Clinical Features and Outcome of Dogs with Epiglottic Retroversion With or Without Surgical Treatment: 24 Cases.

BACKGROUND: Published information describing the clinical features and outcome for dogs with epiglottic retroversion (ER) is limited. HYPOTHESIS/OBJECTIVES: To describe clinical features, comorbidities, outcome of surgical versus medical treatment and long-term follow-up for dogs with ER. We hypothesized that dogs with ER would have upper airway comorbidities and that surgical management (epiglottopexy or subtotal epiglottectomy) would improve long-term outcome compared to medical management alone. ANIMALS: Twenty-four client-owned dogs. METHODS: Retrospective review of medical records to identify dogs with ER that underwent surgical or medical management of ER. RESULTS: Dogs with ER commonly were middle-aged to older, small breed, spayed females with body condition score (BCS) ≥6/9. Stridor and dyspnea were the most common presenting signs. Concurrent or historical upper airway disorders were documented in 79.1% of cases. At last evaluation, 52.6% of dogs that underwent surgical management, and 60% of dogs that received medical management alone, had decreased severity of presenting clinical signs. In dogs that underwent surgical management for ER, the incidence of respiratory crisis decreased from 62.5% before surgery to 25% after surgical treatment. The overall calculated Kaplan-Meier median survival time was 875 days. CONCLUSION AND CLINICAL IMPORTANCE: Our study indicated that a long-term survival of at least 2 years can be expected in dogs diagnosed with epiglottic retroversion. The necessity of surgical management cannot be determined based on this data, but dogs with no concurrent upper airway disorders may benefit from a permanent epiglottopexy to alleviate negative inspiratory pressures.

Short-term wound complications and predictive variables for complication after limb amputation in dogs and cats.

OBJECTIVES: To identify short-term wound complications and associated predictive factors following amputation in dogs and cats. MATERIALS AND METHODS: Retrospective review of case records of dogs and cats undergoing thoracic or pelvic limb amputation. Preoperative data on signalment, body weight, limb amputated, reason for amputation and laboratory parameters were collected. Details regarding surgical procedures and use of anaesthesia such as total surgical and anaesthesia times, incidences of intraoperative hypotension or hypothermia, method of muscle excision and type of skin closure utilized were recorded. Postoperative data on duration of hospital stay, use of postoperative antibiotics, use of a wound soaker catheter, wound complications noted both during hospitalization and at recheck and treatments if applicable were collected. RESULTS: In total, 67 records were identified including 39 dogs and 28 cats. Wound infection/inflammation complications occurred in 20.9% of cases and wound infection complications in 9%; 12.8% in dogs and 3.6% in cats. One (1.5%) complication was classified as major, which occurred immediately postoperatively. Nine (13.4%) minor complications occurred immediately after surgery and four (6.0%) were identified at recheck. Age was the only significant predictor of postoperative infection/inflammation following pelvic or thoracic limb amputation. CLINICAL SIGNIFICANCE: Short-term wound complications following pelvic or thoracic limb amputation in cats and dogs were typically minor and resolved after treatment.

Outcome following liver lobectomy using thoracoabdominal staplers in cats.

OBJECTIVES: To present outcomes and complications following liver lobectomy using thoracoabdominal staplers in cats, to identify factors associated with survival time and to confirm safety and feasibility. METHODS: Retrospective analysis of case records (n=18) of cats that underwent liver lobectomy with a thoracoabdominal stapler. RESULTS: Fourteen of the 18 cats (78%) survived to discharge. Median survival time was 136·5 days. On log-rank univariate analysis, preoperative abdominal fluid (P=0·002), preoperative anaemia (P=0·03) and perioperative transfusion (P=0·01) were associated with decreased survival time. Perioperative anaemia was common (89%), and rate of transfusion during hospitalisation was 61%. Clinical signs of illness, azotaemia, elevated liver enzyme activities and malignant neoplasia did not appear to impact survival; however, anaemia, abdominal fluid and transfusion may be associated with decreased survival time. CLINICAL SIGNIFICANCE: Liver lobectomy using thoracoabdominal staplers was effective in removal of hepatic lesions and all cats survived surgery. Outcome was negatively associated with preoperative abdominal fluid (haemorrhagic and non-haemorrhagic), preoperative anaemia or perioperative transfusion. Surgeons should be prepared to employ ancillary methods of haemostasis to augment the staple line, and need for blood transfusion should be anticipated.

Achieving cardiovascular health through continuing interprofessional development.

In order to achieve cardiovascular health for all Canadians, the ACHIC (Achieving Cardiovascular Health in Canada) partnership advocates that health promotion for healthy lifestyles be incorporated into practice, and that the consistent messages and professional skills required to motivate patients and the public be acquired through interprofessional education and development. Professional education specialists are essential members of health care promotion teams with expertise to develop educational interventions that impact behaviours of health professionals and subsequent patient outcomes. Continuing medical education (CME) is in evolution to continuing professional development (CPD), and then to continuing inter-professional development (CID). Providers of health promotion, public health, and health care can work with health educators to complete the cascade of learning, change in practice, and improvement in patient outcomes. The Canadian health care system can empower Canadians to achieve cardiovascular health, the most important health challenge in the 21st century.

From death and disability to patient empowerment: an interprofessional partnership to achieve cardiovascular health in Canada.

This paper proposes a paradigm shift in health care from a focus on death and disability to one on health empowerment resulting in improved cardiovascular lifestyles for all Canadians. It describes a national interprofessional initiative to achieve this new vision in the area of cardiovascular health promotion. Achieving Cardiovascular Health in Canada (ACHIC) is a partnership of health professional associations and other health advocate groups whose vision is to promote optimal cardiovascular health (including cerebrovascular health) for all Canadians through interprofessional partnership initiatives and support systems. ACHIC's objectives are to: 1) identify system barriers and supports to cardiovascular health; 2) develop strategies that will have a positive impact on the practices of health professionals/educators in the promotion of cardiovascular health; 3) develop an interprofessional national approach to support strategies to achieve cardiovascular health in Canada; and 4) support the development and delivery of consistent, evidence-based messages by health professionals/educators for promotion of cardiovascular health.

Continuing educational needs in computers and informatics. McGill survey of family physicians.

OBJECTIVE: To describe family physicians' perceived educational needs in computers and informatics. DESIGN: Mailed survey. SETTING: General or family practices in Canada. PARTICIPANTS: Physicians (489 responded to a mailing sent to 2,500 physicians) who might attend sessions at the McGill Centre for CME. Two duplicate questionnaires were excluded from the analysis. METHOD: Four domains were addressed: practice profile, clinical CME needs, professional CME needs, and preferred learning formats. Data were entered on dBASE IV; analyses were performed on SPSS. MAIN FINDINGS: In the 487 questionnaires retained for analysis, "informatics and computers" was mentioned more than any other clinical diagnostic area, any other professional area, and all but three patient groups and service areas as a topic where improvement in knowledge and skills was needed in the coming year. Most physicians had no access to computer support for practice (62.6%); physicians caring for neonates, toddlers, or hospital inpatients were more likely to report some type of computer support. CONCLUSIONS: Family physicians selected knowledge and skills for computers and informatics as an area for improvement in the coming year more frequently than they selected most traditional clinical CME topics. This educational need is particularly great in small towns and in settings where some computerized hospital data are already available.

The importance of the case management approach: perceptions of multidisciplinary team members.

This article attempts to determine the importance of the case management approach as perceived by health professionals working in multidisciplinary teams. The case management approach is reported to streamline care and contain cost. The literature calls for continuing education in a multidisciplinary forum for all health professions; however, data on perceived or actual educational needs is scant. One hundred forty-one health practitioners working in clinical teams rated four case management components on 100 mm scales: assessing patient needs; educating caregivers; community agency liaison; and, cost monitoring. Statistical significance of differences was determined by Mann Whitney U and Wilcoxon rank sum testing. All scores were high, and of all variables tested, varied only by profession (p < .01). Administrators and nurses had relatively higher scores than physicians and physiotherapists. Patient needs were valued above education, education above liaison, and liaison above cost monitoring (p < .01, < .01, < .01, respectively). Continuing education providers should note that health professionals value case management and may be receptive to education. Further study is required to design educational modules for multidisciplinary use, test impact on knowledge and skills, and determine if transdisciplinary case management education can improve quality of care while containing costs.

Foot position awareness in younger and older men: the influence of footwear sole properties.

OBJECTIVES: To test the hypotheses that foot position awareness is related positively to stability, positively to shoe sole hardness, and negatively to shoe sole thickness, and that foot position awareness declines with advancing years. SETTING: Older subjects were consecutive volunteers from a medical clinic; younger subjects were volunteers from the community. DESIGN: Randomized-order, cross-over, controlled comparison. PARTICIPANTS: Older subjects were a random sample of 13 healthy men, mean age 72.58 years, SD +/- 4.50. Younger subjects were a random sample of 13 male subjects from the general population, mean age 28.13 years, SD +/- 3.96. Additional selection criteria were absence of disabilities influencing ability to walk and no history of frequent falls. MEASUREMENTS: Balance failure frequency, defined as falls per 100 meters of beam walking; rearfoot angle in degrees, measured via an optical position measurement system; perceived maximum supination when walking, in degrees, estimated by subjects using a ratio scale; foot position error, in degrees, was defined as the rearfoot angle minus perceived maximum supination. RESULTS: Foot position error during walking: (1) increases with advancing years; footwear conditions absolute mean error for older sample of 15.48 degrees, SE +/- 1.56 degrees, and younger sample 5.44 degrees, SE +/- 1.03 degrees (P > .001); (2) is positively related to stability (r = .367, P < .001); (3) is positively related to midsole thickness (F(1,11) = 19.89, P < .001); (4) is negatively related to midsole hardness (F(2,22) = 29.80, P < .001); (5) correlates best with perceived maximum supination (r = .901, P < .001). CONCLUSION: Foot position awareness is related causally to stability; shoes with thin, hard soles provide better stability for men than those with thick, soft midsoles. Foot position awareness declines with advancing years.

Long hospital stays and need for alternate level of care at discharge. Does family make a difference for elderly patients?

OBJECTIVE: To determine whether parental and marital status of elderly patients admitted to acute care affect the likelihood of a need for long hospital stay or alternate level of care (nursing home) at discharge. DESIGN: A 1-year descriptive study was carried out prospectively on elderly hospitalized patients. Marital status and parental status were treated as risk factors for resource use, as were sex, age, admitting service, and diagnosis. SETTING: A 672-bed university hospital. PATIENTS: We studied 495 patients aged 65 years or more sequentially admitted over a 1-year period. Excluded from study were critically ill patients, patients admitted to intensive care, and patients with whom we could not communicate on the day were considered for the study. MAIN OUTCOME MEASURES: Whether acute hospital stay exceed 44 days and need for alternate level of care at discharge. RESULTS: Many (43.4%) of the patients had no spouse and 19.4% had no children; 32.9% stayed 45 days or more and 6.9% required alternate level of care at discharge. Predictive of a long hospital stay were being without children (adjusted RR = 1.85), having a neurologic or psychiatric diagnosis (adjusted RR = 3.39), and having surgery unrelated to reason for admission (adjusted RR = 5.88). Predictive of need for alternate level of care at discharge were increasing age (adjusted RR = 1.08), having no spouse (adjusted RR = 2.59), having no children (adjusted RR = 3.27), and having a neurologic or psychiatric diagnosis (adjusted RR = 7.56).

Alcohol inhibits epidermal growth factor-stimulated progesterone secretion from human granulosa cells.

In this study, luteinized human granulosa cells (GC) obtained during in vitro fertilization procedures were used as a model system to evaluate the effects of ethanol (EtOH), a well-known reproductive toxin, on epidermal growth factor (EGF) and gonadotropin-stimulated steroidogenesis. Our results demonstrate that the basal progesterone (P4) and estradiol (E2) secretion by human GC in vitro was dependent on the ovarian stimulation protocol. EGF significantly enhanced P4, but not E2, secretion in human GC from clomiphene citrate (CC), human menopausal gonadotropin (hMG), and hMG/gonadotropin-releasing hormone agonist (GnRH-a)-treated patients. The effects of EGF plus luteinizing hormone (LH) were additive in cells from the CC group, but less than additive in hMG and hMG/GnRH-a groups. EtOH at 20 mM or more inhibited EGF stimulated P4 secretion in human GC from all three patient groups. EtOH inhibited P4 secretion stimulated by EGF and LH cotreatment in the CC and hMG/GnRH-a groups, but not in human GC from the hMG-treated patients. These results suggest that basal and EGF or LH-stimulated P4 secretion by human GC, as well as the effects of EtOH, are profoundly influenced by the follicle's hormonal milieu.

Proprioception and stability: foot position awareness as a function of age and footwear.

We examined the hypothesis that awareness of foot position in terms of the slope of the weight-bearing surface declines with age. We further postulated that the decline would be due to a change in plantar tactile sensibility, and that footwear would further impair position judgments. We compared 15 men aged over 65 years (mean age 73) with 36 men aged under 40 (mean age 30) in terms of estimates of amplitude and direction of surface slopes. We employed a ratio scale of 0-10 representing actual slopes of 0 degrees-25 degrees in increments of 2.5 degrees. In order to examine whether subjects overestimated high angles they were told that the scale ranged from 0 to 15. We found significant differences between the two groups in terms of estimates and the effect of footwear. Psychophysical functions for estimate of slope were 0.95 for the young when barefoot and 0.71 when shod compared with 0.80 and 0.81 respectively for the older men. We conclude that sensitivity to foot position declines with age, mainly owing to loss of plantar tactile sensitivity. Footwear impairs foot position awareness in both young and old. Loss of foot position awareness may contribute to the frequency of falls in later life.

Athletic footwear affects balance in men.

Stable equilibrium during locomotion is required for both superior performance of sports and prevention of injuries from falls. A recent report indicated that currently available athletic footwear impairs stability in older men. Since this discovery, if confirmed, seems important to both competitive athletes and the physically active general public, we performed an experiment using similar methods on a younger population. We tested the hypothesis that midsole thickness is negatively, and hardness positively related to dynamic equilibrium, in 17 healthy adult men (mean(s.d.) age 33(11.13) years) via a balance beam method. Subjects walked along a 9-m long beam at 0.5 m s-1 once barefoot and six times wearing identical pairs of experimental shoes which differed only in midsole hardness and thickness which spanned the respective ranges currently available in footwear. Falls from the beam (balance failures) were quantified. Balance failures varied significantly in relation to midsole hardness and thickness, and there was a strong trend toward interaction of these variables (P = 0.09). Midsole hardness was positively related to stability, and midsole thickness was negatively related, which confirms the previous report. Hence, shoes with thick-soft soles, similar to modern athletic footwear and 'walking shoes', destabilize men, and shoes with thin-hard soles provide superior stability. The pair with the poorest stability (A 15-thick; 12.34 balance failures per 100 m) produced 217% more balance failures than those associated with the best stability (A 50-thin; 3.89 balance failures per 100 m). Since most types of athletic footwear and many other shoes incorporate midsoles with hardness and thickness associated with poor stability, we conclude that both athletic performance and public safety could be enhanced through stability optimized footwear.

Protective sensation of the plantar aspect of the foot.

The scientific literature suggests that barefoot activity may be beneficial. There is a current trend in recreational barefoot activity in children and adults, and barefoot running among athletes. Although the type of skin over most of the body (hairy skin) seems to be easily injured by painful abrading loads, little is known about protection provided by plantar sensory feedback against damage from excessive wear during barefoot locomotion. To evaluate this, we administered a volley of 35 painful abrading loads to glabrous and hairy skin sites over a 5-min period, and examined its effects for signs of cutaneous injury in a sample of 12 normally shod healthy male subjects. Compared with hairy skin of the thigh, plantar skin required approximately 600% greater abrading loads to reach pain threshold. Furthermore, painful stimulation produced visible redness and hypersensitivity in all subjects at the hairy skin site 24 hr after stimulation, whereas only 8.3% reported hypersensitivity and none showed erythema at the plantar area 1 day later. We found that plantar skin possesses a higher pain threshold to abrading stimuli than hairy skin. In fact, loading of the plantar area was limited to innocuous levels due to intolerable pain. We conclude that plantar skin is well protected through sensory feedback from abrasive injuries when barefoot. This information combined with previous reports suggests that risk of injury when normally shod individuals perform barefoot locomotion should be low.

Adult children's perceptions of their responsibility to provide care for dependent elderly parents.

We examined how adult children in Canada whose parents were hospitalized in an acute care setting perceived responsibility for their parents' care. Using a visual analogue scale, adult children rated the amount of financial, emotional, and physical support families "should" and "could" give to elderly persons described in four vignettes. All scores were high, with "should" consistently higher than "could" for every vignette and for each of the three types of support. For daughters, the more aggressive the parent, the lower the "should" score for financial support. The same relationship was observed for incontinence and these findings were consistent over all four vignettes.

Shoe sole thickness and hardness influence balance in older men.

OBJECTIVE: To test the hypothesis that shoes with thick, soft midsoles, such as modern running shoes, provide better stability in older individuals than those with thin-hard midsoles. In addition, we examined the relation between footwear comfort and stability and stability when barefoot. DESIGN: Randomized-order, cross-over, controlled comparison. SETTING: Subjects were drawn from an internal medicine practice. PARTICIPANTS: A random sample of 25 healthy men, minimum age 60 years. Additional selection criteria were absence of disabilities influencing ability to walk and lack of history of frequent falls. MEASUREMENTS: Balance failure frequency, which was defined as falls from the beam per 100 meters of beam walking when 10 passes were made down a 9 M long balance beam. Comfort rating was based on an ordinal scale. RESULTS: Contrary to the hypothesis: (1) midsole softness was associated with poor stability (F(2,48) = 17.9, P < 0.0001); (2) thick midsoles also provided poor stability (F(1,24) = 7.36, P < 0.01). When barefoot, subjects showed 19% higher balance failure frequency than with the poorest shoe and 171% greater than the best shoe (t = 5.33, P < 0.0001). Higher comfort was generally found in shoe types associated with higher balance failure frequency. CONCLUSIONS: For optimal stability, shoes with thin, hard soles are preferable for older individuals. Health professionals should exercise caution when recommending shoes with thick, yielding midsoles, such as running shoes, to unstable elderly individuals. Older men and women with a history of falls or who are obviously unstable, should avoid barefoot locomotion.

Chronic status patients in a university hospital: bed-day utilization and length of stay.

OBJECTIVE: To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient. DESIGN: Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis. SETTING: University hospital. PATIENTS: All 115 inpatients formally declared as achieving chronic status by July 31, 1987. OUTCOME MEASURES: Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed. RESULTS: The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement. CONCLUSIONS: Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients in acute care hospitals. Lack of access to the assigned resource is the most important reason for a delay in discharge. Interventions, whether undertaken at the patient, hospital or provincial level, must to some degree address this issue. Further study is required to determine which risk factors will predict lags at each discharge stage. Since our discharge staging reflects not only the experience of the patient but also the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners.

[Significance of inhibitors of conversion enzymes in elderly subjects. The example of perindopril]. / Intérêt des inhibiteurs de l'enzyme de conversion chez le sujet âgé. L'exemple du perindopril.

The effectiveness and safety of perindopril in elderly hypertensive patients has clearly been demonstrated. In a randomized, double-blind drug versus placebo study involving 34 such patients of mean age 84 years, we observed a 10 p. 100 fall in systolic arterial pressure (p less than 0.01) and a 9 p. 100 fall in diastolic arterial pressure (p less than 0.01) in the perindopril group. The corresponding figures in the placebo group were 5 p. 100 and 4 p. 100 respectively, the difference between the two groups not being significant. The drug was well tolerated, both clinically and biochemically. However, a significant (p less than 0.01) increase in blood potassium level (albeit within normal limits) was observed in the treated group. An open trial conducted in 91 patients (mean age 79.1 years) followed up for 6 years confirmed the acceptability of the drug despite a transient decrease of creatinine clearance recorded in one patient. The effectiveness of perindopril, evaluated less unquestionably in this open trial, was excellent, the hypertension being controlled at the end of treatment in 92.5 p. 100 of the patients. In a trial performed on healthy volunteers, Reid found that perindopril had a greater effect of arterial pressure in elderly subjects, probably due in part to their high blood pressure and to an earlier and more prolonged inhibition of the angiotensin-converting enzyme (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Nicardipine in elderly patients with hypertension: a review of experience in France.

A double-blind, placebo-controlled clinical trial in France has studied the efficacy and safety of nicardipine in 31 elderly patients, aged 57 to 95 years (mean age 84 years), 16 of whom were actively treated with nicardipine, 10 to 30 mg three times a day (mean dose 69.4 mg/day). After 4 weeks, nicardipine lowered mean blood pressure (186/99 to 150/83 mm Hg; p less than 0.001), and the changes in systolic and diastolic blood pressure were significantly greater in the nicardipine group than in the placebo group. Nicardipine was well tolerated; orthostatic hypotension was not observed and there was no change in heart rate. Plasma renin activity (PRA) was measured in eight patients, but there was no correlation between PRA and the antihypertensive effect of nicardipine. Results of a pharmacokinetic study performed in 15 elderly patients showed a rapid rate of absorption and higher plasma levels than those observed in younger patients with hypertension (mean age 54 years). The results support those of the major French multicenter open study of 29, 104 elderly patients with hypertension (mean age 64 +/- 12 years) treated with nicardipine. The findings of this trial are reviewed and discussed, and recommendations made on the directions for future research in cardiovascular medicine with calcium channel blockers. Results of the trials discussed in this article show that nicardipine is an effective and well-tolerated drug in elderly patients and has wide-ranging effects on the cardiovascular system.

Value of angiotensin converting enzyme inhibitors in the elderly: the example of perindopril.

The efficacy and safety of perindopril in hypertension (HT) in the elderly have now been clearly demonstrated. In a randomized, double-blind placebo-controlled study conducted in 34 patients with a mean age of 84 years, we observed a significant reduction in systolic blood pressure (SBP) by 10% (p less than 0.001) and in diastolic blood pressure (DBP) by 9% (p less than 0.01) in the perindopril group. In the placebo group, the reduction observed was 5% and 4% respectively, although the difference between the two groups was not significant. The clinical and laboratory safety was satisfactory. However, in the treated group, there was a significant increase in serum potassium (p less than 0.01), which nevertheless remained within normal limits. An open study conducted in 91 patients with a mean age of 79.1 years, followed over a period of 6 months, confirmed the very good acceptability of the drug, despite the transient reduction in creatinine clearance observed in one female patient. The efficacy, evaluated less reliably in an open study, appeared to be excellent as 92.5% of patients were controlled by the end of treatment. In a study in healthy subjects, Reid observed a more intense effect on blood pressure (BP) in elderly subjects, which could be partly explained by a higher blood pressure level and by earlier and more prolonged converting enzyme inhibition (not significant). The practical value of this angiotensin converting enzyme (ACE) inhibitor, related to its efficacy and safety, is reinforced by a theoretical value: its action on arterial compliance, its beneficial effect on cardiac function, its potential action on the renin-angiotensin system of the brain, the structural modifications induced in the arterial wall open extremely stimulating prospects in the field of aging.