Age, sex, race and ethnicity representativeness of randomised controlled trials in peri-operative medicine.

The applicability of the results of any clinical trial will depend to a large extent on whether the study population is representative of the population seen in clinical practice. The growing older surgical population presents challenges for peri-operative researchers to ensure there is adequate representation of patients in terms of their age, sex, race and ethnicity in clinical trials. A review of purposively sampled published randomised controlled trials was performed to establish the age, sex, race and ethnicity of study participants. These data were compared with national registry data for the relevant surgical populations. We included 224 peri-operative trials that were cited in 469 retrieved meta-analyses. Of these, 50 (22.3%) had an upper age limit to recruitment. The median (range [IQR]) difference in study population age from the registry population age was: -2.4 (-6.2 to 1.0 [-34.7 to 14.5]) years for all randomised controlled trials; -6.2 (-9.4 to -2.8 [-18.6 to 4.6]) years for randomised controlled trials of patients undergoing hip arthroplasty; and -3.4 (-9.6 to -1.1 [-34.7 to 2.9]) years for randomised controlled trials of patients undergoing hip fracture surgery. In 92 (41.1%) randomised controlled trials, the proportion of each sex in the study population was more than 25% different from the proportion in the registry population. Only 5 (2.2%) trials published data on the race or ethnicity of participants. We conclude that peri-operative randomised controlled trials are unlikely to be representative of the age and sex of clinically treated surgical populations. Researchers must endeavour to ensure representative study populations are recruited to future clinical trials.

Bilateral hypoglossal nerve injury following the use of the laryngeal mask airway.

A healthy 54-year-old man undergoing elective knee arthroscopy developed bilateral hypoglossal nerve palsy, lasting 6 weeks following the use of a laryngeal mask airway. He suffered impairment of speech and difficulty in swallowing, the latter resulting in almost 7 kg loss of weight within 2 weeks of surgery. We discuss the possible aetiology of the injury and review the literature describing injuries to the hypoglossal nerve.

Use of famciclovir for the treatment of endotheliotrophic herpesvirus infections in Asian elephants (Elephas maximus).

Two juvenile Asian elephants (Elephas maximus) presented with an acute onset of facial edema and lethargy. Examination of the oral cavity of each animal revealed cyanosis of the tip and distal margins of the tongue suggestive of endothelial inclusion body disease (EIBD) of elephants. Whole-blood samples were obtained, and polymerase chain reaction tests confirmed the presence of elephant herpesvirus. The animals were administered famciclovir (Famvir, SmithKline Beecham Pharmaceuticals, Philadelphia, Pennsylvania 19101, USA), a potent human anti-herpesvirus drug, in the course of their disease, and recovery followed a treatment regime of 3-4 wk. These are the first known cases of elephants surviving EIBD.

Ultrasonographic appearance of ruptured peroneus tertius in a horse.

Ultrasonography was a valuable diagnostic tool for examination of a ruptured peroneus tertius in a horse, because it allowed visualization of the extent of the injury and evaluation of healing prior to return of the horse to athletic activity.

Rectal and colonic injury in the llama. Anatomic considerations and surgical management in four llamas.

Transrectal palpation in llamas can result in iatrogenic rectal and colonic injury. The purpose of this report is to define the caudal extent of the peritoneal cavity in llamas and to describe the surgical management of rectal or colonic injuries in four llamas. Measurements were made of six adult llamas during necropsy. The mean distance from the peritoneal reflection to the anus was 3.9 +/- 0.1 cm (3.4-4.3 cm). Four llamas were examined for rectal or colonic perforations. One laceration was of partial thickness and three lacerations were of full thickness. Two of the defects were repaired by a transanal approach and two by celiotomy to facilitate removal of fecal debris and abdominal lavage. Successful repair of the rectal or colonic tears was achieved in all four llamas. Wound infection and incisional hernia occurred in both llamas that underwent celiotomy. Two llamas died 3 and 18 months later, and two llamas have survived 2 years. Rectal tears in llamas are accompanied by a high risk of peritoneal contamination, and primary closure is recommended. If fecal contamination of the abdomen has occurred, celiotomy is indicated to allow mechanical removal of fecal debris and peritoneal lavage.

Evaluation of intestinal villus height in rats after ischemia and reperfusion by administration of superoxide dismutase, polyethylene glycol-conjugated superoxide dismutase, and two 21-aminosteroids.

Intestinal ischemia was induced and maintained for 60 minutes in male Sprague-Dawley rats weighing 175 to 225 g. Prior to reperfusion, the following drugs were administered via the caudal vena cava: 0.9% NaCl (0.5 ml), superoxide dismutase (SOD; 1,000 IU/kg of body weight), polyethylene glycol-conjugated SOD (PEG-SOD; 1,000 IU/kg), or the 21-aminosteroids, U74006F (3 mg/kg) or U78715G (3 mg/kg). A sham-operated control group was included. Animals from each group were euthanatized at 5 periods of reperfusion: 5 minutes, 30 minutes, 18 hours, 3 days, and 7 days after reperfusion. Fixed tissues were embedded in paraffin, sectioned at 5 microns, and stained with H&E. Villi profiled in cross section were measured from the crypt villus junction to the tip of the villus. The mean villus height for each rat was calculated and compared by two-way ANOVA to determine the effects of time and treatment. Villus height was maintained after 30 minutes of reperfusion in rats of the sham- and U74006F-treated groups; U78715G and SOD treatment attenuated the loss in villus height, and villus height was not maintained in the PEG-SOD- and 0.9% NaCl-treated rats. In all rats, villus height was comparable to, or was greater than villus height in sham-operated controls by 18 hours after reperfusion in all animals and remained constant through 7 days. Administration of the 21-aminosteroids maintained villus height after ischemia and reperfusion. Treatment with PEG-SOD did not maintain villus height to the degree observed in rats treated with SOD.

Anesthetic management of an incisional dehiscence in recovery following exploratory laparotomy in a horse.

A 5-year old Arabian mare fell during recovery from general anesthesia after an exploratory laparotomy. This fall resulted in dehiscence of the abdominal closure, and a substantial amount of intestines were exteriorized. Chemical and manual restraints were rapidly used to prevent trauma to the exposed intestines. A second general anesthesia was initiated to clean the intestines and close the incision. Multiple anesthetic problems were encountered, including arterial hypotension and hypoxemia. The horse recovered from the second general anesthesia and surgery, and all complications gradually resolved. The horse was discharged and has not had further problems to date.

Pedicle skin flaps in ponies: viable length is related to flap width.

The relationship between pedicle flap width and viable length was characterised for skin flaps of the flank in ponies. Four dorsally based, pedicle type skin flaps of 20 cm in length and 3, 6, 9 or 12 cm in width were created in a random sequence on one flank in each of 10 ponies. Flap survival length was assessed by skin texture and appearance, depilation of hair and wound healing at 14 days after surgery. There was considerable variation between animals in the viable length of flaps of the same width; however, a significant difference in the viable length of flaps of different widths was detected (P = 0.002). The viable length of the 3 cm flaps was significantly different from that of the 12 cm flaps (9.69 +/- 1.1 cm vs 12.97 +/- 1.0 cm, mean +/- se P less than 0.05). There was a positive correlation between flap width and viable length (r2 = 0.141, P = 0.017). There was no effect of flap order (cranial to caudal positioning relative to the other flaps) on viable length (P = 0.286). The results of this study demonstrate a significant relationship between flap width and viable length, confirming a previously unsupported assumption that flap width and viable length are related. These findings suggest that the clinician should employ broad pedicles when using local flaps to reconstruct skin defects on the flank of the horse.

A comparison of techniques to enhance the evaluation of equine laryngeal function.

This study was designed to define a simple, unequivocal test for the evaluation of laryngeal function and the diagnosis of idiopathic laryngeal hemiplegia (ILH). ILH is a disorder that results from left recurrent laryngeal neuropathy and in which there is no movement of the left arytenoid cartilage and vocal fold. Laryngeal function was evaluated in seven horses using four techniques designed to stimulate laryngeal movements:-nasal occlusion, exercise, swallowing and administration of a respiratory stimulant. In addition, the effects of sedation and twitching on the endoscopic examination were also examined. The cross-sectional area of the rima glottidis was measured in each horse at rest and after each technique was performed. There was no statistically significant difference in the increase in area seen after nasal occlusion or exercise. Doxapram hydrochloride increased the cross-sectional area of the rima glottidis, whereas xylazine caused a decrease. Neither of these pharmacological agents exaggerated or decreased the amount of asynchronous movement or tremoring of the arytenoid cartilages. Manual occlusion of the external nares during endoscopy is a simple, yet effective method of stimulating arytenoid function and hence diagnosing ILH.

Preferential denervation of the adductor muscles of the equine larynx. I: Muscle pathology.

The laryngeal muscles of 18 horses were examined histologically. The neurogenic changes found in each muscle were scored by four reviewers and the results evaluated statistically. Fifteen of these horses had endoscopic evidence of abnormal laryngeal function, three of which were defined as having adductor paralysis. Measurement of muscle fibre area in two horses with idiopathic laryngeal hemiplegia (ILH) was performed. In the quantitative study of neurogenic change, the adductor muscles were more significantly affected than the abductor muscle. This was also true in the clinical cases of ILH where measurement of muscle fibre area demonstrated that the lateral cricoarytenoid (adductor) muscles showed a wider range of pathological changes than the dorsal cricoarytenoid muscle (abductor). Those horses with the most severe muscle pathology also had the most abnormal endoscopic findings. The propensity for denervation of the adductor muscles should provide clues as to the pathogenesis and natural history of horses with sub-clinical laryngeal disease and ILH.

Problem wounds of the horse.

Three clinical cases are presented to illustrate some of the problems that may complicate the treatment of wounds in horses. The three examples are a lower limb laceration, a chronic draining chest wound, and complications associated with a fiberglass cast. The use of ancillary diagnostic aids such as arthrocentesis, diagnostic nerve blocks, radiographs, and ultrasonography are indicated to assess change to deeper structures.

Equine bandaging techniques.

Topical medications and bandages play an important role in the management of equine wounds. Certain water-soluble antibacterial ointments (povidone-iodine, polymixin-neosporin-bacitracin) may be appropriate for use on contaminated wounds. A well-designed equine bandage is usually composed of primary, secondary, and tertiary layers. Because so many different products are available, the practitioner is advised to become familiar with the handling characteristics of a few. Because of the irregular contours of the equine limb, only products that stretch and conform should be used. Bandages should be applied snugly and secured in such a fashion that they will not slip or ride up. The horse should be confined to a stall while bandaged, and, even then, bandages must be changed at frequent intervals.

Vascular anatomy of the equine small colon.

The vasculature of 22 small colons from dead adult ponies was perfused with latex or barium sulphate solution. The vascular anatomy was studied by use of dissection and alkali digestion of the latex specimens and microangiography of the barium sulphate-perfused specimens. The small colon is supplied by the caudal mesenteric artery. The left colic artery arises from the caudal mesenteric artery, which then becomes the cranial rectal artery. Branches from the left colic and cranial rectal arteries form anastomosing arcades that become narrower distally along the length of the small colon. From these arcades arise terminal arteries, which enter the small colon wall and give rise to a subserosal, an intermuscular, and a large submucosal plexus, with frequent anastomoses between them. The venous drainage closely parallels the arterial supply, except near to its origin from the portal vein, when the left colic vein and caudal mesenteric vein are separate from the corresponding arteries.

Induction of equine postanesthetic myositis after halothane-induced hypotension.

Wick catheters were used to measure intracompartmental pressures of the extensor carpi radialis muscles and long heads of the triceps brachii muscles of 7 horses maintained under halothane anesthesia during controlled ventilation. Horses were positioned in left lateral recumbency on a water bed for 4 hours. Using a crossover design, 6 of the 7 horses were subjected to normotensive and hypotensive anesthesia on separate occasions. Hypotension was achieved by increasing the inspired halothane concentration. Hematologic and biochemical measurements were determined at designated intervals before, during, and for 7 days after each anesthetic episode. Under hypotensive conditions, 2 horses developed severe generalized myositis and were euthanatized. Three of the 5 other horses developed swelling of the downside masseter muscle, 4 demonstrated mild extensor deficits of the downside forelimb, and 1 had a severe extensor deficit of the uppermost hind limb. As a group, the hypotensive horses had markedly increased activities of serum enzymes (creatine kinase, aspartate transaminase, and blood lactate) and abnormalities in calcium-phosphorus homeostasis. Lameness or enzyme alterations were not observed in normotensive horses. Although the intracompartmental pressure values were markedly increased in the muscle bellies of the compressed limbs of all horses, there was a statistically significant difference in intracompartmental pressures between the downside or compressed muscle compartments of the extensor carpi radialis of hypotensive and normotensive horses. High concentrations of halothane may predispose anesthetized horses to postanesthetic myositis, even when protective padding is used. Intracompartmental muscle pressure, as measured by the wick catheter, may not be a reliable predictor of equine postanesthetic lameness.

A comparison of enterotomies through the antimesenteric band and the sacculation of the small (descending) colon of ponies.

Three pairs of longitudinal enterotomies were performed in the small colon of 10 ponies. Each pair consisted of one enterotomy through the antimesenteric band and one through the sacculation. The ponies were destroyed 96 h after surgery. The enterotomies in the two sites were compared for: speed of surgery, adhesions, bursting wall tension, neovascularisation by micro-angiography, and histological reaction. Enterotomies made through the antimesenteric band were superior because they were quicker to perform, stronger, more accurately apposed, and had less inflammation than those made through the sacculation.

Arthrodesis of the equine distal tarsal joints by perforated stainless steel cylinders.

Perforated stainless steel cylinders filled with autogenous cancellous bone were implanted in the distal tarsal joints of four horses. Graft cell survival was poor two weeks after surgery in one horse. In two horses, at 10 months there was partial arthrodesis of the joints with incorporation of the implants into the osseous union. The implants were filled with vascularised woven bone. These two horses were sound nine months after surgery. One horse fractured its third tarsal bone and was still positive to a hock flexion test 12 months after surgery.

Successful surgical repair of a vascular shunt of the corpus cavernosum penis and penile fibropapillomata in a bull.

A single vascular connection between the corpus cavernosum penis and the superficial penile vasculature was diagnosed in an 18-month old Holstein bull with a history of acquired failure to maintain penile erection. Previously normal serving ability had been documented. Multiple penile fibropapillomata were also found. The vascular shunt was identified by contrast cavernosography and ligated, and the fibropapillomata excised. The bull returned to normal function within three months after surgery, and no recurrence of either problem had been experienced by 12 months after surgery.