[Percutaneous aortic valve replacement: outcome of patients evaluated by EMG at Toulouse University Hospital preprocedure]. / Remplacement valvulaire aortique par voie percutanée : devenir des patients évalués par l'EMG au CHU de Toulouse en préprocédure.

Transcatheter Aortic Valve Implantation has become the preferred method of aortic valve replacement in the elderly. Preoperative standardized geriatric assessment (SGA) helps guide the decision to proceed, taking into account geriatric parameters not targeted by surgical risk scores. This is a descriptive, retrospective study of patients who underwent EGS at the Toulouse University Hospital, analyzing their length of stay and postoperative care pathway.

Frailty in Older Patients with Transthyretin Cardiac Amyloidosis.

Background-Transthyretin cardiac amyloidosis (ATTR-CA) prevalence increases with age. The interplay between frailty and heart failure has been increasingly recognized. The objective of this study is to compare clinical, biological, and transthoracic echocardiography (TTE) characteristics of older ATTR-CA patients according to the G8 frailty screening tool. Methods-Patients over 75 years old with a confirmed diagnosis of ATTR-CA were included between January 2020 and April 2021. All patients underwent a routine blood test, TTE, and a functional assessment with a six-minute walking distance test (6MWD) or cardiopulmonary exercise testing (CPET), and the G8 score was calculated. Results-Fifty-two patients were included. Thirty-nine (75%) patients were frail and their mean NYHA stage was more severe (2.2 vs. 1.7; p = 0.004); 62% of them had a Gilmore stage of 2 or 3 (p = 0.05). Global left ventricular strain (GLS) was lower (-11.7% vs. -14.9%; p = 0.014) and the interventricular septum was thicker (18 ± 2 mm vs. 17 ± 2 mm; p = 0.033) in frail patients. There were no significant differences according to functional tests. Conclusion-The majority of older patients with ATTR-CA are frail according to the G8 score. They are more symptomatic and have an increased cardiac involvement and a poorer prognosis, requiring more personalized cardiac management.

Recurrence and survival in dogs with excised colorectal polyps: A retrospective study of 58 cases.

BACKGROUND: Compared to humans, colorectal polyps are relatively rare in dogs. Epidemiological and prognostic data remain accordingly sparse, although they could help veterinary clinicians in the management of these cases. OBJECTIVES: To report the epidemiological data of dogs with colorectal polyps and identify factors associated with recurrence and survival. ANIMALS: Fifty-eight client-owned dogs with colorectal polyps admitted to 7 veterinary hospitals (53 dogs from France, 5 dogs from Spain, and 4 dogs from Portugal) were included. METHODS: Retrospective multicentric cohort study. Medical records and long-term outcome of the dogs were reviewed. When available, histological samples were reassessed by 2 board-certified pathologists according to the revised Vienna classification (RVC). RESULTS: The West Highland White Terrier (WHWT) breed was significantly associated with the presence of colorectal polyps (OR: 20; 95% CI: 7.5-52; P < .001). The overall median time to recurrence was not reached after 2000 days. The overall estimated median survival time was 1640 days. WHWT breed and larger polyps were significantly associated with a shorter time of polyp recurrence after surgical removal (respectively, P = .05 and P = .01). CONCLUSIONS AND CLINICAL IMPORTANCE: The probability of recurrence of colorectal polyps in dogs is low, but increased in WHWTs and larger polyps, which might benefit from routine screening after removal. No effective predictors of polyp recurrence and survival were identified using the RVC.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units.

BACKGROUND: Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU. METHODS: This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7. RESULTS: A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group. CONCLUSIONS: Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

CONTEXTE: On ignore si la fragilité, définie comme un syndrome biologique reflétant une diminution des réserves physiologique et une vulnérabilité au stress, impacte le pronostic des sujets âgés admis en unité de soins intensifs cardiologiques (USIC). Notre objectif était de déterminer la prévalence de la fragilité et son impact sur la mortalité chez les sujets âgés de 80 ans ou plus admis en USIC. MÉTHODOLOGIE: Il s'agit d'une étude prospective monocentrique observationnelle conduite sur les patients de 80 ans ou plus admis en USIC dans un centre tertiaire. La fragilité a été évaluée par l'échelle de fragilité d'Edmonton (EFS) qui donne un score allant de 0 (pas fragile) à 17 (très fragile). La population a été divisé en 3 classes : score EFS de 0 à 3, score EFS de 4 à 6, et score EFS de > 7. RÉSULTATS: Cent quatre-vingt-dix-neuf patients ont été inclus avec un suivi médian de 365 jours. L'âge moyen était de 84,8 ans. Cinquante patients (25,1 %) sont décédés au cours de la période de suivi. Quarante-cinq patients (22,6 %) avaient un score EFS de 0 à 3, 60 patients (30,2 %) avaient un score EFS de 4 à 6 et 94 patients (47,2 %) avaient un score EFS de ≥ 7. Les taux de mortalité toutes causes étaient de 4,4 % dans la classe de score EFS de 0 à 3, 27,1 % dans la classe de score EFS de 4 à 6 et 37,2 % dans la classe de score EFS de ≥ 7, (p < 0.001). En analyse multivariée, la fragilité demeurait associée avec la mortalité toutes causes : le rapport de risques instantanés (RRI) était à 2,60 (intervalle de confiance [IC] à 95 % [0,54 - 12,45]) dans la classe de score EFS de 4 à 6, et le RRI était à 5,46 (IC à 95 % [1,23 - 24,08]) dans la classe de score EFS de ≥ 7. CONCLUSION: La fragilité est fortement prévalente dans la population des sujets âgés admis en USIC et constitue un facteur pronostique fort de mortalité toutes causes à un an.

Impact of a Pharmacist-included Mobile Geriatrics team intervention on potentially inappropriate drug prescribing: protocol for a prospective feasibility study (PharMoG study).

INTRODUCTION: Research has shown that potentially inappropriate drug prescription (PIDP) is highly prevalent in older people. The presence of PIDPs is associated with adverse health outcomes. This study aims to evaluate the impact of a PHARmacist-included MObile Geriatrics (PharMoG) team intervention on PIDPs in older patients hospitalised in the medical, surgical and emergency departments of a university hospital. METHODS AND ANALYSIS: The PharMoG study is a prospective, interventional, single-centre feasibility study describing the impact of a PharMoG team on PIDPs in older hospitalised patients. Pharmacist intervention will be a treatment optimisation (clinical medication review) based on a combination of explicit and implicit criteria to detect PIDPs. The primary outcome is the acceptance rate of the mobile team's proposed treatment optimisations related to PIDPs, measured at the patient's discharge from the department. This pharmacist will work in cooperation with the physician of the mobile geriatric team. After the intervention of the mobile geriatric team, the proposals for improving therapy will be sent to the hospital medical team caring for the patient and to the patient's attending physician. The patient will be followed for 3 months after discharge from the hospital. ETHICS AND DISSEMINATION: This study was approved by the South-West and Overseas Territories II Ethics Committee. Oral consent must be obtained prior to participation, either from the patient or from the patient's representative (trusted person and/or a family member). The results will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04151797.

Whole-Genome Sequencing and Bioinformatics as Pertinent Tools to Support Helicobacteracae Taxonomy, Based on Three Strains Suspected to Belong to Novel Helicobacter Species.

The present study describes three putative novel species received at the French National Reference Center for Campylobacters & Helicobacters (CNRCH). The CNRCH 2005/566H strain was isolated in 2005 from the feces of a patient with a hepatocellular carcinoma and gastroenteritis. Strain 48519 was isolated in 2017 from the blood of a male patient suffering from a bacteremia. Strain Cn23e was isolated from a gastric biopsy from a dog suffering from chronic gastritis. Biochemical and growth characteristics and electron microscopy for these three strains were studied. Their genomes were also sequenced. gyrA based phylogeny built with 72 nucleotide sequences placed CNRCH 2005/566H among the unsheathed enterohepatic helicobacters, close to Helicobacter valdiviensis; strain 48519 among the sheathed enterohepatic helicobacters, close to Helicobacter cinaedi; and strain Cn23e among gastric helicobacters, close to Helicobacter felis. 16S rRNA gene phylogeny showed similar results, but with weak discriminant strength. Average nucleotide identity and in silico DNA-DNA hybridization analyses revealed that CNRCH 2005/566H and 48519 strains belong to new putative species, but confirmed that Cn23e corresponds to H. felis. Cn23e was able to infect C57BL6 mice and to induce gastric inflammation. The genomics data, together with their different morphological and biochemical characteristics, revealed that these two strains represent novel Helicobacter species. We propose the following names: 'Helicobacter burdigaliensis,' with the type strain CNRCH 2005/566H ( =CECT 8850 =CIP 111660), and 'Helicobacter labetoulli,' with the type strain 48519 ( =CCUG 73475 =CIP 1111659). This study highlights that the diversity of the Helicobacteraceae family remains to be fully explored.

Interest of Combined Blood Pressure Measurements in Very Old Frail Subjects: The PARTAGE Study.

BACKGROUND: Several clinical studies have shown that blood pressure (BP) measurements in very old frail individuals are of limited interest due to the fact that several age-related alterations and geriatric syndromes may modify BP. We studied in persons over 80-year old living in nursing homes the combined effects of 3 BP patterns on total mortality and major cardiovascular (CV) events: (i) low pulse pressure amplification (L-PPA) between carotid and brachial artery, (ii) systolic BP (SBP) <130 mm Hg (L-SBP), under >1 antihypertensive drugs, and (iii) changes in SBP between supine and upright position of >20 mm Hg in both directions (hypotension/hypertension, orthostatic SBP [O-SBP]). METHODS: This analysis was performed in subjects of the PARTAGE study presenting all these 3 measurements (n = 883). The combined effects of L-PPA, L-SBP, and O-SBP were studied during the 2 years followed-up period. RESULTS: After adjusting for age, sex, and history of CV events, all 3 BP patterns were independent determinants of major CV events (L-PPA, (P = 0.023); L-SBP, (P = 0.050); O-SBP, (P = 0.015)), whereas L-PPA (P = 0.012) and L-SBP (P = 0.006) were also independent determinants of total mortality. Compared with the subjects without any BP pattern, the presence of 2 or 3 BP patterns was associated with an increase in total mortality and major CV events greater than 2 and 2.5 times, respectively. CONCLUSIONS: In very old frail subjects, there is a particular interest for using different BP measurement approaches, than in younger populations, in order to evaluate the risks related to the BP levels. CLINICAL TRIALS REGISTRATION: Trial Number: NCT00901355 (Clinical Trials.gov).

Prognosis Impact of Frailty Assessed by the Edmonton Frail Scale in the Setting of Acute Coronary Syndrome in the Elderly.

BACKGROUND: Elderly patients represent a large proportion of patients admitted for acute coronary syndrome (ACS). Whether frailty-defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors-may impact the clinical outcomes in this population remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted for ACS. METHODS: This prospective observational study was conducted in patients aged 80 years or older admitted to a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS score 0-3, EFS score 4-6; and EFS score >7. RESULTS: Two hundred thirty-six patients were included, with a mean follow-up duration of 470 days. The mean age was 85.9 years. Seventy-five patients died during the follow-up period. One hundred nineteen patients (50.4%) had an EFS score of 0-3, 68 patients (28.8%) had an EFS score of 4-6, and 49 patients (20.8%) had an EFS score ≥ 7. The all-cause mortality rate was 17.7% in the EFS 0-3 group, 35.3% in the EFS 4-6 group, and 61.2% in the EFS ≥ 7 group (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: the hazard ratio (HR) was 1.53 (95% confidence interval [CI], 0.74-3.16) in the EFS 4-6 group, and the HR was 3.60 (95% CI, 1.70-7.63) in the EFS ≥ 7 group. CONCLUSIONS: Frailty is a strong and independent prognostic factor for midterm all-cause mortality in elderly patients presenting with ACS.

Health-related quality of life after transcatheter aortic valve implantation in elderly patients with severe aortic stenosis.

BACKGROUND: Severe aortic stenosis may affect both normal daily living and survival. Transcatheter aortic valve implantation (TAVI) has become an appropriate alternative to surgery for elderly patients with high surgical risk, and it results in improved survival in this population. OBJECTIVE: To describe health-related quality of life (QoL) before, and at 1 and 6 months after TAVI. SETTING: Cardiovascular Department, Toulouse University Hospital, France. METHODS: One hundred sixty-four consecutive patients with at least 6 months follow-up who underwent TAVI in our institution between February 2009 and June 2011 were enrolled in the study. Of this population, 73 (mean age: 82.3 ± 7.3 years, 56% men) completed QoL assessment using the EuroQOL Five Dimensions (EQ-5D) questionnaire and a visual analogue scale at baseline, and at 1 and 6 months. At each visit, medical data and New York Heart Association functional class were collected. RESULTS: The median preprocedure EQ-5D index value (interquartile range) was 0.66 (range, 0.36-0.78) showing severely impaired QoL in almost all patients. Significant improvement occurred from baseline to 1 month of follow-up in EQ-5D index value [0.73 (range, 0.59-0.79)] and this was maintained at 0.73 (range, 0.62-0.81) at 6 months. The improvement was significant for 3 dimensions of the EQ-5D score at the 6-month follow-up: usual activities in 43.8% of patients (P < .001); anxiety/depression in 37% (P < .001) and pain/discomfort in 28.8% (P < .05). Mean New York Heart Association class improved significantly from 3.24 at baseline to 2.04 at 1 month and 1.89 at 6 months. CONCLUSIONS: In high-risk patients with severe aortic stenosis, QoL and health status improved substantially at 1 month and improvement persisted 6 months after TAVI.

Mortality and cardiovascular events are best predicted by low central/peripheral pulse pressure amplification but not by high blood pressure levels in elderly nursing home subjects: the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study.

OBJECTIVES: The aim of the longitudinal PARTAGE study was to determine the predictive value of blood pressure (BP) and pulse pressure amplification, a marker of arterial function, for overall mortality (primary endpoint) and major cardiovascular (CV) events, in subjects older than 80 years of age living in a nursing home. BACKGROUND: Assessment of pulse indexes may be important in the evaluation of the CV risk in very elderly frail subjects. METHODS: A total of 1,126 subjects (874 women) who were living in French and Italian nursing homes were enrolled (mean age, 88 ± 5 years). Central (carotid) to peripheral (brachial) pulse pressure amplification (PPA) was calculated with the help of an arterial tonometer. Clinical and 3-day self-measurements of BP were conducted. RESULTS: During the 2-year follow-up, 247 subjects died, and 228 experienced major CV events. The PPA was a predictor of total mortality and major CV events in this population. A 10% increase in PPA was associated with a 24% (p < 0.0003) decrease in total mortality and a 17% (p < 0.01) decrease in major CV events. Systolic BP, diastolic BP, or pulse pressure were either not associated or inversely correlated with total mortality and major CV events. CONCLUSIONS: In very elderly individuals living in nursing homes, low PPA from central to peripheral arteries strongly predicts mortality and adverse effects. Assessment of this parameter could help in risk estimation and improve diagnostic and therapeutic strategies in very old, polymedicated persons. In contrast, high BP is not associated with higher risk of mortality or major CV events in this population. (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population [PARTAGE]; NCT00901355).

Pulse wave velocity is associated with 1-year cognitive decline in the elderly older than 80 years: the PARTAGE study.

OBJECTIVES: Studies have shown the importance of vascular risk factors in the pathogenesis and evolution of cognitive disorders and dementia especially among the very elderly. The aim of the present longitudinal 1-year cohort analysis was to evaluate the influence of arterial stiffness on cognitive decline in institutionalized subjects older than 80 years. DESIGN: Longitudinal study. SETTING: Nursing homes in France and Italy. PARTICIPANTS: A total of 873 subjects (79% women), aged 87 ± 5 years were included in this longitudinal analysis from the PARTAGE cohort. MEASUREMENTS: All completed the Mini-Mental Status Examination (MMSE) on the 2 visits over 1 year and underwent a measurement of carotid-femoral pulse wave velocity (PWV), an indicator of aortic stiffness. Clinical and 3-day self-measurements of blood pressure (BP) and activities of daily living (ADL) were evaluated at baseline visit. RESULTS: According to PWV tertiles and after adjustment for baseline MMSE, mean BP (MBP), age, education level, and ADL, Δ MMSE was -1.42 ± 3.60 in the first tertile, -1.78 ± 4.08 in the second tertile, and -2.20 ± 3.98 in the third tertile (P < .03). Similar analyses with self-measured MBP failed to show any association between BP on MMSE decline. CONCLUSION: This 1-year longitudinal study in institutionalized patients older than 80 years shows that the higher the aortic stiffness, the more pronounced the decline in cognitive function. These results point out the interest of measuring PWV, a simple noninvasive and validated method for arterial stiffness assessment, to detect high-risk patients for cognitive decline.

Intracranial meningioma causing partial amaurosis in a cat.

OBJECTIVE: To describe a case of intracranial meningioma causing visual impairment in a cat, successfully treated by surgery. PROCEDURES: An adult neutered male domestic cat was referred with a 10-month history of progressive visual impairment and altered behavior. Investigations included physical, ophthalmologic and neurological examinations as well as hematology, serum biochemistry and CT scan of the head. RESULTS: The menace response was absent in the left eye and decreased in the right eye. Electroretinograms were normal on both eyes, as was ophthalmic examination, ruling out an ocular cause and allowing a presumptive diagnosis of partial amaurosis due to a post-retinal lesion. CT scan demonstrated a large sessile extra axial mass along the right parietal bone and thickening of the adjacent bone. Cerebrospinal fluid was not collected because high intracranial pressure represented a risk for brain herniation. A right rostrotentorial craniectomy was performed to remove the tumor. Ten days after surgery, vision was improved, neurological examination was normal and normal behavior was restored. Ten months after surgery, ophthalmological examination showed no visual deficit and CT scan did not reveal any sign of recurrence. CONCLUSION: Advanced imaging techniques allow veterinarians to detect early cerebral diseases and to provide specific treatment when it is possible. In cases of feline amaurosis due to intracranial meningioma, the vital prognosis is good while the visual prognosis is more uncertain, but recovery of normal vision and normal behavior is possible as demonstrated in the present case.

Extravasation injury associated with parenteral nutrition in a cat with presumptive gastrinomas.

OBJECTIVE: To describe the pathologic consequences of parenteral nutrition (PN) extravasation into the mediastinum of a cat. CASE SUMMARY: An 8-year-old domestic short hair cat with persistent vomiting and anorexia was initiated on PN for nutritional support. PN was being administered at a rate of 12.9 mL/h when inadvertent jugular catheter migration resulted in thrombophlebitis and cellulitis and 40-80 mL of PN extravasated into the SC and mediastinal tissues. The cat was euthanized 36 hours after the extravasation of PN due to poor prognosis related to the gastric complications associated with a presumed primary gastrinoma. Grossly there was excessive mediastinal lymphatic drainage and pronounced edema in the cervical SC and mediastinal tissue. Histopathologic examination of the PN-extravasated area revealed a severe mixed inflammatory reaction, represented by a severe neutrophilic and mild histiocytic infiltrate with lymphoplasmacytic perivascular cuffing. No bacterial agents were observed or cultured from this area. UNIQUE INFORMATION PROVIDED: This is the first case report of a foreign body-type reaction due to extravasation of PN (extravasation injury) in a cat. Extravasation of PN is not without pathologic consequence, and can result in a severe inflammatory reaction in affected tissues.

Sensory alien hand syndrome in corticobasal degeneration: a cerebral blood flow study.

The presence of alien hand syndrome (AHS) is suggestive of the diagnosis of corticobasal degeneration when it develops in a progressive way. Sensory AHS (sAHS) should be distinguished from the motor form described more commonly. The physiopathology of sAHS remains unclear. The aim of this study is to determine cerebral regions involved in sAHS. We compared perfusion single photon emission computer tomography scans of patients with sAHS (n = 3) and without (n = 4). We observed significant decrease of regional cerebral blood flow over the nondominant thalamus in sAHS+ compared to sAHS- patients. This result suggests the involvement of the nondominant thalamus in sAHS.

Blood pressure and pulse wave velocity values in the institutionalized elderly aged 80 and over: baseline of the PARTAGE study.

OBJECTIVE: The aim of the longitudinal study PARTAGE (predictive values of blood pressure and arterial stiffness in institutionalized very aged population) was to determine the predictive value of blood pressure (BP) and arterial stiffness for overall mortality, major cardiovascular events and cognitive decline in a large population of institutionalized patients aged 80 and over. In the study herein, we present the baseline data values of this study. METHODS: A total of 1130 patients were recruited (878 women), living in French and Italian nursing homes. Clinical and 3-day self-measurements of BP were conducted. Aortic and upper limb pulse wave velocity were obtained using a PulsePen tonometer. RESULTS: Of this population, 76% of women and 60% of men had a known hypertension and over 91% of the patients were under antihypertensive treatment; 51% of the treated hypertensive patients were well controlled (systolic BP <140 mmHg). No significant differences were found between clinical and self-measured BP. With age, there was an increase in pulse pressure (P < 0.001) due to a decrease in diastolic BP (P < 0.001), without any increase in systolic BP. Aortic but not peripheral pulse wave velocity significantly increased with age (P < 0.005). CONCLUSION: Baseline values obtained herein demonstrate that elderly patients living in nursing homes present hemodynamic characteristics which are different to those described in community-living elderly populations, and indicate the interest of assessing, in longitudinal studies, the role of BP and arterial stiffness in morbidity and mortality in this population.

Predictive factors of attrition in a cohort of Alzheimer disease patients. The REAL.FR study.

BACKGROUND: Attrition, i.e. patient dropout, can threaten the validity of results in longitudinal studies. The aim of this study was to identify patient and caregiver factors predictive of attrition in a cohort of Alzheimer disease (AD) patients. METHODS: 686 patients with mild to moderate AD were included in the multicenter prospective REAL.FR study. Standardized gerontological evaluations were carried out twice yearly. Factors associated with attrition were assessed by survival analysis using a Cox proportional hazard model. RESULTS: After 2 years, 278 (40.5%) patients had dropped out. Causes of attrition included refusal (20.9%), death (20.1%), institutionalization (19.8%), and loss to follow-up (19.8%). Attrition rates between each 6-month wave were constant at 12%. After adjustment, several independent factors remained associated with attrition: patients cared for by an unrelated caregiver [HR 1.7; 95% CI (1.08-2.59)], loss of autonomy [HR = 1.37; (1.03-1.82)], increasing caregiver burden [HR = 1.014; (1.005-1.022)], use of cholinesterase inhibitors [HR = 0.40; (0.27-0.59)], use of 1 to 3 other types of medication [HR = 0.57; (0.36-0.89)]. CONCLUSIONS: The identification of both patient and caregiver factors predictive of attrition is of particular interest for the development and targeting of attrition prevention strategies. In patients with chronic diseases, particular attention should be paid to caregiver well-being to limit attrition.

Evaluation of plasma protein C activity for detection of hepatobiliary disease and portosystemic shunting in dogs.

OBJECTIVE: To determine the diagnostic value of protein C (PC) for detecting hepatobiliary disease and portosystemic shunting (PSS) in dogs. DESIGN: Prospective study. ANIMALS: 238 clinically ill dogs with (n = 207) and without (31) hepatobiliary disease, including 105 with and 102 without PSS. PROCEDURES: Enrollment required routine hematologic, serum biochemical, and urine tests; measurement of PC activity; and a definitive diagnosis. Total serum bile acids (TSBA) concentration and coagulation status, including antithrombin activity, were determined in most dogs. Dogs were grouped into hepatobiliary and PSS categories. Specificity and sensitivity were calculated by use of a PC cutoff value of 70% activity. RESULTS: Specificity for PC activity and TSBA concentrations was similar (76% and 78%, respectively). Best overall sensitivity was detected with TSBA, but PC activity had high sensitivity for detecting PSS and hepatic failure. Protein C activity in microvascular dysplasia (MVD; PC > or = 70% in 95% of dogs) helped differentiate MVD from portosystemic vascular anomalies (PSVA; PC < 70% in 88% of dogs). A receiver operating characteristic curve (PSVA vs MVD) validated a useful cutoff value of < 70% activity for PC. CONCLUSIONS AND CLINICAL RELEVANCE: Combining PC with routine tests improved recognition of PSS, hepatic failure, and severe hepatobiliary disease and signified a grave prognosis when coupled with hyperbilirubinemia and low antithrombin activity in hepatic failure. Protein C activity can help prioritize tests used to distinguish PSVA from MVD and sensitively reflects improved hepatic-portal perfusion after PSVA ligation.