Stakeholder perceptions of thoroughbred yearling sales endoscopy in Australia: can we do better?

OBJECTIVE: To identify thoroughbred industry stakeholders' views on the yearling sales endoscopy in Australia. DESIGN: Semi-structured qualitative group interviews with equine veterinarians, thoroughbred breeders and yearling purchasers. METHODS: Twenty-nine experienced thoroughbred industry stakeholders participated in online focus groups: (1) equine veterinarians involved in yearling endoscopy; (2) thoroughbred breeders; and (3) yearling buyers. The focus groups were audio and video recorded and digital whiteboards were available. Data was transcribed, live-coded and analysed thematically. RESULTS: The main themes identified included the uncertainty surrounding the relationship between yearling laryngeal function and future performance, especially the significance of yearlings with grade 3 out of 5 laryngeal function; interobserver variability in the laryngeal function grade assigned by veterinarians to the same endoscopic exam; and the presence of intra-horse variability in laryngeal function over different time points. DISCUSSION: Stakeholders raised multiple concerns about the current yearling sales endoscopy process in Australia. Recommendations to address these concerns include further investigation into the race performance of yearlings identified with grade 3 laryngeal function; training of veterinarians to reduce inter-observer variability; and the need to determine the most appropriate grading system to use in yearlings. Future research should evaluate the significance of intra-horse variability in a yearling population.

Review of the clinical diagnosis of sacroiliac dysfunction in horses - Challenges and limitations.

Sacroiliac dysfunction (SID) is a condition seen in horses associated with poor performance that affects hind limb gait and impulsion. The condition comprises pain and dysfunction but there lacks clarity around the aetiopathogenesis and whether SID encompasses abnormal joint pathology, abnormal joint movement, abnormal regional biomechanical function, joint laxity and pain, or various combinations of these that may vary over time. Clinical assessment remains challenging for equine clinicians due to the deep location of the sacroiliac joint (SIJ) and surrounding structures which limits access for palpation, diagnostic imaging and joint-specific injection. There is no recognised single reference standard diagnostic test for SID. Clinical diagnosis has been based on ruling out other causes of hind limb lameness, along with combinations of ultrasonography, scintigraphy and periarticular anaesthesia of the SIJ. Recent studies have highlighted the lack of specificity of injections targeting the SIJ, with significant dispersal of injectate into surrounding structures including around the lumbosacral joint (LSJ). Advanced imaging modalities such as computed tomography offers promise for assessment of the structure and pathology of the SIJ and surrounding bony structures. However, there is a need to improve the understanding of the significance of anatomic variation of the sacroiliac region structures, with recent studies reporting detailed anatomic variation in groups of horses with and without SID. There are also limitations around functional assessment of the joint which is still largely reliant on a thorough clinical examination. This review aims to present an update on clinical approaches to the diagnosis of horses with SID, and to consider the challenges and limitations.

Evaluation of postsale endoscopy as a predictor of future racing performance in an Australian thoroughbred yearling population.

INTRODUCTION: Upper airway endoscopy of thoroughbred (TB) yearlings is commonly used in an attempt to predict laryngeal function (LF) and its impact on future race performance. The aim of this study was to determine if different grading systems and laryngeal grades were correlated with future performance. MATERIALS AND METHODS: Postsale endoscopic recordings were obtained from an Australian TB yearling sale during a four-year period from 2008 to 2011. Horses were included if they had a diagnostic postsale video endoscopic recording and raced within Australia. Recordings were graded using the Havemeyer system and subsequently recategorised according to the Lane scale and two condensed scales. Performance data were sourced from Racing Australia and comparisons were made between groups. RESULTS: A total of 1244 horses met the inclusion criteria. There were no significant differences in sex or sales price between groups. There were no significant differences in the number of starts or wins between groups for any grading system. For the condensed Havemeyer scale, horses with intermediate LF were separated into two groups. Significant differences in earnings were found between 'normal' and 'abnormal' (P = 0.02) and 'intermediate-low' and 'abnormal' grades (P = 0.03). There were no significant differences between horses with 'intermediate-high' and 'abnormal' grades (P = 0.40). No significant differences were found between the two intermediate grades (P = 0.60) or between horses with normal LF and either 'intermediate-low' or 'intermediate-high' grades (P = 0.99). DISCUSSION: Resting LF in Australian yearling TBs assessed using a condensed Havemeyer grading scale had some predictive value for future racing performance. This information should be considered when performing yearling endoscopic examinations.

Application of an electrocardiography device (iECG) for heart rhythm analysis after exercise in Thoroughbred horses.

AliveCor is a smartphone electrocardiography device (iECG) providing automated heart rate (HR) and rhythm determination. Atrial fibrillation (AF) in horses often is paroxysmal and rapid ECG acquisition is needed for diagnostic confirmation. iECGs were collected post-race from 15 horses with AF and 64 horses in sinus rhythm (SR). Results of manual assessment were compared to 3 commercial algorithms for HR and rhythm. Agreement between manually derived HR (HRM ) and HR derived by the AliveECG Vet (HRVET ) and Kardia version-1 (KV1 HR) and Kardia advanced (KADV HR) algorithms was quantified by the Bland-Altman limits of agreement test. Agreement between manual rhythm classification and KV1 and KADV algorithms for AF and SR was calculated by the Kappa statistical coefficient. The agreement (bias, 95% limits), between HRM and HRVET was 7.1 BPM (-29 to 43) in AF and -4.2 BPM (-38 to 30) in SR, between HRM and KV1 HR, was -0.3 BPM (-31 to 30) in AF and 0.2 BPM (-3 to 4) in SR, and between HRM and KADV HR was 7.0 BPM (-29 to 43) in AF and 0.2 BPM (-3.9 to 4.2) in SR. Agreement between manual rhythm classification and KV1 was 0.36 (0.13-0.59), and KADV was 0.84 (0.68-0.99). Sensitivity and specificity for identification of AF and SR of the KV1 algorithm were 60, 100% and 83, 100%, respectively, and of KADV was 87, 100% and 93, 100% respectively. The Kardia algorithms improved precision for HR determination in SR but not AF. The advanced algorithm accurately distinguished between AF and SR. The iECG is suitable for recording episodes of AF following exercise.

Inspiratory muscle training for the treatment of dynamic upper airway collapse in racehorses: A preliminary investigation.

Exercise-induced upper airway collapse (UAC) probably occurs when the stabilising muscles of the upper airway are unable to withstand the dramatic changes in airflow and pressure that occurs during exercise. In racehorses, the mainstay of treatment is surgical intervention. In human athletes, exercise-induced laryngeal obstruction has been treated successfully with inspiratory muscle training (IMT). The aims of this study were: (1) to assess the feasibility of IMT in racehorses; and (2) describe the exercising endoscopy findings pre- and post-IMT in racehorses diagnosed with dynamic UAC. Horses undergoing IMT wore a mask with an attached threshold-valve to apply an additional load during inspiration, creating a training stimulus with the purpose of increasing upper airway muscle strength. Each horse underwent IMT once daily, while standing in the stable, 5-6 days/week for 10 weeks. Endoscopy recordings were analysed in a blinded manner using an objective grading scheme and subjective pairwise analysis. Seventeen horses successfully completed the IMT protocol, with full information available for 10 horses. Objective grading analysis showed a lower grade of vocal fold collapse (6/9 horses), palatal instability (7/10 horses) and intermittent dorsal displacement of the soft palate (5/7 horses) post-IMT. Pairwise subjective analysis suggested better overall airway function post-IMT in 3/10 horses. The main limitations of this preliminary investigation were the low number of horses examined and lack of a control population. Further research is required to investigate the effects of IMT on upper airway muscle strength and to evaluate its efficacy for prevention and treatment of UAC.

Tongue-tie use in Thoroughbred racehorses in Australia.

Tongue-ties (TTs) are used to aid control and aim to conservatively treat upper airway disorders in racehorses. However, welfare concerns have led to their use being banned in other equestrian disciplines. In the United Kingdom, TTs have been reported to be used in approximately 5% of starts. The frequency of their use elsewhere is unknown. The objectives of this retrospective single cohort study were to estimate the frequency of TT use within the Australian Thoroughbred (TB) racing industry, and to describe usage patterns. Data of all Australian TB horse races from 2010 to 2013 calendar years were collected by accessing the Racing Information Services Australia database. Frequency of TT use was calculated, and usage patterns were explored at the start, horse and trainer levels. Between 2010 and 2013, there were a total of 728,678 starts from 62,377 horses prepared by 4927 trainers and that raced on 1453 race dates across 402 venues. Tongue-ties were used in 21.4% of starts; however, frequency varied according to location, race, trainer and horse. At the horse level, 32.2% wore a TT at least once and 7.6% wore it at every race on record. At the trainer level, 71.3% used TTs in at least one of their horses but only 1.4% used them systematically. The present study concludes that TT use in Australian TB racehorses, during the period 2010-2013, was common and considerably higher than previously reported in the United Kingdom. Most Australian trainers use the device and appear to adapt its usage according to individual horse and race factors.

Effect of inclusion or exclusion of epithelial cells in equine respiratory cytology analysis.

Published studies vary as to whether epithelial cells are included in differential counts for tracheal wash (TW) and bronchoalveolar lavage (BAL) cytology in horses. The aim of this study was to determine whether inclusion or exclusion of epithelial cells affects interpretation of airway cytology. Using criteria of >20% TW neutrophils, >10% BAL neutrophils and/or >5% BAL mast cells to indicate airway inflammation, there was a change in categorisation from 'normal' to 'abnormal' in 21%, 4% and 8% horses, respectively, when epithelial cells were excluded from differential counts. It is recommended that future equine respiratory research studies explicitly state whether epithelial cells are included or excluded in differential counts. A consensus on epithelial cell inclusion during cytology reporting is required.

The prevalence of abnormal breathing patterns during exercise and associations with dynamic upper respiratory tract obstructions.

REASONS FOR PERFORMING STUDY: There is very limited published information on the prevalence and significance of abnormal breathing patterns adopted during canter/gallop. OBJECTIVES: The aim of this study was to report the prevalence of abnormal breathing patterns during canter/gallop and to investigate whether these may be associated with dynamic upper respiratory tract (URT) obstructions. STUDY DESIGN: Retrospective analysis of clinical records. METHODS: Simultaneous audio and URT videoendoscopy recordings from 365 horses referred for treadmill evaluation were analysed. RESULTS: Thirty percent of horses had an abnormal breathing pattern at canter or gallop, of which 23% had a 2:1 breathing pattern (i.e. one breath is taken over two strides). The prevalence of abnormal breathing patterns was higher at low canter speeds than during strenuous exercise. There was a significant association between breathing pattern during strenuous exercise and the presence of an URT obstruction. CONCLUSIONS: This study suggests that abnormal breathing patterns during canter and gallop may be associated with dynamic URT obstructions; therefore, horses identified by owners or veterinary surgeons to have an abnormal breathing pattern during exercise, in particular a 2:1 breathing pattern, may warrant investigations for diagnosis of respiratory tract disease.

The effect of the laryngeal tie-forward procedure and soft palate cautery on nasopharyngeal diameter in horses.

The laryngeal tie-forward (LTF) procedure has been shown to move the larynx rostrally and dorsally whilst repositioning the basihyoid bone caudally and dorsally. Other studies have shown that the position of the hyoid bones influences the size of the nasopharynx. The effect of the LTF procedure on the size of the nasopharynx is unknown. It was hypothesised that the LTF procedure would result in a decrease in dorsoventral nasopharyngeal diameter. Twenty-five thoroughbred horses which underwent LTF with or without soft palate cautery (LTF±SPC) for treatment of dorsal displacement of the soft palate were included in this study. Preoperative and postoperative lateral radiographs were used to determine changes in laryngohyoid position and nasopharyngeal diameter. The LTF±SPC procedure resulted in a significant reduction (14-17 per cent) in dorsoventral nasopharyngeal diameter (P<0.001). The LTF procedure decreases nasopharyngeal diameter. The impact on upper respiratory tract function during exercise remains unclear.

Respiratory diseases and their effects on respiratory function and exercise capacity.

Given that aerobic metabolism is the predominant energy pathway for most sports, the respiratory system can be a rate-limiting factor in the exercise capacity of fit and healthy horses. Consequently, respiratory diseases, even in mild forms, are potentially deleterious to any athletic performance. The functional impairment associated with a respiratory condition depends on the degree of severity of the disease and the equestrian discipline involved. Respiratory abnormalities generally result in an increase in respiratory impedance and work of breathing and a reduced level of ventilation that can be detected objectively by deterioration in breathing mechanics and arterial blood gas tensions and/or lactataemia. The overall prevalence of airway diseases is comparatively high in equine athletes and may affect the upper airways, lower airways or both. Diseases of the airways have been associated with a wide variety of anatomical and/or inflammatory conditions. In some instances, the diagnosis is challenging because conditions can be subclinical in horses at rest and become clinically relevant only during exercise. In such cases, an exercise test may be warranted in the evaluation of the patient. The design of the exercise test is critical to inducing the clinical signs of the problem and establishing an accurate diagnosis. Additional diagnostic techniques, such as airway sampling, can be valuable in the diagnosis of subclinical lower airway problems that have the capacity to impair performance. As all these techniques become more widely used in practice, they should inevitably enhance veterinarians' diagnostic capabilities and improve their assessment of treatment effectiveness and the long-term management of equine athletes.

Respiratory responses to exercise in the horse.

Horses are elite athletes when compared with other mammalian species. In the latter, performance is limited by cardiovascular or musculoskeletal performance whereas in athletic horses it is the respiratory system that appears to be rate limiting and virtually all horses exercising at high intensities become hypoxaemic and hypercapnoeic. This is due to both diffusion limitation and a level of ventilation inadequate for the metabolic level that enables horses to exercise at these intensities. In conjunction with these blood gas changes, total pulmonary resistance increases and the work of breathing rises exponentially and airflow eventually plateaus despite increases in inspiratory and expiratory intrapleural pressures. Horses breathe at comparatively high frequencies when galloping due to the tight 1:1 coupling of strides to breathing. Whether this effects gas exchange and, if so, to what extent, has not been fully elucidated.

Retrospective study investigating causes of abnormal respiratory noise in horses following prosthetic laryngoplasty.

REASONS FOR PERFORMING THE STUDY: To investigate causes of respiratory noises in horses following prosthetic laryngoplasty (with or without a ventriculocordectomy) and to examine potential associations between degree of arytenoid abduction and the presence of other upper respiratory tract (URT) abnormalities, including right-sided collapse. METHODS: Clinical records and dynamic videoendoscopic recordings were examined from horses presented between 1995 and 2010 for investigation of respiratory noise during exercise, following a prosthetic laryngoplasty (+/- a ventriculocordectomy). Relationships between the degree of left arytenoid cartilage abduction and the presence of other URT disorders were investigated. RESULTS: Thirty horses matched the inclusion criteria. All horses had previously undergone a prosthetic laryngoplasty in different hospitals and in 63% (19/30) of these horses a left-sided ventriculocordectomy had also been performed. The majority of cases (87%) had multiple respiratory abnormalities and only 13% had a single URT disorder. Palatal dysfunction was the most common diagnosis (83%), followed by axial deviation of the aryepiglottic folds (60%) and vocal cord collapse (43%). The right arytenoid cartilage was fully abducted in all cases and no statistically significant correlation between the degree of left arytenoid abduction and any other URT disorders was detected. CONCLUSIONS: Multiple forms of dynamic URT disorders were diagnosed in horses that presented with abnormal respiratory noise following laryngoplasty. There was no association between degree of left arytenoid abduction and other URT abnormalities. Furthermore, horses with suboptimal left arytenoid cartilage abduction were not predisposed to right-sided laryngeal collapse. CLINICAL RELEVANCE: Our results demonstrate the fundamental role of dynamic endoscopy in correctly diagnosing dynamic airway collapse in horses that have undergone surgical treatment of the upper respiratory tract.

A systematic review of the efficacy of interventions for dynamic intermittent dorsal displacement of the soft palate.

There are numerous treatments for correction of dorsal displacement of the soft palate (DDSP). However, the efficacy of these treatments is controversial and there is little consensus on how best to treat this condition. The aims of this study were to systematically review the literature and to assess the evidence on the clinical effects of interventions for dynamic intermittent DDSP. A secondary objective was to assess whether factors relating to study quality affected reported success rates. Twenty-three studies were included, covering a wide number of interventions but also differing widely is terms of study design, sample size, method of diagnosis, outcome measure and the number lost to follow-up. The assessment of adverse effects was severely limited because of lack of reporting. The way in which success is measured appears to have a great effect on the reported results. Research synthesis has been severely limited because of the heterogeneity in the included studies. The low level of evidence makes it difficult to draw firm conclusions as to the efficacy of procedures for DDSP. Hence it is currently not possible to determine which procedure is the most appropriate. This systematic review highlights the difficulties of studying palatal dysfunction and suggests areas where improvements can be made in future studies.

Horizontal moment around the hoof centre of pressure during walking on right and left circles.

REASONS FOR PERFORMING STUDY: Recent research indicates that the digital joints experience some degree of extrasagittal motion during stance and that the moments under the hoof are asymmetric in horses walking in a straight line. On a circle, these have not been defined. OBJECTIVES: To quantify the amplitude and symmetry of horizontal twisting moments around the vertical axis through the hoof's centre of pressure on left and right circles at walk. METHODS: Six Thoroughbred horses were led at walk across a Kistler force platform on a left and a right circle of 5 m radius. The resultant moment around the hoof was calculated from the 4 horizontal forces and their moment arms. RESULTS: Five of the 6 horses exerted an internal moment around their left forehoof, and 4 exerted an internal moment around their right forehoof on the left circle. On the right circle, 5 of the 6 exerted an internal moment around the left forehoof and a weak external moment around the right forehoof. The moments under the hind hooves were bilaterally similar for right and left circles. CONCLUSION: Intrahorse variability in the applied moments is low, but there is some interhorse variability, especially in the forelimb moments, that indicates future studies of movements of the distal limb joints should be bilateral to account for mechanical asymmetry. POTENTIAL RELEVANCE: The finding that horizontal moments vary between forelimbs in some horses will apply to how exercise on a circle is approached, especially in rehabilitation programmes for horses with orthopaedic injury of the distal limb.

Investigation of the incidence and type of injuries associated with high-speed treadmill exercise testing.

REASONS FOR PERFORMING STUDY: During the past 20 years, treadmill exercise testing has played an important role in both the study of equine exercise physiology and the investigation of poor athletic performance. However, it has been suggested that some trainers and veterinarians may be reluctant to refer horses for treadmill exercise testing because of fears that horses may be at increased risk of musculoskeletal injury during treadmill exercise. OBJECTIVE: To investigate the incidence and types of injuries sustained by horses undergoing treadmill exercise. METHODS: Data were collated from 9 centres in the UK, France and Belgium, and the prevalence and types of injury were established. RESULTS: A total of 2305 records were reviewed, with 2258 horses performing treadmill exercise. There was an overall injury rate of 5.4%. However, the majority of injuries sustained were minor in nature (4.7%). Only 13 horses (0.6%) sustained major injuries in association with treadmill exercise. These included 5 cases of severe exercise-induced myopathy, 4 fractures (of which 1 was catastrophic), 2 tendon injuries, 1 case with undiagnosed severe lameness and 1 with marked exacerbation of a previously diagnosed lameness. Two other major incidents were reported but were not directly associated with treadmill exercise (one had iliac thrombosis and one collapsed and died as a result of a pulmonary embolism). CONCLUSIONS: This study confirms that the majority of horses undergo treadmill exercise without incident. The majority of injuries that did occur were minor in nature and the incidence of major injuries was similar to that reported during competition elsewhere. POTENTIAL RELEVANCE: Treadmill exercise is a safe procedure and does not appear to pose an increased risk of injury in comparison with overground exercise.

Assessment of the exercise tests used during overground endoscopy in UK Thoroughbred racehorses and how these may affect the diagnosis of dynamic upper respiratory tract obstructions.

REASONS FOR PERFORMING STUDY: Overground endoscopy is being performed with increasing frequency in the UK. A previous study has shown that the type of exercise test may affect the diagnosis of upper respiratory tract (URT) obstructions. The successful clinical application of overground endoscopy systems requires understanding of appropriate field exercise testing protocols. OBJECTIVES: The aim of this study was to report the exercise test parameters used during overground endoscopy in UK Thoroughbred racehorses and to investigate potential effects of these on the diagnosis of URT obstructions. METHODS: The exercise test parameters used and the endoscopic observations of the URT during exercise were recorded for 140 Thoroughbred racehorses referred for the investigation of abnormal respiratory noise and/or poor athletic performance. RESULTS: The exercise test parameters varied widely between horses. The presenting complaint was easiest to reproduce in horses with a history of abnormal noise in training and hardest to reproduce in those referred for investigation of poor performance with no abnormal noise. No associations between the presence or not of an URT obstruction and exercise test parameters was identified. For horses referred for abnormal noise during racing DDSP was more likely to be observed when longer distances were performed. CONCLUSIONS: It is difficult to standardise exercise tests in the field when multiple premises are used and when training gallops differ markedly to racecourses. It was not possible to establish exercise test protocols which should be used for all Thoroughbred racehorses. Therefore, at present the best advice for horses which make abnormal noise during a race or have poor race performance, can only be to replicate race conditions as closely as possible. For horses that race over longer distances this will require the use of a circular gallops (e.g. racecourse) if only short gallops are available at the trainer's premises.

Comparisons of overground endoscopy and treadmill endoscopy in UK Thoroughbred racehorses.

REASONS FOR PERFORMING STUDY: To date there is no information on the comparison of the more recently documented technique of performing endoscopy during ridden exercise in the field, with the more traditional method of endoscopy during high-speed treadmill exercise. OBJECTIVES: To compare the results of upper respiratory tract endoscopy in UK Thoroughbred racehorses performed during ridden exercise in the field with those obtained during exercise on the treadmill. METHODS: A direct comparison was undertaken in 4 horses whereby both procedures were performed in the same horse within 10 days of each other. An indirect comparison was also undertaken whereby the results of overground endoscopy performed in 50 racehorses was compared to the results obtained during treadmill endoscopy in a further 50 racehorses. Horses were matched for age, gender, use (National Hunt vs. Flat) and presenting complaint (abnormal respiratory noise vs. poor performance). RESULTS: Dorsal displacement of the soft palate was diagnosed less frequently during overground endoscopy than during treadmill endoscopy. There was no significant difference in the diagnosis of dynamic laryngeal collapse between the 2 techniques. The treadmill exercise test was performed over longer distances at higher inclines, albeit at lower speeds than the overground test. In contrast to the treadmill test, the overground test was frequently performed in intervals. CONCLUSIONS: The results of both the direct and indirect comparisons suggest that dorsal displacement of the soft palate is diagnosed less often during overground endoscopy than during treadmill endoscopy. Strenuous exercise tests may be more easily performed on a treadmill than by performing multiple exercise intervals in the field. POTENTIAL RELEVANCE: Care should be taken in interpreting negative findings during both procedures, but particularly during overground endoscopy if racing conditions have not been appropriately replicated.

Horizontal moment around the hoof's centre of pressure during walking in a straight line.

REASONS FOR PERFORMING STUDY: Joint congruity and ligaments restrain the distal limb joints from excessive motion in the transverse and frontal planes, but the magnitudes and direction of the horizontal twisting moments around the hoof's centre of pressure (CoP) that induce these motions are unknown. OBJECTIVES: To quantify the horizontal moment around the vertical axis through the hoof's CoP at walk, and to determine whether these are symmetric. METHODS: Nine sound Thoroughbred horses (mean age 53 years; mean mass 502 kg) were led at walk in a straight line across a Kistler force platform. Five trials were collected for each fore and hindlimb. The resultant moment around the hoof's CoP was calculated from the horizontal moment arms between the calculated CoP and the 4 horizontal forces in the transverse (X) and cranio-caudal (Y) directions. RESULTS: The calculated moments were consistent within limbs and horses, but variable between horses. Hindlimbs demonstrated a biphasic moment pattern and the largest moments were typically in the first half of stance. Mean +/- s.d. peak moments were internal under both hindlimbs (L: Int 14.1 +/- 4.6 Nm; R: Int 133 +/- 5.5 Nm). In the forelimbs, 7/9 horses demonstrated an asymmetric moment pattern, with the left forelimb exerting an internal moment (L: Int 6.9 +/- 2.9 Nm) and the right forelimb an external moment (R: Ext 8.4 +/- 4.4 Nm), while the remaining 2 horses exerted internal moments in both forelimbs (L: Int 11.7 +/- 1.4 Nm; R:Int 6.6 +/- 1.9 Nm). CONCLUSION: In 7/9 horses, the forelimbs exerted asymmetric horizontal moments around the hoof CoP. The hindlimbs appear to behave with mechanical symmetry during stance, exerting an internal moment during retraction. POTENTIAL RELEVANCE: Extrasagittal joint motions in the forelimb are unlikely to be symmetric and future studies should account for possible bilateral variations.