Risk of Mortality Following Surgery in Patients With a Previous Cardiovascular Event.

Importance: There is a lack of consensus regarding the interval of time-dependent postoperative mortality risk following acute coronary syndrome or stroke. Objective: To determine the magnitude and duration of risk associated with the time interval between a preoperative cardiovascular event and 30-day postoperative mortality. Design, Setting, and Participants: This is a longitudinal retrospective population-based cohort study. This study linked data from the Hospital Episode Statistics for National Health Service England, Myocardial Ischaemia National Audit Project and the Office for National Statistics mortality registry. All adults undergoing a National Health Service-funded noncardiac, nonneurologic surgery in England between April 1, 2007, and March 31, 2018, registered in Hospital Episode Statistics Admitted Patient Care were included. Data were analyzed from July 2021 to July 2022. Exposure: The time interval between a previous cardiovascular event (acute coronary syndrome or stroke) and surgery. Main Outcomes and Measures: The primary outcome was 30-day all-cause mortality. Secondary outcomes were postoperative mortality at 60, 90, and 365 days. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios. Results: There were 877 430 patients with and 20 582 717 without a prior cardiovascular event (overall mean [SD] age, 53.4 [19.4] years; 11 577 157 [54%] female). Among patients with a previous cardiovascular event, the time interval associated with increased risk of postoperative mortality was surgery within 11.3 months (95% CI, 10.8-11.7), with subgroup risks of 14.2 months before elective surgery (95% CI, 13.3-15.3) and 7.3 months for emergency surgery (95% CI, 6.8-7.8). Heterogeneity in these timings was noted across many surgical specialties. The time-dependent risk intervals following stroke and myocardial infarction were similar, but the absolute risk was greater following a stroke. Regarding surgical urgency, the risk of 30-day mortality was higher in those with a prior cardiovascular event for emergency surgery (adjusted hazard ratio, 1.35; 95% CI, 1.34-1.37) and an elective procedure (adjusted hazard ratio, 1.83; 95% CI, 1.78-1.89) than those without a prior cardiovascular event. Conclusions and Relevance: In this study, surgery within 1 year of an acute coronary syndrome or stroke was associated with increased postoperative mortality before reaching a new baseline, particularly for elective surgery. This information may help clinicians and patients balance deferring the potential benefits of the surgery against the desire to avoid increased mortality from overly expeditious surgery after a recent cardiovascular event.

Strangulating intestinal obstructions in four captive elephants (Elephas maximus and Loxodonta africana).

Three captive-born (5-day-old, 8-day-old, and 4-yr-old) Asian elephants (Elephas maximus) and one captive-born 22-yr-old African elephant (Loxodonta africana) from three private elephant facilities and one zoo in the United States presented with depression, anorexia, and tachycardia as well as gastrointestinal signs of disease including abdominal distention, decreased borborygmi, tenesmus, hematochezia, or diarrhea. All elephants showed some evidence of discomfort including agitation, vocalization, or postural changes. One animal had abnormal rectal findings. Nonmotile bowel loops were seen on transabdominal ultrasound in another case. Duration of signs ranged from 6 to 36 hr. All elephants received analgesics and were given oral or rectal fluids. Other treatments included warm-water enemas or walking. One elephant underwent exploratory celiotomy. Three animals died, and the elephant taken to surgery was euthanized prior to anesthetic recovery. At necropsy, all animals had severe, strangulating intestinal lesions.

Nonsurgical repair of an umbilical hernia in two Asian elephant calves (Elephas maximus).

Umbilical hernias were diagnosed in two captive-born, female Asian elephant (Elephas maximus) calves several weeks after birth. Daily manual reduction of the hernias for 5 wk in the first case and for 5 mo in the second resulted in complete closure of the defects. Nonsurgical repair of uncomplicated, fully reducible umbilical hernias in Asian elephants can be an alternative to surgery.

Pericardial mesothelioma in a Bengal tiger (Panthera tigris).

A 17-year-old Bengal tiger (Panthera tigris) presented with dyspnea and tachypnea. Radiographs revealed severe pleural and pericardial effusion, but no obvious mass. During attempts to remove the fluid under anesthesia, the cat developed cardiac tamponade and died. At necropsy, a nodular mass was found at the heart base and was identified as a pericardial mesothelioma. This is the first report of this tumor in any large cat.

Medical management of a corneal stromal abscess in a female Asian elephant (Elephas maximus).

A 47-yr-old female Asian elephant (Elephas maximus) developed a corneal stromal abscess in her right eye. The elephant was trained to open her eye for topical ophthalmic therapy, and was treated six times daily with antibiotics and an antifungal solution for almost 2 mo. Nonsteroidal anti-inflammatory drugs were used to control pain, and atropine was applied topically to dilate the pupil and provide additional comfort. Vascularization of the abscess began shortly after initiating therapy, and complete resolution was obtained by 7 wk.

Nasopharyngeal myxosarcoma in a Bengal tiger (Panthera tigris).

An 18- to 25-yr-old intact female Bengal tiger (Panthera tigris) was diagnosed antemortem and postmortem with nasopharyngeal myxosarcoma metastatic to the lung, chronic lymphoplasmacytic otitis media, and lymphoplasmacytic and eosinophilic stomatitis. Myxosarcomas are rare in domestic animals and seldom metastasize; this tumor has not been previously reported in an exotic felid. Computed tomography of the skull was used during the diagnoses.

Management of zebras and zebra hybrids (zebroids).

Equine practitioners are sometimes asked to treat zebras or zebra-horse or zebra-donkey hybrids. Although these equids are subject to many of the same health issues as domestic horses, they cannot be handled like horses and generally require heavy sedation to full anesthesia, even for minor procedures. This usually necessitates the use of ultrapotent narcotics administered by remote delivery systems. This article discusses the handling, sedation, anesthesia, and common medical issues of zebras and zebra hybrids.

Estimates of the pharmacokinetics of famciclovir and its active metabolite penciclovir in young Asian elephants (Elephas maximus).

OBJECTIVE: To determine plasma pharmacokinetics of penciclovir following oral and rectal administration of famciclovir to young Asian elephants (Elephas maximus). ANIMALS: 6 healthy Asian elephants (5 females and 1 male), 4.5 to 9 years old and weighing 1,646 to 2,438 kg. PROCEDURES: Famciclovir was administered orally or rectally in accordance with an incomplete crossover design. Three treatment groups, each comprising 4 elephants, received single doses of famciclovir (5 mg/kg, PO, or 5 or 15 mg/kg, rectally); there was a minimum 12-week washout period between subsequent famciclovir administrations. Serial blood samples were collected after each administration. Samples were analyzed for famciclovir and penciclovir with a validated liquid chromatography-mass spectroscopy assay. RESULTS: Famciclovir was tolerated well for both routes of administration and underwent complete biotransformation to the active metabolite, penciclovir. Mean maximum plasma concentration of penciclovir was 1.3 µg/mL at 1.1 hours after oral administration of 5 mg/kg. Similar results were detected after rectal administration of 5 mg/kg. Mean maximum plasma concentration was 3.6 µg/mL at 0.66 hours after rectal administration of 15 mg/kg; this concentration was similar to results reported for humans receiving 7 mg/kg orally. CONCLUSIONS AND CLINICAL RELEVANCE: Juvenile Asian elephants are susceptible to elephant endotheliotropic herpesvirus. Although most infections are fatal, case reports indicate administration of famciclovir has been associated with survival of 3 elephants. In Asian elephants, a dose of 8 to 15 mg of famciclovir/kg given orally or rectally at least every 8 hours may result in penciclovir concentrations that are considered therapeutic in humans.

Immune responses of Asian elephants (Elephas maximus) to commercial tetanus toxoid vaccine.

Although captive elephants are commonly vaccinated annually against tetanus using commercially available tetanus toxoid vaccines marketed for use in horses and livestock, no data exists to prove that tetanus toxoid vaccination produces measurable antibody titers in elephants. An ELISA test was created to measure antibody responses to tetanus toxoid vaccinations in 22 Asian elephants ranging in age from 24 to 56 years (mean age 39 years) over a 7-month period. All animals had been previously vaccinated with tetanus toxoid vaccine, with the last booster administered 4 years before the start of the study. The great majority of elephants had titers prior to booster vaccination, and following revaccination all elephants demonstrated anamnestic increases in titers, indicating that this species does respond to tetanus vaccination. Surprisingly older animals mounted a significantly higher response to revaccination than did younger animals.