Nanosecond anomaly detection with decision trees and real-time application to exotic Higgs decays.

We present an interpretable implementation of the autoencoding algorithm, used as an anomaly detector, built with a forest of deep decision trees on FPGA, field programmable gate arrays. Scenarios at the Large Hadron Collider at CERN are considered, for which the autoencoder is trained using known physical processes of the Standard Model. The design is then deployed in real-time trigger systems for anomaly detection of unknown physical processes, such as the detection of rare exotic decays of the Higgs boson. The inference is made with a latency value of 30 ns at percent-level resource usage using the Xilinx Virtex UltraScale+ VU9P FPGA. Our method offers anomaly detection at low latency values for edge AI users with resource constraints.

Incremental value of machine learning for risk prediction in tetralogy of Fallot.

OBJECTIVE: Machine learning (ML) can facilitate prediction of major adverse cardiovascular events (MACEs) in repaired tetralogy of Fallot (rTOF). We sought to determine the incremental value of ML above expert clinical judgement for risk prediction in rTOF. METHODS: Adult congenital heart disease (ACHD) clinicians (≥10 years of experience) participated (one cardiac surgeon and four cardiologists (two paediatric and two adult cardiology trained) with expertise in heart failure (HF), electrophysiology, imaging and intervention). Clinicians identified 10 high-yield variables for 5-year MACE prediction (defined as a composite of mortality, resuscitated sudden death, sustained ventricular tachycardia and HF). Risk for MACE (low, moderate or high) was assigned by clinicians blinded to outcome for adults with rTOF identified from an institutional database (n=25 patient reviews conducted by five independent observers). A validated ML model identified 10 variables for risk prediction in the same population. RESULTS: Prediction by ML was similar to the aggregate score of all experts (area under the curve (AUC) 0.85 (95% CI 0.58 to 0.96) vs 0.92 (0.72 to 0.98), p=0.315). Experts with ≥20 years of experience had superior discriminative capacity compared with <20 years (AUC 0.98 (95% CI 0.86 to 0.99) vs 0.80 (0.56 to 0.93), p=0.027). In those with <20 years of experience, ML provided incremental value such that the combined (clinical+ML) AUC approached ≥20 years (AUC 0.85 (95% CI 0.61 to 0.95), p=0.055). CONCLUSIONS: Robust prediction of 5-year MACE in rTOF was achieved using either ML or a multidisciplinary team of ACHD experts. Risk prediction of some clinicians was enhanced by incorporation of ML suggesting that there may be incremental value for ML in select circumstances.

INVITED REVIEW: Prevalence, risk factors, treatment, and barriers to best practice adoption for lameness and injuries in dairy cattle: A narrative review.

Lameness and leg injuries are both painful and prevalent across the dairy industry, and are a major welfare concern. There has been a considerable amount of research focused on investigating the risk factors associated with lameness and injuries and how they might be prevented and treated. The objectives of this narrative review were to summarize herd-level prevalence estimates, risk factors, strategies for prevention, control, and treatment of these conditions, and the barriers to best practice adoption for lameness and injuries on dairy farms. There is a relatively high within-herd prevalence of lameness on dairy farms globally, with a recent systematic review estimating the mean prevalence at 22.8%. Similarly, there is a relatively high prevalence of hock injuries, with within-herd estimates ranging from 12 to 81% of cows affected. Knee and neck injuries have been reported to be less common; 6-43% and 1-33%, respectively. Numerous risk factors have been associated with the incidence of lameness, notably housing (e.g., access to pasture, bedding depth, bedding type, flooring type, stall design), management (e.g., stall cleanliness, frequency of trimming, holding times, stocking density), and cow-level (e.g., body condition, parity, injured hocks) factors. Risk factors associated with hock injuries can be similarly classified into housing (e.g., bedding type and depth, outdoor access, parlor type, stall design), management (e.g., bedding depth, cleanliness), and cow (e.g., parity, days in milk, lameness) factors. Key preventative approaches for lameness include routine preventative and corrective hoof trimming, improving hoof cushioning and traction through access to pasture or adding rubber flooring, deep-bedded stalls, sand bedding, ensuring appropriate stocking densities, reduced holding times, and the frequent use of routine footbaths. Very little research has been conducted on hock, knee, and neck injury prevention and recovery. Numerous researchers have concluded that both extrinsic (e.g., time, money, space) and intrinsic (e.g., farmer attitude, perception, priorities, and mindset) barriers exist to addressing lameness and injuries on dairy farms. There are many diverse stakeholders in lameness and injury management including the farmer, farm staff, veterinarian, hoof trimmer, nutritionist, and other advisors. Addressing dairy cattle lameness and injuries must, therefore, consider the people involved, as it is these people who are influencing and implementing on-farm decisions related to lameness prevention, treatment, and control.

Long-Term Outcomes of Unrepaired Isolated Partial Anomalous Pulmonary Venous Connection With an Intact Atrial Septum.

The natural history of an unrepaired isolated partial anomalous pulmonary venous connection(s) (PAPVC) and the absence of other congenital anomalies remains unclear. This study aimed to expand the understanding of the clinical outcomes in this population. Isolated PAPVC with an intact atrial septum is a relatively uncommon condition. There is the perception that patients with isolated PAPVC are usually asymptomatic, that the lesion generally has a limited hemodynamic impact, and that surgical repair is rarely justified. For this retrospective study, we reviewed our institutional database to identify patients with either 1 or 2 anomalous pulmonary veins that drain a portion of but not the complete ipsilateral lung. Patients with previous surgical cardiac repair, coexistence of other congenital cardiac anomalies that would result in either pretricuspid or post-tricuspid loading of the right ventricle (RV), or scimitar syndrome were excluded. We reviewed their clinical course over the follow-up period. We identified 53 patients; 41 with a single and 12 with 2 anomalous PAPVC. A total of 30 patients (57%) were men, with a mean age at the latest clinic visit of 47 ± 19 years (18 to 84 years). Turner syndrome (6 of 53, 11.3%), bicuspid aortic valve (6 of 53, 11.3%), and coarctation of the aorta (5 of 53, 9.4%) were commonly associated anomalies. A single anomalous left upper lobe vein was the most commonly identified variation. More than half of the patients were asymptomatic. Cardiopulmonary exercise test demonstrated a maximal oxygen consumption of 73 ± 20% expected (36 to 120). Transthoracic echocardiography demonstrated a mean RV basal diameter of 4.4 ± 0.8 cm, RV systolic pressure of 38 ± 13 (16 to 84) mm Hg. A total of 8 patients (14.8%) had ≥moderate tricuspid regurgitation. Cardiac magnetic resonance in 42 patients demonstrated a mean RV end-diastolic volume index of 122 ±3 0 ml/m2 (66 to 188 ml/m2), of which in 8 (14.8%), it was >150 ml/m2. Magnetic resonance imaging-based Qp:Qs was 1.6 ± 0.3. A total of 5 patients (9.3%) had established pulmonary hypertension (mean pulmonary artery pressure ≥25 mm Hg). In conclusion, isolated single or dual anomalous pulmonary venous connection is not necessarily a benign congenital anomaly because a proportion of patients develop pulmonary hypertension and/or RV dilation. Regular follow-up and on-going patient surveillance with cardiac imaging is advised.

Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease.

Objectives: A quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. Methods: We performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. Results: In-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. Conclusions: Both in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.

Invited review: Qualitative research in dairy science-A narrative review.

The use of qualitative research in dairy science has increased considerably in recent years, providing the opportunity to inform research and practice. This review aims to enhance the accessibility of qualitative research among a range of audiences and specifically: (1) provide an overview of what qualitative research is and the value it can bring to scientific inquiries in the dairy context, (2) illustrate the emergence of qualitative dairy science research in the past 15 to 20 years, (3) outline the role of the researcher and key philosophical assumptions underlying qualitative research, (4) describe qualitative research approaches and methods used in dairy science research, and (5) highlight key aspects of qualitative inquiry used to ensure research trustworthiness. Qualitative approaches in dairy science enable researchers to understand myriad topics including stakeholder relationships, decision-making, and behaviors regarding dairy cattle management, animal welfare, and disease prevention and control measures. Approaches that were used often for qualitative data collection were individual interviews and focus groups, and variations of thematic analysis were common analytical frameworks. To assess public values, attitudes, and perceptions, mixed methods questionnaires that combined quantitative data with qualitative data from open-ended questions were used regularly. Although still used infrequently, action research and participatory approaches have the potential to bridge the research-implementation gap by facilitating group-based learning and on-farm changes. Some publications described the philosophical assumptions inherent to qualitative research, and many authors included reflexivity and positionality statements. Although a comprehensive description of strategies to meet trustworthiness criteria for qualitative research was uncommon, many publications mentioned certain aspects of trustworthiness, such as member checking, researcher triangulation, and the recording of reflexive notes. Qualitative research has been used to deepen our understanding of phenomena relevant to the dairy sector and has opened the door for a broad array of new opportunities. In addition to having merit on its own, qualitative research can guide, inform, and expand on quantitative research, and an understanding of the core pillars of qualitative research can foster interdisciplinary collaborations.

Machine Learning for Prediction of Adverse Cardiovascular Events in Adults With Repaired Tetralogy of Fallot Using Clinical and Cardiovascular Magnetic Resonance Imaging Variables.

BACKGROUND: Existing models for prediction of major adverse cardiovascular events (MACE) after repair of tetralogy of Fallot have been limited by modest predictive capacity and limited applicability to routine clinical practice. We hypothesized that an artificial intelligence model using an array of parameters would enhance 5-year MACE prediction in adults with repaired tetralogy of Fallot. METHODS: A machine learning algorithm was applied to 2 nonoverlapping, institutional databases of adults with repaired tetralogy of Fallot: (1) for model development, a prospectively constructed clinical and cardiovascular magnetic resonance registry; (2) for model validation, a retrospective database comprised of variables extracted from the electronic health record. The MACE composite outcome included mortality, resuscitated sudden death, sustained ventricular tachycardia and heart failure. Analysis was restricted to individuals with MACE or followed ≥5 years. A random forest model was trained using machine learning (n=57 variables). Repeated random sub-sampling validation was sequentially applied to the development dataset followed by application to the validation dataset. RESULTS: We identified 804 individuals (n=312 for development and n=492 for validation). Model prediction (area under the curve [95% CI]) for MACE in the validation dataset was strong (0.82 [0.74-0.89]) with superior performance to a conventional Cox multivariable model (0.63 [0.51-0.75]; P=0.003). Model performance did not change significantly with input restricted to the 10 strongest features (decreasing order of strength: right ventricular end-systolic volume indexed, right ventricular ejection fraction, age at cardiovascular magnetic resonance imaging, age at repair, absolute ventilatory anaerobic threshold, right ventricular end-diastolic volume indexed, ventilatory anaerobic threshold % predicted, peak aerobic capacity, left ventricular ejection fraction, and pulmonary regurgitation fraction; 0.81 [0.72-0.89]; P=0.232). Removing exercise parameters resulted in inferior model performance (0.75 [0.65-0.84]; P=0.002). CONCLUSIONS: In this single-center study, a machine learning-based prediction model comprised of readily available clinical and cardiovascular magnetic resonance imaging variables performed well in an independent validation cohort. Further study will determine the value of this model for risk stratification in adults with repared tetralogy of Fallot.

Calf management and welfare in the Canadian and US dairy industries: Where do we go from here?

The objective of this narrative review was to compare the results of the 2015 Canadian National Dairy Study and the 2014 US National Animal Health Monitoring System (NAHMS) Dairy Studies, with a specific focus on calf management and welfare, and to interpret these findings within more recent calf health research to describe where we need to go next in the North American dairy industry. Situating results of periodic national studies within the context of past and recent research provides an opportunity to gauge adoption of recommendations and best practices and to help identify persistent and new challenges that the industry is wrestling with to help guide research needs. Through this review of the 2 national studies, we identified several strengths of the Canadian and US dairy industries. In each area of calf health management, improvements relative to previous NAHMS studies and the published literature have been found in the level of mortality, amount of colostrum fed, housing, and the number of producers using pain control for disbudding and dehorning. There were, however, some areas that present clear opportunities for improvement. Specifically, although mortality levels have improved, a large number of calves die at birth, within the first 48 h of life, and during the preweaning period. To improve the health of calves in early life, producers could look at feeding high-quality colostrum at 10% of body weight in the first feeding, as well as feeding a larger amount of milk during the preweaning period. The barriers to making these management changes and improving overall calf health need to be identified in future studies. The majority of preweaning calves in Canada and the United States are housed in individual housing. This represents a clear opportunity for improvement because recent research has identified the positive aspects of group housing. Finally, with respect to pain control, improvements are needed (particularly in the United States) to ensure that pain management is provided when disbudding and dehorning calves. Although the science is clear on pain management, discussions with producers are needed to identify reasons for the lack of uptake.

Investigating Ontario dairy farmers motivations and barriers to the adoption of biosecurity and Johne's control practices.

For the control of Johne's disease (JD), management practices to minimize disease transmission must be implemented and maintained. Once infected, animals will enter a latent phase and will typically only manifest clinical symptoms years later. As young calves are the main susceptible group on farm, the observed effects of management practices geared toward minimizing their exposure to infective material may not be realized until years later. This delayed feedback limits the sustained implementation of JD control practices. Although quantitative research methods have demonstrated changes to management practices as well as their association with changes to JD prevalence, dairy farmers can offer insights into the current challenges relating to JD implementation and control. Thus, this study aims to use qualitative methods and in-depth interviews (n = 20) with Ontario dairy farmers who had previously been engaged in a Johne's control program to explore their motivations and barriers to the implementation of JD control practices and general herd biosecurity. A thematic analysis using inductive coding was completed generated the following 4 overarching themes: (1) the hows and whys of Johne's control, (2) barriers to general herd biosecurity, (3) barriers to Johne's control, and (4) overcoming barriers. Farmers no longer believed JD was an issue on their farm. Johne's was low on their list of concerns due to little public discourse, absence of animals displaying clinical signs, and no financial support for diagnostic testing. Producers who were still actively engaged in JD control cited animal and human health as their primary motivations. Financial support, targeted education, and promoting engagement through discourse may help encourage producers to reconsider their participation in JD control. Government and industry collaboration with producers may help to develop more effective biosecurity and disease control programs.

Management practices associated with Johne's bulk tank milk ELISA positivity.

Johne's disease (JD) control is often based on the culling of positive animals and the adoption of management practices that minimize exposure of young stock to the pathogen (Mycobacterium avium ssp. paratuberculosis). Throughout 2010 to 2013, the province of Ontario, Canada, instituted a voluntary Johne's control program consisting of whole-herd testing and risk assessment. The JD risk assessment evaluated 5 management areas to characterize herd JD risk. Using a modified milk ELISA technique with an optical density cut-off of 0.089, province-wide bulk tank milk (BTM) testing was used to assess the prevalence of JD high-risk herds at the end of the control program and again 4 yr after its completion. Approximately 71% of Ontario bulk tanks were classified as positive in 2017 compared with roughly 46% in 2013. In 2019, the same JD risk assessment used in the original program was readministered on 180 Ontario dairy farms. Using this cross-sectional approach, logistic regression models were built using data from the original program risk assessment and follow-up risk assessment as well as the BTM ELISA results to determine management factors associated with the control of JD. We demonstrated that management of the maternity area is an important factor in the control of Johne's disease. Although it is believed that the highest risk group for JD infection is calves under 6 mo, the cleanliness scores of older heifers and their exposure to mature cow manure was significantly associated with JD control; farms with highly contaminated weaned and bred heifers and those that had exposure to mature cow manure were more likely to be unsuccessful in their JD control efforts. Careful management of young calves appears to be important for JD control, and this management should continue even after calves have left the maternity area.

Tetralogy of Fallot Across the Lifespan: A Focus on the Right Ventricle.

Tetralogy of Fallot is a cyanotic congenital heart disease, for which various surgical techniques allow patients to survive to adulthood. Currently, the natural history of corrected tetralogy of Fallot is underlined by progressive right ventricular (RV) failure due to pulmonic regurgitation and other residual lesions. The underlying cellular mechanisms that lead to RV failure from chronic volume overload are characterized by microvascular and mitochondrial dysfunction through various regulatory molecules. On a clinical level, these cardiac alterations are commonly manifested as exercise intolerance. The degree of exercise intolerance can be objectified and aid in prognostication through cardiopulmonary exercise testing. The timing for reintervention on residual lesions contributing to RV volume overload remains controversial; however, interval assessment of cardiac function and volumes by echocardiography and magnetic resonance imaging may be helpful. In patients who develop clinically important RV failure, clinicians should aim to maintain a euvolemic state through the use of diuretics while paying particular attention to preload and kidney function. In patients who develop signs of cardiogenic shock from right heart failure, stabilization through the use of inotropes and pressor is indicated. In special circumstances, the use of mechanical support may be appropriate. However, cardiologists should pay particular attention to residual lesions that may impact the efficacy of the selected device.

De nombreuses techniques chirurgicales permettent aux patients présentant une tétralogie de Fallot (TF), une forme de cardiopathie congénitale, de survivre jusqu'à l'âge adulte. À l'heure actuelle, l'évolution naturelle de la TF corrigée est caractérisée par une insuffisance ventriculaire droite (VD) progressive attribuable à une régurgitation pulmonaire et à d'autres lésions résiduelles. Les mécanismes cellulaires sous-jacents qui mènent à l'insuffisance VD due à une surcharge volumique chronique sont caractérisés par une dysfonction microvasculaire et mitochondriale faisant intervenir diverses molécules régulatrices. Sur le plan clinique, ces atteintes cardiaques se manifestent par une intolérance à l'effort qui peut être évaluée au moyen d'une épreuve d'effort cardiorespiratoire, ce qui permet de faciliter l'établissement d'un pronostic. Le moment propice pour une réintervention en cas de lésions résiduelles contribuant à la surcharge volumique du ventricule droit demeure controversé; toutefois, il peut être utile d'évaluer régulièrement la fonction et les volumes cardiaques au moyen d'une échocardiographie et de tests d'imagerie par résonance magnétique. En présence d'une insuffisance VD cliniquement importante, les cliniciens doivent tenter de maintenir les patients dans un état euvolémique en utilisant des diurétiques, tout en accordant une attention particulière à la précharge et à la fonction rénale. Si les patients manifestent des signes de choc cardiogénique associé à une insuffisance cardiaque droite, il convient de leur administrer des inotropes et des vasopresseurs pour stabiliser leur état. Dans certains cas, l'utilisation d'un dispositif d'assistance mécanique peut être appropriée. Cependant, les cardiologues doivent être attentifs aux lésions résiduelles, car elles peuvent influencer l'efficacité de ce dispositif.

Management of Heart Failure With Arrhythmia in Adults With Congenital Heart Disease: JACC State-of-the-Art Review.

Together, heart failure and arrhythmia represent the most important cardiovascular sources of morbidity and mortality among adults with congenital heart disease (ACHDs). Although traditionally conceptualized as operating within 2 distinct clinical silos, these scenarios frequently coexist within the same individual; consequently the mechanistic, therapeutic, and prognostic overlap between them demands increased recognition. In fact, given the near ubiquity of heart failure and arrhythmia among ACHDs, there is perhaps no other arena within cardiology where this critical intersection is more frequently observed. Optimal care for ACHDs therefore requires a heightened awareness of the relevant interactions as well as the pharmacologic and interventional resources that are increasingly available to the treating cardiologist. This review explores and highlights the overlap between these 2 fields to recommend a parallel, yet interactive, multidisciplinary approach to clinical management. Congenital heart disease categories are broken down into their archetypal subtypes to highlight subtleties of the pathophysiology, evaluation, and therapeutic approach.

Descriptive analysis of the changes in Johne's disease management practices on Ontario dairy farms through repeat risk assessment.

Johne's disease (JD) control is often based on the culling of positive animals and the adoption of management practices that minimize exposure of calves to the pathogen Mycobacterium avium ssp. paratuberculosis (MAP). From 2010 to 2013, Ontario, Canada, instituted a voluntary Johne's control program consisting of whole-herd testing and a Risk Assessment and Management Plan (RAMP). The RAMP consisted of 38 questions that evaluated 5 different management areas to characterize herd risk for MAP introduction and within-herd spread. The RAMP produced a numerical score for each area, with higher scores associated with higher risk. The RAMP focused on animal purchases, calving management, calf management, and heifer and cow cleanliness and management. In the summer of 2019, the RAMP was repeated on 180 farms that had participated in the JD program of 2010 to 2013 and had bulk tank milk ELISA results from 2013 and 2017. This cross-sectional study demonstrated that many producers changed management practices over the 4- to 7-year period. Producers changed their cattle buying practices, with a reduction in purchasing from multiple sources and more herds refraining from buying in animals. However, overall scores were higher in 2019 than in 2013. The 2019 RAMP indicated that fewer farms were utilizing individual calving pens in 2019 than in 2013 (13% vs. 26%), yet more farms had policies in place to deal with sick or suspect JD cows entering the maternity area (92% vs. 74%). Management changes occurred over time, some of which represent increased risk (crowded maternity pens) and others decreased risk (closed herd, protocols in place for JD-positive cows) for MAP introduction and transmission. These results highlight the importance of frequent risk assessments and the documentation of changes to management practices on-farm as a means to assess herd disease risk more accurately.

FMD vaccine allocation and surveillance resourcing options for a potential Australian incursion.

Australian Animal Disease Spread (AADIS) epidemiological simulation modelling of potential foot-and-mouth disease outbreaks in the state of Victoria, Australia examined the targeted use of limited vaccine supplies in combination with varying surveillance resources. Updated, detailed estimates of government response costs were prepared based on state level data inputs of required and available resources. Measures of outbreak spread such as duration and numbers of animals removed through depopulation of infected and vaccinated herds from the epidemiological modelling were compared to summed government response costs. This comparison illustrated the trade-offs between targeted control strategies combining vaccination-to-remove and varying surveillance capacities and their corresponding costs. For this intensive cattle and sheep producing region: (1) Targeting vaccination toward intensive production areas or toward specialized cattle operations had outbreak control and response cost advantages similar to vaccination of all species. The median duration was reduced by 27% and response costs by 11%. (2) Adding to the pool of outbreak surveillance resources available further decreased outbreak duration and outbreak response costs. The median duration was reduced by an additional 13% and response costs declined by an additional 8%. (3) Pooling of vaccine resources overcame the very early binding constraints under proportional allocation of vaccines to individual states with similar reductions in outbreak duration to those with additional surveillance resources. However, government costs rose substantially by over 40% and introduced additional risk of a negative consumer response. Increased knowledge of the outbreak situation obtained from more surveillance led to better-informed vaccination deployment decisions in the short timeframe they needed to be made.

Promoting farm advisor engagement and action toward the improvement of dairy cattle lameness.

Lameness represents a significant management challenge in the dairy industry worldwide. In addition to farmers, many advisors are involved in lameness management, including veterinarians, hoof trimmers, and nutritionists. These advisors support farmers through lameness prevention practices, treatments, and advice, but little is known about how advisors view others' roles and the extent to which they work together. This study used qualitative participatory methods to facilitate the formation of lameness advisory groups among 13 advisors (4 veterinarians, 5 hoof trimmers, and 4 nutritionists), with the aims of promoting advisors' engagement with one another and documenting their perceptions of the benefits and challenges of the research activities through semi-structured interviews and thematic analysis. Participants shared predominantly positive views toward the project and voiced appreciation about the quality of discussions and the opportunity to connect and build relationships with other advisors. Participants reported improved communication with others via sharing reports and farm information, as well as increased confidence in reaching out to other advisors. Reported challenges included time constraints and discomfort in leading the lameness advisory group meetings. Difficulties were also found in bringing issues to farmers' attention when they might not align with the farmers' goals or priorities, as well as participants' questioning other advisors' knowledge and intentions. This study describes a promising avenue of facilitating advisor engagement, although more work is needed to determine whether such engagement translates to a reduction of lameness on farms.

Heart Transplant Indications, Considerations, and Outcomes in Fontan Patients: Age-Related Nuances, Transplant Listing, and Disease-Specific Indications.

In the current era, 5%-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure of any mechanism, with a 1-year post-transplant survival rate approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein-losing enteropathy and plastic bronchitis can be expected to resolve post-transplant, and limited data suggest patients with Fontan-associated liver disease who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx, and late referrals and failure to refer adult patients remain problematic. Very little is known about the numbers of patients who are not referred, are turned down following assessment for HTx, or die on the waiting list-numbers that are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality-improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status-listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing adult congenital heart disease transplant centres with expertise that can also offer combined heart-liver transplant when appropriate, and improving single-ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.

Outcome and right ventricle remodelling after valve replacement for pulmonic stenosis.

BACKGROUND: Complications and need for reinterventions are frequent in patients with pulmonary valve stenosis (PVS). Pulmonary regurgitation is common, but no data are available on outcome after pulmonary valve replacement (PVR). METHODS: We performed a retrospective analysis of 215 patients with PVS who underwent surgical valvotomy or balloon valvuloplasty. Incidence and predictors of reinterventions and complications were identified. Right ventricle (RV) remodelling after PVR was also assessed. RESULTS: After a median follow-up of 38.6 (30.9-49.4) years, 93% of the patients were asymptomatic. Thirty-nine patients (18%) had at least one PVR. Associated right ventricular outflow tract (RVOT) intervention and the presence of an associated defect were independent predictors of reintervention (OR: 4.1 (95% CI 1.5 to 10.8) and OR: 3.6 (95% CI 1.9 to 6.9), respectively). Cardiovascular death occurred in 2 patients, and 29 patients (14%) had supraventricular arrhythmia. Older age at the time of first intervention and the presence of an associated defect were independent predictors of complications (OR: 1.0 (95% CI 1.0 to 1.1) and OR: 2.1 (95% CI 1.1 to 4.2), respectively). In 16 patients, cardiac magnetic resonance before and after PVR was available. The optimal cut-off values for RV volume normalisation were 193 mL/m2 for RV end-diastolic volume indexed(sensitivity 80%, specificity 64%) and 100 mL/m2 for RV end-systolic volume indexed(sensitivity 80%, specificity 56%). CONCLUSIONS: Previous RVOT intervention, presence of an associated defect and older age at the time of first repair were predictors of outcome. More data are needed to guide timing of PVR, and extrapolation of tetralogy of Fallot guidelines to this population is unlikely to be appropriate.