Cadaveric study of movement of an unstable atlanto-axial (C1/C2) cervical segment during laryngoscopy and intubation using the Airtraq(®) , Macintosh and McCoy laryngoscopes.

Concern that laryngoscopy and intubation might create or exacerbate a spinal cord injury has generated extensive research into cervical spinal movement during laryngoscopy. We performed a randomised trial on six cadavers, using three different laryngoscopes, before and after creating a type-2 odontoid peg fracture. Our primary outcome measure was the change in the space available for the spinal cord at the C1/2 segment measured by cinefluoroscopy. Tracheal intubation was performed using a minimal view of the glottis, a bougie, and manual in-line stabilisation. In a cadaveric model of type-2 odontoid fracture, the space available for the cord was preserved in maximum flexion and extension, and changed little on laryngoscopy and intubation.

AGR2 is a SMAD4-suppressible gene that modulates MUC1 levels and promotes the initiation and progression of pancreatic intraepithelial neoplasia.

The mechanisms controlling expression of the putative oncogene Anterior gradient 2 (AGR2) in pancreatic ductal adenocarcinoma (PDAC) are not well understood. We now show that AGR2 is a transforming growth factor-ß (TGF-ß)-responsive gene in human pancreatic cancer cells, whose downregulation is SMAD4 dependent. We also provide evidence supporting a role for AGR2 as an ER-chaperone for the cancer-associated mucin, MUC1. AGR2 is both sufficient and required for MUC1 expression in pancreatic cancer cells. Furthermore, AGR2 is coexpressed with MUC1 in mouse pancreatic intraepithelial neoplasia (mPanIN)-like lesions and in the cancer cells of four distinct genetically engineered mouse models of PDAC. We also show that Pdx1-Cre/LSL-Kras(G12D)/Smad4(lox/lox) mice heterozygous for Agr2 exhibit a delay in mPanIN initiation and progression to PDAC. It is proposed that loss of Smad4 may convert TGF-ß from a tumor suppressor to a tumor promoter by causing the upregulation of AGR2, which then leads to increased MUC1 expression, at which point both AGR2 and MUC1 facilitate mPanIN initiation and progression to PDAC.

An evaluation of conscious sedation using propofol and remifentanil for tension-free vaginal tape insertion.

Tension-free vaginal tape insertion is a recommended treatment for stress incontinence. There is evidence that intra-operative testing of continence by asking patients to cough may improve outcomes, but an optimal sedation regimen has not been determined. We prospectively evaluated the effectiveness of propofol and remifentanil infusions in 25 patients using pre- and post-sedation peak cough pressures and pain scores. Patient satisfaction was assessed using the Iowa Satisfaction with Anaesthesia Score (ISAS). Post-sedation cough pressures were improved compared to baseline, with a mean peak pressure increase of 24 mmHg (95% CI 15.5-32.5; p < 0.001). Pain scores (median, IQR [range]) were low for local anaesthetic infiltration (0, [0-1]) and first (0, [0-1]) and second (0, [0-3.5]) needle insertions. Of the 19 patients completing the ISAS, all felt safe and satisfied. Sedation using propofol and remifentanil provides acceptable analgesia, satisfaction and effective continence testing.

Pain during awake nasal intubation after topical cocaine or phenylephrine/lidocaine spray.

Although several local anaesthetic techniques are described for nasal analgesia during awake intubation, there has been little attempt to evaluate their effectiveness. We examined pain scores associated with nasal intubation in a randomised cross-over study of 25 volunteers. Local anaesthesia consisted of topical aerosol spray using either cocaine 5% or Co-phenylcaine Forte (a proprietary mixture of phenylephrine hydrochloride 0.5% and lidocaine hydrochloride 5%), followed by lidocaine gel. Topical anaesthesia using an atomiser resulted in incomplete analgesia for insertion of nasopharyngeal airways. Larger diameter tubes resulted in higher pain scores. There was no difference in pain scores between the two drugs.

Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?

Arthroscopic shoulder surgery has a 45% incidence of severe postoperative pain. Opiates and interscalene nerve blocks have a high incidence of side effects, and intraarticular local anesthetic has been shown to be ineffective when used for postoperative pain relief. The suprascapular nerve supplies 70% of the sensory nerve supply to the shoulder joint, and local anesthetic block of this nerve is effective in certain shoulder pain disorders. To determine the efficacy of a suprascapular nerve block, subcutaneous saline was compared with a suprascapular nerve block using 10mL of 0.5% bupivacaine with 1:200,000 epinephrine before general anesthesia was induced. In the immediate postoperative period, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a patient-controlled analgesic system was demonstrated. There was more than fivefold reduction in the incidence of nausea, as well as reduced visual analog and verbal pain scores for patients who received a suprascapular nerve block. The duration of hospital stay was reduced by 24% in the suprascapular nerve block group. A 24-h phone call interview revealed a 40% reduction in analgesic consumption and a reduction in verbal pain scores at rest and on abduction. There were no complications from the suprascapular nerve block. This study demonstrates that a suprascapular nerve block for pain relief in arthroscopic shoulder surgery is an effective and safe modality of postoperative pain relief.

Late radiation change in the CNS: MR imaging following gadolinium enhancement.

Magnetic resonance imaging is the best imaging technique for the detection of radiotherapy-induced changes in the central nervous system but there are few studies detailing the MRI appearances of radiation effects following enhancement with intravenous gadolinium. In this paper, gadolinium enhanced MR imaging findings were reviewed in seven patients with evidence of late radiation injury following radiotherapy for primary head and neck tumours. On T1-weighted enhanced sequences, abnormal focal areas were present in the anterior temporal lobes and antero-inferior aspects of the frontal lobes. These lesions were well defined and enhanced intensely following intravenous gadolinium. They were present in the white matter in five patients and involved both grey and white matter in two patients. Cystic components were present in larger lesions in three patients and mass effect was present around the enhancing lesions in four patients. All abnormalities occurred within the radiation treatment portals and corresponded to the distribution of increased signal intensity changes in the brain on T2-weighted images. Late radiation-induced injury should be considered in the differential diagnosis of any intensely enhancing lesion occurring within irradiated brain tissue.

Evaluation of dogs and cats with tumors of the ear canal: 145 cases (1978-1992).

OBJECTIVE: To characterize the frequency, clinical signs, biologic behavior, and response to treatment of tumors of the ear canal in dogs and cats. DESIGN: Retrospective analysis of medical records. ANIMALS: Medical records of 81 dogs (48 malignant tumors, 33 benign tumors) and 64 cats (56 malignant tumors, 8 benign tumors). PROCEDURE: Data were analyzed for cats and dogs with malignant tumors, and risk factors were analyzed for their potential impact on survival time. RESULTS: Malignant tumor types most commonly reported included ceruminous gland adenocarcinoma, squamous cell carcinoma, and carcinoma of undetermined origin. Median survival time of dogs with malignant aural tumors was > 58 months, whereas that of cats was 11.7 months. A poor prognosis was indicated by extensive tumor involvement (dogs) and by neurologic signs at time of diagnosis, diagnosis of squamous cell carcinoma or carcinoma of undetermined origin, and invasion into lymphatics or blood vessels (cats). CLINICAL IMPLICATIONS: Malignant tumors of the ear canal in dogs and cats have a propensity for local invasion, but tend not to metastasize. Squamous cell carcinoma and carcinoma of undetermined origin were the most locally aggressive tumors. Malignant tumors of the ear canal are best managed by aggressive surgical excision. Radiotherapy may be useful when tumors cannot be completely removed.

Amputation and carboplatin for treatment of dogs with osteosarcoma: 48 cases (1991 to 1993).

Forty-eight dogs with histologically confirmed appendicular osteosarcoma (OSA) entered a prospective clinical trial evaluating treatment with amputation and up to 4 doses of carboplatin given every 21 days. The median disease-free interval (DFI) was 257 days, with 31.2% of the dogs disease-free at 1 year. The median survival time was 321 days, with 35.4% of the dogs alive at 1 year. Dogs with proximal humeral OSA had shorter DFI (P = .016) and survival (P = .037) times than dogs with OSA at other locations. Dogs with lower body weights ( < 40 kg) had longer DFI (P = .0056) and survival (P = .007) times than larger dogs. Survival times for dogs that received carboplatin were statistically longer than those previously reported for amputation alone (P < .001). DFI and survival times are similar to those previously reported for 2 to 4 doses of cisplatin. Carboplatin appears to be a well-tolerated chemotherapeutic drug that can be given safely every 21 days at a dose of 300 mg/m2. Neutropenia was the dose-limiting toxicity in this study.

Macronodular congenital adrenal hyperplasia in an adult with female pseudohermaphroditism.

We report a case of previously undiagnosed congenital adrenal hyperplasia presenting with virilisation in a 59-year-old woman. Biochemical analysis revealed C-21 hydroxylase deficiency. CT demonstrated adrenal hyperplasia and a 3.8-cm adrenal nodule, raising the possibility of the development of an autonomous adrenal adenoma or carcinoma. The adrenal nodule regressed significantly with oral replacement steroid therapy over the next 30 months, indicating it to be an ACTH-dependent hyperplastic nodule and thus avoiding the need for biopsy or surgical excision. Macronodular adrenal hyperplasia should be considered in the differential diagnosis of a patient presenting with virilisation and an adrenal mass.

Evaluation of prognostic factors for dogs with synovial sarcoma: 36 cases (1986-1991).

Medical records of 36 dogs with synovial sarcoma confirmed by microscopic examination of H&E-stained sections of tissue were selected for retrospective analysis from dogs admitted between 1986 and 1991 to participating institutions of the Veterinary Cooperative Oncology Group. Metastasis was evident at the time of diagnosis in 8 (22%) dogs, and 15 (41%) dogs ultimately developed metastatic tumors. Median survival time for all dogs, as determined by life-table analysis, was 17 months. For dogs that were subsequently treated and became tumor free, the median disease-free interval was 30 months. Nine dogs had previously had localized excision attempted, but all had recurrence of the tumor locally (median, 4.5 months). Of 29 dogs that underwent amputation, including the 9 with localized recurrence, 2 had tumor recurrence on the amputation stump. Most dogs had survival time and disease-free interval of > 36 months after amputation. Four dogs that had received chemotherapy for tumors of advanced clinical stages did not respond to treatment. One dog that had received locally applied radiotherapy after localized excision did not have evidence of tumor recurrence 2 years after radiotherapy. Clinical stage, histologic grade, and a positive result for tests that used cytokeratin immunohistochemical staining significantly (P < 0.05) influenced survival time and disease-free interval. Analysis of data for the study reported here suggested that histologic criteria can be an excellent predictor of dogs that are likely to have tumor recurrence after amputation and that would most likely benefit from aggressive treatment with adjuvants.

Canine bladder and urethral tumors: a retrospective study of 115 cases (1980-1985).

One hundred and fifteen dogs with neoplasms of the lower urinary tract (bladder and/or urethra) were retrospectively evaluated at five referral institutions participating in ongoing studies by the Veterinary Cooperative Oncology Group. Most tumors were malignant (97%) and of epithelial origin (97%). Lower urinary tract tumors were more common in older dogs weighing greater than 10 kg. The following significant (P less than 0.05) statistical associations were found using the University of Guelph hospital population as control; there was no sex predisposition although the female:male ratio was 1.95:1. Neutered dogs were predisposed as were Airedale Terriers, Beagles, and Scottish Terriers, whereas German Shepherds were significantly under-represented among dogs with lower urinary tract tumors. These statistical associations should be interpreted cautiously because of possible demographic differences in hospital populations among the University of Guelph and other cooperating institutions. There were no significant correlations between age, gender, weight, breed, response to therapy, and survival time. Clinical signs were indicative of lower urinary tract disease and included hematuria, stranguria, and pollakiuria. The laboratory data were nonspecific except for urinalysis test results. Hematuria and inflammatory urinary sediments were most commonly reported; neoplastic cells were identified in the urine sediment of 30% of dogs with lower urinary tract tumors. Contrast cystography was a useful noninvasive diagnostic method since 96% of the dogs had a mass or filling defect in the lower urinary tract demonstrated by this technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute and short-term toxicoses associated with the administration of doxorubicin to dogs with malignant tumors.

One hundred eighty-five dogs with histologically confirmed, measurable malignant tumors were used in a study to determine the toxicity of the anthracycline antitumor antibiotic, doxorubicin, which was administered once or twice (at a 21-day interval) at the rate of 30 mg/m2 of body surface area, iv. During this study, 7 dogs died as a direct result of doxorubicin-induced toxicosis and 16 died as a direct result of the malignant neoplastic disease. Each dog was evaluated for signs of toxicosis for 3 weeks after the last dose was administered (15 dogs received 1 dose, 170 dogs received 2 doses) or until the dog died, whichever came first. The most common signs of toxicosis were vomiting, diarrhea, colitis, anorexia, and pruritus. The probability of doxorubicin-induced toxicosis decreased significantly (P less than 0.0001) in inverse relationship to body weight. Dogs with signs of toxicosis during the 21-day interval from administration of the first dose of doxorubicin were 17.2 times (P less than 0.01; 95% confidence interval; 5.5, 54.2) more likely to develop signs of toxicosis during the 21-day interval from the second dose of doxorubicin. The performance status of each dog was evaluated using a modified Karnofsky performance scheme; the only time the performance status was adversely affected to a significant extent by doxorubicin-induced toxicosis was during the 21-day period, starting with the second dose (P less than 0.0001).

Phase II evaluation of doxorubicin for treatment of various canine neoplasms.

One hundred eighty-five dogs with histologically confirmed, measurable malignant tumors were used in a prospective study to determine the response to 2 doses of the anthracycline antitumor antibiotic, doxorubicin. Eighty-three dogs had been refractory to one or more previous treatment modalities (surgery, n = 54; chemotherapy, n = 22; radiation, n = 10; hyperthermia, n = 1; biological response modifier, n = 1). The extent of neoplastic disease was determined immediately prior to and 3 weeks after 2 doses of doxorubicin were administered (30 mg/m2 of body surface area, iv) 21 days apart. Eighty-four percent (n = 157) of the dogs received 2 doses of doxorubicin and were evaluated. Of the 28 dogs ruled ineligible, 4 had serious side effects to the first dose of doxorubicin, and 24 others acquired complications resulting from their malignant tumors. A partial or complete remission was obtained in 41% (64/157) of all evaluable dogs: 26% (11/43) of the dogs with carcinoma, 67% (42/63) of the dogs with lymphoma, and 22% (11/51) of the dogs with sarcoma. Tumors in which there was at least a 50% volume reduction (partial or complete remission) included malignant lymphoma (42/63), fibrosarcoma (1/14), solid follicular thyroid carcinoma (3/13), mammary adenocarcinoma (2/8), hemangiosarcoma (2/8), osteosarcoma (1/6), circumanal carcinoma (3/5), synovial cell sarcoma (2/3), undifferentiated sarcoma (2/3), nasal adenocarcinoma (1/2), liposarcoma (1/2), infiltrating lipoma (1/1), malignant melanoma (1/1), sclerosing mesothelioma (1/1), and neurofibrosarcoma (1/2).(ABSTRACT TRUNCATED AT 250 WORDS)

Vulvovaginectomy and perineal urethrostomy for neoplasms of the vulva and vagina.

Vulvovaginectomy and perineal urethrostomy were performed in three dogs with extensive neoplasms of the vulva and vagina. One benign tumor (fibroleiomyoma) and two malignant tumors (transitional cell carcinoma and anaplastic spindle cell sarcoma) were diagnosed. Survival times were 9 weeks to 10 months. Urinary continence was preserved in all three dogs. The procedure may be curative for benign tumors or malignant tumors that have not yet metastasized; it is a palliative procedure for advanced malignancies.

Laboratory diagnosis of malassimilation.

In many instances, the cause for malassimilation can be determined with ease, but finding the cause sometimes can be elusive and require the use of sophisticated laboratory techniques not available to the general veterinary practitioner. In either case, the clinician, whether generalist or specialist, must make an informed decision based on the results of many different testing modalities, and not only on the results of the laboratory tests described here. A flow chart is provided to assist the diagnostician in selecting and applying the more clinically oriented laboratory tests useful in dealing with a patient with chronic diarrhea and weight loss.