Many providers (61.8%) reported that a trial of anticholinergics was required by insurance companies prior to authorizing mirabegron. CONCLUSIONS: The recent literature associating anticholinergic medications with the development of dementia has changed practice patterns among survey respondents, with a shift away from anticholinergic medications and toward ß3-adrenoceptor agonists. The majority of respondents report insurance barriers to non-anticholinergic therapies, resulting in alteration of their preferred practices.

Anti-SU Antibody Responses in Client-Owned Cats Following Vaccination against Feline Leukaemia Virus with Two Inactivated Whole-Virus Vaccines (Fel-O-Vax® Lv-K and Fel-O-Vax® 5).

A field study undertaken in Australia compared the antibody responses induced in client-owned cats that had been vaccinated using two inactivated whole feline leukaemia virus (FeLV) vaccines, the monovalent vaccine Fel-O-Vax® Lv-K and the polyvalent vaccine Fel-O-Vax® 5. Serum samples from 428 FeLV-uninfected cats (118 FeLV-vaccinated and 310 FeLV-unvaccinated) were tested for anti-FeLV neutralising antibodies (NAb) using a live virus neutralisation assay to identify 378 FeLV-unexposed (NAb-negative) and 50 FeLV-exposed (NAb-positive; abortive infections) cats, following by anti-surface unit (SU) FeLV-A and FeLV-B antibody ELISA testing. An additional 42 FeLV-infected cats (28 presumptively regressively infected, 14 presumptively progressively infected) were also tested for anti-SU antibodies. NAb-positive cats displayed significantly higher anti-SU antibody ELISA responses compared to NAb-negative cats (p < 0.001). FeLV-unexposed cats (NAb-negative) that had been vaccinated less than 18 months after a previous FeLV vaccination using the monovalent vaccine (Fel-O-Vax® Lv-K) displayed higher anti-SU antibody ELISA responses than a comparable group vaccinated with the polyvalent vaccine (Fel-O-Vax® 5) (p < 0.001 for both anti-FeLV-A and FeLV-B SU antibody responses). This difference in anti-SU antibody responses between cats vaccinated with the monovalent or polyvalent vaccine, however, was not observed in cats that had been naturally exposed to FeLV (NAb-positive) (p = 0.33). It was postulated that vaccination with Fel-O-Vax® 5 primed the humoral response prior to FeLV exposure, such that antibody production increased when the animal was challenged, while vaccination with Fel-O-Vax® Lv-K induced an immediate preparatory antibody response that did not quantitatively increase after FeLV exposure. These results raise questions about the comparable vaccine efficacy of the different FeLV vaccine formulations and correlates of protection.

Rethinking Second-Line Therapy for Overactive Bladder to Improve Patient Access to Treatment Options.

Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. ß3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to ß3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.

A comparison of multivalent and bivalent vaccination strategies for the control of virulent ovine footrot.

Virulent footrot is a significant economic and animal welfare concern. The disease can be treated, controlled, and eliminated with vaccine, but selecting the appropriate vaccination strategy can be challenging. There are two main strategies: outbreak (serogroup)-specific univalent or bivalent vaccination, or use of a multivalent vaccine containing up to nine of the most common serogroups. The objective of this study was to compare these approaches in sheep flocks infected with multiple Dichelobacter nodosus serogroups. In the first phase, we undertook an immunogenicity trial in which we compared four pre-commercial multivalent recombinant fimbrial vaccines containing six (A, B, C, G, H, I) or nine (A, B, C, D, E, F, G, H, I) serogroups, and compared them to commercial bivalent vaccines. Two multivalent vaccines stimulated significantly higher antibody responses than two other multivalent vaccines but the number of serogroups included in the multivalent vaccine formulations did not have a significant effect. In the first phase, we also compared inter-vaccination intervals of two- and three-months between sequential bivalent vaccines, and found that a two-month interval was sufficient to avoid antigenic competition. In the second phase, the most immunogenic multivalent vaccine (nine serogroups) was compared to sequential bivalent vaccines and monthly foot-bathing in a field trial in four commercial Merino flocks. The duration of protection afforded by the multivalent vaccine was likely to be less than that of the bivalent vaccines, as the antibody titres stimulated were lower and less persistent.

Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

ABSTRACT: Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Ready for the robot? A cross-sectional survey of OB/GYN fellowship directors' experience and expectations of their incoming fellow's robotic surgical skills.

To describe OB/GYN fellowship directors' (FDs) observations, expectations, and preferences of incoming fellow's robotic surgery preparedness. Cross-sectional study. OB/GYN FDs in gynecologic oncology, minimally invasive gynecologic surgery, female pelvic medicine and reconstructive surgery, and reproductive endocrinology and infertility in the United States. 60 FDs answered the questionnaire. Participants completed an online questionnaire about their preferences and expectations of robotic surgery experience for incoming fellows. FDs observed that many incoming first-year fellows had a baseline understanding of robotic technology (60%) and robotic bedside assist experience (53%). However, few could perform more advanced robotic tasks; with FDs indicating fellows could infrequently robotically suture (18%), or perform the entire hysterectomy (15%). FDs reported higher composite observation than expectation scores (34.3 versus 22.2, p < 0.0001), and higher preference than expectation scores (34.0 versus 22.2, p < 0.0001). The composite expectation score of high-volume divisions was greater than of low-volume divisions (23.7 versus 14.0, p = 0.04). Among the domains identified, FDs most strongly preferred their fellows be able to bedside assist, have a basic understanding of robotic technology, and have basic robotic operative skills. While incoming fellows have more robotic skill than their FDs expect, few are deemed competent to independently operate the robot. Higher volume robotic surgery divisions have higher expectations of the robotic skills of their incoming fellows compared to low-volume divisions; however, FDs neither expected nor preferred their incoming fellows to be fully competent in all aspects of robotic surgery.

Prevalence of Infectious Spleen and Kidney Necrosis Virus (ISKNV), Nervous Necrosis Virus (NNV) and Ectoparasites in Juvenile Epinephelus spp. Farmed in Aceh, Indonesia.

A cross-sectional survey was used to estimate the prevalence of infections with the Infectious spleen and kidney necrosis virus (ISKNV, Megalocytivirus), nervous necrosis virus (NNV, Betanodavirus), and infestations with ectoparasites during the rainy season in juvenile grouper (Epinephelus spp.) farmed in Aceh, Indonesia. The survey was intended to detect aquatic pathogens present at 10% prevalence with 95% confidence, assuming 100% sensitivity and specificity using a sample size of 30 for each diagnostic test. Eight populations of grouper from seven farms were sampled. Additional targeted sampling was conducted for populations experiencing high mortality. Infection with NNV was detected at all farms with seven of the eight populations being positive. The apparent prevalence for NNV ranged from 0% (95% CI: 0-12) to 73% (95% CI: 54-88). All of the fish tested from the targeted samples (Populations 9 and 10) were positive for NNV and all had vacuolation of the brain and retina consistent with viral nervous necrosis (VNN). Coinfections with ISKNV were detected in five populations, with the highest apparent prevalence being 13% (95% CI: 4-31%). Trichodina sp., Cryptocaryon irritans and Gyrodactylus sp. were detected at three farms, with 66% to 100% of fish being infested. Hybrid grouper sourced from a hatchery were 5.4 and 24.9 times more likely to have a NNV infection and a higher parasite load compared to orange-spotted grouper collected from the wild (p < 0.001). This study found that VNN remains a high-impact disease in grouper nurseries in Aceh, Indonesia.

A low-cost approach to salpingectomy at cesarean delivery.

There is increasing adoption of opportunistic salpingectomy for ovarian cancer prevention at the time of gynecologic surgery, which includes the postpartum period. However, there is no consensus on an ideal surgical approach for the parturient vasculature. We describe a safe, low-cost, and accessible approach for bilateral salpingectomy during cesarean delivery that we call the "Mesosalpinx Isolation Salpingectomy Technique" (MIST) that can guide institutions to standardize their postpartum salpingectomy procedures when advanced vessel-sealing devices are not available. In the MIST technique, avascular windows are created within the mesosalpinx close to the tubal vessels. The vasculature is thus fully skeletonized and isolated from the adjacent mesosalpinx before suture ligation, which ensures security of the free-tie to the individual vessels and avoids sharp injury to the mesosalpinx. Not using vessel-sealing devices also eliminates the risk of thermal injury to the adjacent ovarian tissue and vasculature and potentially achieves a cost-savings for the hospital and patient. MIST has been performed in 141 cesarean deliveries in the past 4 years. There were no noted bleeding complications during the salpingectomy procedure, blood transfusions, or instances of postoperative surgical reexploration. In our experience, a surgeon who is new to the procedure takes approximately 15 minutes to complete a bilateral salpingectomy. Those surgeons who are experienced in MIST need only 5 minutes. A video is included that demonstrates the technique.