Cardiovascular MRI evidence of reduced systolic function and reduced LV mass in rheumatoid arthritis: impact of disease phenotype.

The accelerated risk of cardiovascular disease (CVD) in Rheumatoid Arthritis (RA) requires further study of the underlying pathophysiology and determination of the at-risk RA phenotype. Our objectives were to describe the cardiac structure and function and arterial stiffness, and association with disease phenotype in patients with established) RA, in comparison to healthy controls, as measured by cardiovascular magnetic resonance imaging (CMR). 76 patients with established RA and no history of CVD/diabetes mellitus were assessed for RA and cardiovascular profile and underwent a non-contrast 3T-CMR, and compared to 26 healthy controls. A univariable analysis and multivariable linear regression model determined associations between baseline variables and CMR-measures. Ten-year cardiovascular risk scores were increased in RA compared with controls. Adjusting for age, sex and traditional cardiovascular risk factors, patients with RA had reduced left ventricular ejection fraction (mean difference - 2.86% (- 5.17, - 0.55) p = 0.016), reduced absolute values of mid systolic strain rate (p < 0.001) and lower late/active diastolic strain rate (p < 0.001) compared to controls. There was evidence of reduced LV mass index (LVMI) (- 4.56 g/m2 (- 8.92, - 0.20), p = 0.041). CMR-measures predominantly associated with traditional cardiovascular risk factors; male sex and systolic blood pressure independently with increasing LVMI. Patients with established RA and no history of CVD have evidence of reduced LV systolic function and LVMI after adjustment for traditional cardiovascular risk factors; the latter suggesting cardiac pathology other than atherosclerosis in RA. Traditional cardiovascular risk factors, rather than RA disease phenotype, appear to be key determinants of subclinical CVD in RA potentially warranting more effective cardiovascular risk reduction programs.

Identifying and exploring factors influencing career choice, recruitment and retention of anaesthesia trainees in the UK.

BACKGROUND: Many acute hospital specialties are experiencing low recruitment and high attrition of trainees. Understanding what is important to current trainees is critical in terms of identifying and addressing factors which adversely affect recruitment and retention. OBJECTIVES: To identify and explore factors involved in anaesthetic trainees' career decision making. METHODS: This was a mixed methods study using a questionnaire survey (assessing how influential 18 different factors were when choosing anaesthetics, using a five-point Likert scale), supplemented by semi-structured interviews, carried out in August-December 2014, in Scotland, UK. RESULTS: 42/68 (62%) completed responses were received, representing over half of all core (58%) and Acute Care Common Stem (65%) trainees across Scotland. Overall, questionnaire data indicated that the following were most important in career decision making: perceived job satisfaction among those already in the specialty, structured training, the nature of the work (practical, varied, immediate outcomes). Thirteen interviews were carried out. These highlighted that prior positive exposure and experience with anaesthetists encouraged trainees into the specialty. Enthusiastic, supportive colleagues and structured training (including clear milestones, regular teaching and feedback) were considered to enhance the quality of training. Sustainable working conditions, flexibility within programme and out-of-programme opportunities were valued. Respondents reported concerns about the impact of increasing service delivery demands on training quality. CONCLUSIONS: Many of the elements important to today's anaesthetics trainees are related to positive learning and working environments. This fits with research findings from other professional groups. These findings can inform the development of programmes which cultivate trainee commitment to, and enthusiasm for, anaesthetics.

The patient journey from symptom onset to pacemaker implantation.

BACKGROUND: Regional variation in permanent pacemaker (PPM) implantation rates is well described, the reasons for which are unclear. Significant delays to PPM implantation in UK practice were described 20 years ago, but contemporary data are lacking. AIM: To investigate delays to PPM implantation and their causes. DESIGN: Prospective observational study in a UK regional pacing centre and its referring district hospitals. METHODS: A total of 95 consecutive patients receiving first PPM implant for bradycardia indications from 1 June 2006 to 31 August 2006 were included. Hospital records from the referring and implanting centres were reviewed to determine the timings of: symptom onset; first hospital contact; documented pacing indication (defined by 2002 ACC/AHA/NASPE guidelines); referral to implanter; and PPM implantation. RESULTS: Forty-eight patients (51%) were referred for pacing urgently; median delay from symptoms to PPM 15 days (range 0-7332 days). Forty-seven patients (49%) were referred electively; median delay from symptoms to PPM 380 days (range 33-7505 days), P < 0.0001. Twenty-three of the 47 elective patients (49%) had previous hospitalization with symptoms suggestive of bradycardia. Thirty-three of the 95 patients (35%) had a Class I or IIa pacing indication which did not trigger a pacing referral. CONCLUSION: There are significant delays to PPM implantation in the United Kingdom, longer in those treated electively than those managed as emergencies. Some delays are due to 'process' problems including waiting lists, but a substantial proportion of patients had delays due to failure to refer for pacing once a pacing indication was documented.

Four cases of equine polysaccharide storage myopathy in the United Kingdom.

This paper describes four cases of equine polysaccharide storage myopathy which were confirmed by histological examination of muscle biopsy specimens. The horses were of mixed breeding, with warmblood and thoroughbred dominating. They all had recurrent episodes of rhabdomyolysis, indicated by clinical signs and increased plasma levels of muscle enzymes. They were managed conservatively and have continued athletic careers despite their disease.

Acquired flexural deformity of the metacarpophalangeal joint in five horses associated with tendonous damage in the palmar metacarpus.

Five cases of acquired flexural deformity of the metacarpophalangeal joint (MCPJ) in older horses and ponies were studied. The mean age of affected horses was 14-8 years. Four deformities developed following desmitis of the accessory ligament of the deep digital flexor tendon (ALDDFT) and superficial digital flexor tendon (SDFT) and one following tendonitis of the SDFT alone. All cases were markedly lame and demonstrated variable degrees of flexural deformity. Ultrasonographic examination was performed on all cases which revealed extensive adhesion formation between the ALDDFT and SDFT and reduced cross-sectional area of the deep digital flexor tendon in each case. A variety of treatments were unsuccessfully employed to treat this condition. The prognosis for acquired flexural deformity of the MCPJ in old horses following tendonous damage in the palmar metacarpus is likely to be poor.

An unusual case of distal phalanx fracture in a horse.

A mature thoroughbred cross gelding with an acute onset forelimb lameness was found to have sustained a fracture to the distal phalanx. The fracture traversed the distal phalanx In a lateromedial direction dividing the phalanx into two halves, dorsally and palmarly and was classed a frontal fracture. The horse was treated conservatively and after 14 months rest it returned to work. Three years later the horse has remained sound.

Protozoan encephalomyelitis causing pelvic limb paresis in a yearling sheep.

A pelvic limb paresis of 6 weeks duration in a yearling sheep resulted from protozoan encephalomyelitis involving the spinal cord at the thoracolumbar junction. An elevated lumbosacral cerebrospinal fluid protein concentration but normal cisternal cerebrospinal fluid protein concentration indicated the presence of a thoracolumbar inflammatory lesion resulting in cord compression which obstructed the rostral flow of the cerebrospinal fluid. Under general anaesthesia, myelography at the lumbo-sacral site demonstrated blockage to the rostral flow of contrast medium at T13/L1. At necropsy, there were no gross pathological changes at T13/L1, but histopathology revealed non-tract specific lymphocytic perivascular cuffing, axonal swelling and oedema in the spinal cord, characteristic of a protozoal encephalomyelitis. No parasites were detected in the multiple spinal cord sections examined but immunocytochemistry identified antigens cross-reactive with Sarcocystis spp. antigens in glial cells in these lesions.