Paranasal sinus cysts in the horse: Complications related to their presence and surgical treatment in 37 cases.

BACKGROUND: Paranasal sinus cysts (PSC) are a common cause of equine secondary sinusitis. The outcome and associated complications have not been frequently reported. OBJECTIVES: To review the associated clinical signs, associated morbidities and outcomes of horses treated for PSC. STUDY DESIGN: Retrospective multicentre case series. METHODS: Retrospective analysis of case records and telephone follow up survey. RESULTS: Subjects were 37 horses 1-24 years old that were presented with nasal discharge (n = 31), facial swelling (n = 25) and epiphora (n = 19). Radiography and computed tomography allowed identification of the cyst-induced changes including concomitant tissue destruction (n = 31), leading among other things to local nerve damage causing headshaking (n = 6) and unilateral blindness (n = 1). Radiographic changes to adjacent dental apices were present in 10 horses. Horses over 10 years old showed more of the named associated problems. Post-operative complications included surgical site infection (SSI) (n = 11), nasofrontal suture periostitis (n = 6) and sequestration (n = 1) following removal of the PSC via osteotomy. The long-term response to treatment was available for 28 cases with 22 horses (78.6%) fully cured, 4 (14.3%) partially cured and 2 (7.1%) not responding to treatment. In 7 horses (18.9%) there was recurrence of the cyst post-operatively. MAIN LIMITATIONS: Due to the study being a multicentre retrospective case series with collection of data over an extended period, there may be inconsistency in data recording and absence of reporting of some findings. CONCLUSIONS: Overall, the diagnosis and treatment of sinus cysts is relatively straightforward and carries a good prognosis. In long-standing cases complications secondary to the expansive growth of cysts will dramatically affect the prognosis for full recovery due to pressure-induced changes to facial bones, cheek teeth and nerves. These secondary complications mainly occurring in older horses may be due to a combination of a relatively longer period of affection and the inflexibility of older horses' bones. Cyst recurrence following treatment can occur in up to 19% of cases.

Sequential bacterial sampling of the midline incision in horses undergoing exploratory laparotomy.

BACKGROUND: There is limited information about bacterial isolates that are present on the equine midline incision during and following exploratory laparotomy. OBJECTIVES: To investigate the bacterial species cultured from the ventral midline pre-, intra- and post- laparotomy, whether particular bacterial isolates are associated with the development of surgical site infections (SSIs) and to report the antimicrobial resistance phenotypes of these isolates. STUDY DESIGN: Prospective cohort study. METHODS: The ventral midline of 31 horses undergoing exploratory laparotomy was sampled for bacterial culture at set time-points pre, intra and post-operatively. Inclusion criteria were that horses must have undergone exploratory laparotomy within 90 min of the initial colic examination upon hospital admission and must not have been placed in a stable prior to surgery. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration. RESULTS: Seven horses (22.6%) developed a SSI. None of the variables tested were associated with the altered risk of SSI. The prevalence of a positive bacterial culture from the incision increased progressively over time and a variety of bacteria were isolated. A positive intra-operative culture was not a predictor of SSI; and when a SSI did occur, it was due to a different bacterial isolate. MRSA and ESBL-producers were identified in the post-operative period in one and four different horses respectively, but none of these developed a SSI. MAIN LIMITATIONS: Sampling was limited to hospitalisation and no culture results were available for horses developing SSI following hospital discharge. CONCLUSIONS: A variety of bacterial species may be isolated from equine laparotomy incisions peri-operatively without development of SSI. SSI does not appear to be solely related to bacterial contamination of the incision peri-operatively and other mechanisms such as bacteraemia merit further investigation.

Risk factors for surgical site infection following laparotomy: Effect of season and perioperative variables and reporting of bacterial isolates in 287 horses.

REASONS FOR PERFORMING STUDY: Surgical site infection (SSI) is an important cause of post operative morbidity following laparotomy. OBJECTIVES: To investigate risk factors for SSI, including effect of season and surgery performed outside normal working hours, and to report bacterial isolates and antimicrobial resistance patterns. STUDY DESIGN: Retrospective cohort study. METHODS: Data were obtained from horses that had undergone exploratory laparotomy over a 3-year period (2010-2013) in a UK hospital population. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration that developed during hospitalisation. Multivariable logistic regression was used to identify associations between pre-, intra- and post operative variables and altered likelihood of SSI. RESULTS: Surgical site infection developed in 73/287 (25.4%) horses during hospitalisation. Horses of greater bodyweight (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.0002-1.005, P = 0.03), increased packed cell volume (≥48%) on admission (OR 3.03, 95% CI 1.32-6.94, P = 0.01), small intestinal resection (OR 2.27, 95% CI 1.15-4.46, P = 0.02) and post operative colic (OR 2.86, 95% CI 1.41-5.79, P = 0.003) were significantly associated with increased likelihood of SSI in a multivariable model. SSI was also significantly more likely to occur during winter (OR 3.84, 95% CI 1.38-10.70, P = 0.01) and summer (OR 5.63, 95% CI 2.07-15.3, P = 0.001) months in the model. Three-layer closure of the incision was protective (OR 0.31, 95% CI 0.16-0.58, P<0.001) compared to 2-layer closure. There was no effect of surgery being performed outside normal working hours (P = 0.5). The most common bacterial isolates were Escherichia coli (59.5%), Enterococcus spp. (42.4%) and Staphylococcus spp. (25.4%). Penicillin resistant isolates accounted for 92% (96/104) of isolates while 18% (21/119) of isolates were gentamicin resistant. CONCLUSIONS: Laparotomy during winter and summer months was associated with increased likelihood of SSI but there was no effect of surgery performed outside normal working hours. This information assists in identifying horses at high risk of SSI and informing development of preventive strategies.

Contribution of healthy and unhealthy primary school meals to greenhouse gas emissions in England: linking nutritional data and greenhouse gas emission data of diets.

BACKGROUND/OBJECTIVES: School meals represent the largest sector in Government food procurement in the United Kingdom. This paper aims to quantify, simultaneously, the nutritional quality and carbon footprint of meals provided by primary schools in England. SUBJECTS/METHODS: The School Food Trust conducted the 'Primary School Food Survey 2009' in a nationally representative sample of 139 primary schools in England. The survey included 6690 students who consumed school lunches and 3488 students who brought packed lunches. We estimated the total greenhouse gas emissions (GHGEs) per Kg of the food items contributing to those lunches based on the results of a systematic review of life-cycle analyses. RESULTS: In both school lunches and packed lunches, the 'meat, fish and alternatives' group contributed the largest share of GHGEs. The mean GHGE value per school lunch was estimated to be 0.72 (95% uncertainty interval 0.52-1.34) KgCO2e and per packed lunch was 0.70 (0.58-0.94) KgCO2e. The total GHGE due to primary school meals in England per year is 578.1 million KgCO2e (455-892 million). CONCLUSIONS: If all children achieved a healthy meal defined by having a low level of salt, free sugars and saturated fat, the total GHGEs from primary school meals would be 441.2 million KgCO2e (384-1192), saving 136.9 million KgCO2e compared with the current total emissions from primary school meals. This paper demonstrates that changes in the primary school food sector can have an impact on UK GHGEs.

Age differences in the association of childhood obesity with area-level and school-level deprivation: cross-classified multilevel analysis of cross-sectional data.

OBJECTIVE: Evidence suggests that area-level deprivation is associated with obesity independently of individual socioeconomic status; however, although the school may also have an impact on child health, few studies have investigated the association between school-level deprivation and the body mass index (BMI) of students. The aim of this study was to assess the relationship between the BMI for children of different ages and area-level and school-level deprivation. SUBJECTS: BMI measurements were collected through the National Child Measurement Programme (NCMP) that samples from two school years: 396,171 reception year pupils (4-5-year olds) and 392,344 year 6 pupils (10-11-year olds) from 14,054 primary schools in England. DESIGN: Cross-classified multilevel models with four levels: individual (n=788,525), lower super output areas corresponding to area of residence (n=29,606), schools (n=14,054) and primary care trusts (PCTs, n=143), which coordinate the collection of data within a large area, were used to study the relationship between measures of deprivation at an area and school level, and childhood BMI within England. RESULTS: A positive association was found between the area and school measures of deprivation, and student BMI. Both the measures of deprivation explained a greater proportion of variance in BMI z-scores for year 6 students than for the reception year students, with a greater difference between the year groups found with the school-level measure of socioeconomic status than for the the area-level measure. CONCLUSIONS: Deprivation explains a greater proportion of the variance in BMI for older compared with younger children, perhaps reflecting the impact of deprivation as children age, highlighting the widening of health inequalities through childhood. The association with school-level deprivation illustrates the impact of the school on BMI status throughout the primary school years.

Equine paranasal sinus disease: a long-term study of 200 cases (1997-2009): ancillary diagnostic findings and involvement of the various sinus compartments.

REASONS FOR PERFORMING STUDY: There is a lack of objective information on the value of ancillary diagnostic techniques used to investigate equine sinus disease, and also on which sinus compartments are commonly affected in this disorder. OBJECTIVES: To record the ancillary diagnostic findings used to investigate equine sinus disease and to document which compartments are affected. MATERIALS AND METHODS: The clinical case records of 200 consecutive cases of sinus disease, including subacute (<2 months' duration) primary (n = 52); chronic (>2 months' duration) primary (n = 37); dental (n = 40); traumatic (n = 13); sinus cyst (n = 26); sinus neoplasia (n = 10); dental related oromaxillary fistula (n = 8); mycotic sinusitis (n = 7) and intra-sinus progressive ethmoid haematoma (n = 7) were retrospectively examined. RESULTS: Nasal endoscopy showed exudate draining from the sino-nasal ostia in 88% of cases and a sino-nasal fistula was present in 15% of cases. Sinoscopy was performed in 79% of cases and was of great diagnostic value. More recently, 22% of cases had fenestration of the ventral conchal bulla performed to allow sinoscopy of the rostral sinus compartments. Radiography was performed in 97% of cases and showed intra-sinus fluid lines to be common (69% prevalence) in subacute primary sinusitis. Radiographic dental apical changes were not specific to dental sinusitis, e.g. 29% of chronic primary sinusitis cases had radiographic dental changes. Scintigraphy was performed in 20% of cases and was helpful in identifying dental apical changes when radiography was inconclusive. Overall, the caudal maxillary (78% involvement) and rostral maxillary (61%) sinuses were most commonly affected, with the ventral conchal sinus (VCS) (54% involvement) and conchofrontal sinuses (48%) less so. The VCS showed the greatest tendency to contain inspissated pus (present in 46% of all affected VCS). CONCLUSIONS: Nasal endoscopy, sinoscopy and skull radiography are of great value in diagnosing the presence and causes of equine sinus disease.

Equine paranasal sinus disease: a long-term study of 200 cases (1997-2009): treatments and long-term results of treatments.

REASONS FOR PERFORMING STUDY: There is limited objective information available on the treatment and the long-term response to treatment of the different types of equine sinus disease. OBJECTIVES: To document the treatments and long-term response to these treatments in 200 cases of equine sinus disease (1997-2009). METHODS: The treatments of horses affected with subacute primary sinusitis (n = 52); chronic primary sinusitis (n = 37); dental sinusitis (n = 40); sinus cyst (n = 26); traumatic (n = 13); dental-related oromaxillary fistula (n = 8); sinus neoplasia (n = 10); mycotic sinus disease (n = 7); and intrasinus progressive ethmoid haematoma (n = 7) and the long-term response to these treatments were retrospectively reviewed. RESULTS: Treatments evolved throughout the study and latterly were as conservative as possible, including sinoscopic lavage and standing sinusotomy, with a maxillary sinusotomy approach preferred for the mainly mature horses treated in this study. Removal of intrasinus inspissated pus, including transendoscopically (by sinusotomy and via existing sinonasal fistulae), was the main treatment for chronic primary sinusitis and sinonasal fistulation was seldom performed latterly. Attempted oral extraction of infected cheek teeth, even if unsuccessful, facilitated subsequent dental repulsion, resulting in few post operative problems. Sinus cyst removal carried an excellent prognosis. Except for cases of sinus neoplasia (only 22% cured), an excellent long-term response to treatment (91% fully cured, 7% partially cured) was obtained for all other types of sinus disease following a median of one treatment. CONCLUSIONS: More conservative treatments, including removal of intrasinus inspissated pus by sinoscopy, pre-existing sinonasal fistula or sinusotomy, are effective for chronic primary sinus disease. Standing sinusotomy, mainly using a small maxillary site, was suitable for most cases of sinus disease in mature horses.

Historical and clinical features of 200 cases of equine sinus disease.

The historical and clinical findings in 200 referred cases of equine sinus disease were reviewed retrospectively. Univariable and multivariable analyses were performed to detect significant differences in historical or clinical features between various categories of sinus disease. The causes of sinus disease were classified as subacute primary (less than two months duration) (n=52), chronic primary (more than two months duration) (n=37), dental (n=40), sinus cyst (n=26), traumatic (n=13) or mycotic sinusitis (n=7), sinus neoplasia (n=10), dental-related oromaxillary fistula (n=8) and intrasinus progressive ethmoid haematoma (n=7). The majority of sinus disorders were of chronic duration at the time of referral and most (including 97 per cent of chronic primary sinusitis cases) had not responded to previous antibiotic therapy and/or sinus lavage in some cases. Clinical signs included unilateral nasal discharge in most cases, including purulent or mucopurulent discharge in all horses with primary, dental and mycotic sinusitis. Haemorrhagic nasal discharge was a feature of traumatic sinusitis and intrasinus progressive ethmoid haematomas. Firm facial swellings and nasal airflow obstruction were features of sinus cysts and neoplasms. Ipsilateral lymphadenitis was a more prominent feature of sinus disease with active infections such as primary, dental or mycotic sinusitis.

Investigation of the sensitivity and specificity of radiological signs for diagnosis of periapical infection of equine cheek teeth.

REASONS FOR PERFORMING STUDY: Radiography is commonly used for the diagnosis of equine cheek teeth (CT) infection but, to our knowledge, no study to date has evaluated the relative values of individual specific radiographic signs when making a diagnosis. OBJECTIVES: To investigate the sensitivity and specificity of individual radiographic signs identified from the literature for the diagnosis of CT apical infection using a retrospective case-control study. METHODS: Cropped radiographs taken using computed radiography of 41 apically infected CT and 41 control CT were independently blindly evaluated by 3 clinicians for the presence of 12 predetermined radiographic signs associated with CT apical infection. A final diagnosis of either noninfected or infected was made. Sensitivity and specificity were calculated for the presence or absence of each radiographic sign for each clinician. Uni- and multivariable conditional logistic regression were used to determine strength of association of the 12 radiographic signs with apical infection. RESULTS: Median sensitivity and specificity for the diagnosis of CT apical infection were 76 and 90%, respectively. Periapical sclerosis, clubbing of one or 2 roots, degree of clubbing and periapical halo formation had the highest sensitivities (73-90%), with moderate specificity (61-63%). Multivariable conditional logistic regression revealed that severity of periapical sclerosis and extensive periapical halo were strongly associated with CT apical infection. CONCLUSIONS: The presence of periapical sclerosis and formation of a periapical halo were strongly associated with CT apical infection. Computed radiography appears to have a higher sensitivity but similar specificity to previously published results using film radiography to detect CT apical infection. POTENTIAL RELEVANCE: These findings may aid practitioners when interpreting radiographs of equine CT as to the relative significance of their findings.

Application of mobile phone technology for managing chemotherapy-associated side-effects.

BACKGROUND: Novel mobile phone technology linked to a server that communicates patients' symptoms to healthcare professionals has been adapted to register the side- effects of chemotherapy and provide advice on management of toxicity. We report a feasibility study to examine the utility of home monitoring of patients' symptoms via a mobile phone. METHODS: Six colon cancer patients receiving adjuvant chemotherapy, entered symptom data onto user friendly screens on a mobile phone twice daily. This 'real time' self assessment of nausea, vomiting, mucositis, diarrhoea and hand-foot syndrome and measurement of temperature was sent via a secured connection to a remote computer. In the event of moderate or severe symptoms (generating amber and red alerts respectively), the nurse was immediately alerted by the computer, via a pager. The nurse then contacted the patient to reinforce the automatic advice sent to the patient on their phone and to assess the patient using clinical algorithms. RESULTS: The patient used the mobile phones during the first two cycles of chemotherapy. The data were successfully analysed by the server software and alerts were generated alerting the study nurses to patients' symptoms at the appropriate time. There were 91 alerts-54 red and 37 amber; 54% (29/54) of the red alerts were data delay and transmission problems which were swiftly rectified. The remaining red alerts were managed appropriately by the study nurses. Both patients and staff felt confident in this approach to symptom management. CONCLUSIONS: This study demonstrates that the technology for monitoring patients' symptoms worked well. The patients felt secure in the knowledge that their symptoms were being closely monitored and that they were participating effectively in their own care management.

Interspersed normoxia during live high, train low interventions reverses an early reduction in muscle Na+, K +ATPase activity in well-trained athletes.

Hypoxia and exercise each modulate muscle Na(+), K(+)ATPase activity. We investigated the effects on muscle Na(+), K(+)ATPase activity of only 5 nights of live high, train low hypoxia (LHTL), 20 nights consecutive (LHTLc) versus intermittent LHTL (LHTLi), and acute sprint exercise. Thirty-three athletes were assigned to control (CON, n = 11), 20-nights LHTLc (n = 12) or 20-nights LHTLi (4 x 5-nights LHTL interspersed with 2-nights CON, n = 10) groups. LHTLc and LHTLi slept at a simulated altitude of 2,650 m (F(I)O(2) 0.1627) and lived and trained by day under normoxic conditions; CON lived, trained, and slept in normoxia. A quadriceps muscle biopsy was taken at rest and immediately after standardised sprint exercise, before (Pre) and after 5-nights (d5) and 20-nights (Post) LHTL interventions and analysed for Na(+), K(+)ATPase maximal activity (3-O-MFPase) and content ([(3)H]-ouabain binding). After only 5-nights LHTLc, muscle 3-O-MFPase activity declined by 2% (P < 0.05). In LHTLc, 3-O-MFPase activity remained below Pre after 20 nights. In contrast, in LHTLi, this small initial decrease was reversed after 20 nights, with restoration of 3-O-MFPase activity to Pre-intervention levels. Plasma [K(+)] was unaltered by any LHTL. After acute sprint exercise 3-O-MFPase activity was reduced (12.9 +/- 4.0%, P < 0.05), but [(3)H]-ouabain binding was unchanged. In conclusion, maximal Na(+), K(+)ATPase activity declined after only 5-nights LHTL, but the inclusion of additional interspersed normoxic nights reversed this effect, despite athletes receiving the same amount of hypoxic exposure. There were no effects of consecutive or intermittent nightly LHTL on the acute decrease in Na(+), K(+)ATPase activity with sprint exercise effects or on plasma [K(+)] during exercise.

IgA myeloma of donor origin arising 7 years after allogeneic renal transplant.

We report the case of a 38-year-old man who developed IgA myeloma of donor origin 7 years after allogeneic renal transplant. The diagnosis of multiple myeloma was unequivocal and based on positive results from serum electrophoresis, skeletal survey and bone marrow investigations. The donor origin of the myeloma cells was confirmed by DNA fingerprinting. We believe this is the first reported case of disseminated multiple myeloma of donor origin developing after allogeneic renal transplant and, as such, gives some insight into the natural history and biology of the disease.

Good outcome from surgery for ampullary tumour.

BACKGROUND: Ampulla of Vater tumours are rare but usually resectable. There is debate as to the better surgical approach between the standard radical procedure, which provides adequate resection margins, and local resection, which may carry a lower mortality. This study reports the 16-year experience of a specialist unit with these tumours, and compares our results with that of recently published series. METHOD: A retrospective review of patients admitted with an ampullary tumour to the Hepatobiliary and Pancreatic Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia, between January 1981 and April 1997. RESULTS: Twenty-five patients (13 men, 12 women) of median age 65 years were admitted with an ampullary tumour to the unit during this period. The most common presentation was obstructive jaundice. Multiple endoscopic biopsy was found to be very reliable in distinguishing between benign and malignant tumours. Five patients, all male, had benign neoplasms: three adenomas, one carcinoid and one gangliocytic paraganglioma. Transduodenal local excision was performed in four patients. One patient had a Whipple procedure resulting in the only in-hospital death at 3 months. Twenty patients had adenocarcinoma, of which 13 patients had a pancreaticoduodenectomy, two local excisions, two palliative bypasses, two were unfit for surgery and one declined surgery. The resectability rate was 88%, with no operative mortalities. The 5-year actuarial survival of patients who underwent radical resection was 49%. CONCLUSIONS: Proximal pancreaticoduodenectomy, preferably a pylorus-preserving procedure, is safe and effective in the treatment of ampullary carcinoma, with low operative mortality and good long-term survival. Local resection is only recommended for small benign tumours and for patients who may be unfit for radical surgery.

Inducing amenorrhea during bone marrow transplantation. A pilot study of leuprolide acetate.

OBJECTIVE: To evaluate, in a pilot study, the use and efficacy of a gonadotropin-releasing hormone (GnRH)-agonist in inducing amenorrhea in women undergoing BMT. STUDY DESIGN: We evaluated the use of the GnRH agonist leuprolide acetate (LA) for the induction of amenorrhea in 10 postmenarcheal women prior to BMT. If there was a contraindication to the use of the intramuscular (i.m.) formulation of LA, the subcutaneous (s.c.) formulation was given as a daily intravenous (i.v.) bolus. Once the subject's platelet count was > 50,000/microL, the LA was discontinued. Menstrual bleeding, time from initiation of therapy to amenorrhea, and liver function test results were monitored. RESULTS: All subjects had induction of amenorrhea with the use of LA except for one subject with a large, myomatous uterus, who experienced light spotting. One subject who was thrombocytopenic at the prescribed time of the second dosage of i.m. LA received i.v. LA with documentation of continued pituitary/gonadal suppression. No adverse effects were determined to be directly related to either the i.m. or i.v. LA. CONCLUSION: LA is an option for the induction of amenorrhea in postmenarcheal women undergoing BMT. In thrombocytopenic subjects, administration of the s.c. formulation of LA by an i.v. route served as an alternative to i.m. injection and was documented to maintain gonadotropin suppression.

Primary duct closure versus T-tube drainage following exploration of the common bile duct.

T-tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T-tube drainage of the CBD following exploration for calculous disease. Thirty-seven patients underwent primary closure and 26 underwent closure over T-tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre-operative bilirubin, amylase and white cell count. Forty-three per cent of operations were performed by a consultant in the primary closure group and 65% in the T-tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T-tube group, to a median of 11 days, compared to 8 days in the primary closure group (P = 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T-tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long-term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T-tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of diet and behavior therapy on social and motor behavior of retarded phenylketonuric adults: an experimental analysis.

The effects of a low phenylalanine diet on six retarded phenylketonuric adults were assessed. An ABA individual-subject design was used in experiment I to assess the effects of a low phenylalanine diet on social and motor behavior. Following a baseline during which the subjects ingested a normal phenylalanine diet (phase A), a low phenylalanine diet (phase B) was administered in a double blind fashion. Finally, the baseline condition (phase A) was reinstated (normal diet). The low phenylalanine diet resulted in few significant behavioral changes for those subjects with which proper methodologic controls were employed. However, for two of six subjects motor behavior, including stereotypy and tremor, seem to have ameliorated. In experiment II, applied behavior analysis techniques, including differential reinforcement of other behavior and time out, were combined to radically reduce the frequency of stereotypy and self-abuse exhibited by one of the six subjects of experiment I.