Intranasal Midazolam versus Rectal Diazepam for the Management of Canine Status Epilepticus: A Multicenter Randomized Parallel-Group Clinical Trial.

BACKGROUND: Intranasal administration of benzodiazepines has shown superiority over rectal administration for terminating emergency epileptic seizures in human trials. No such clinical trials have been performed in dogs. OBJECTIVE: To evaluate the clinical efficacy of intranasal midazolam (IN-MDZ), via a mucosal atomization device, as a first-line management option for canine status epilepticus and compare it to rectal administration of diazepam (R-DZP) for controlling status epilepticus before intravenous access is available. ANIMALS: Client-owned dogs with idiopathic or structural epilepsy manifesting status epilepticus within a hospital environment were used. Dogs were randomly allocated to treatment with IN-MDZ (n = 20) or R-DZP (n = 15). METHODS: Randomized parallel-group clinical trial. Seizure cessation time and adverse effects were recorded. For each dog, treatment was considered successful if the seizure ceased within 5 minutes and did not recur within 10 minutes after administration. The 95% confidence interval was used to detect the true population of dogs that were successfully treated. The Fisher's 2-tailed exact test was used to compare the 2 groups, and the results were considered statistically significant if P < .05. RESULTS: IN-MDZ and R-DZP terminated status epilepticus in 70% (14/20) and 20% (3/15) of cases, respectively (P = .0059). All dogs showed sedation and ataxia. CONCLUSIONS AND CLINICAL IMPORTANCE: IN-MDZ is a quick, safe and effective first-line medication for controlling status epilepticus in dogs and appears superior to R-DZP. IN-MDZ might be a valuable treatment option when intravenous access is not available and for treatment of status epilepticus in dogs at home.

Comparison of Preoperative Quantitative Magnetic Resonance Imaging and Clinical Assessment of Deep Pain Perception as Prognostic Tools for Early Recovery of Motor Function in Paraplegic Dogs with Intervertebral Disk Herniations.

BACKGROUND: Prognostic tools to predict early postoperative motor function recovery (MFR) after thoracolumbar intervertebral disk herniation (IVDH) in paraplegic dogs represent an opportunity to timely implement novel therapies that could shorten recovery times and diminish permanent neurological dysfunctions. HYPOTHESIS: Fractional anisotropy (FA) values obtained using diffusion tensor imaging have a higher prognostic value than a lesion extension ratio in T2-weighted images (T2W-LER) and clinical assessment of deep pain perception (DPP) for MFR. ANIMALS: Thirty-five paraplegic dogs with diagnosis of acute or subacute thoracolumbar IVDH. METHODS: Prospective, descriptive observational study. At admission, absence or presence of DPP, T2W-LER, and FA values was evaluated. MFR was assessed within 4 weeks after decompressive surgery. Values of T2W-LER and FA of dogs with and without MFR were compared using t-tests. All 3 methods were evaluated for their sensitivity and specificity as a prognostic factor. RESULTS: No differences were found between groups regarding T2W-LER. FA values differed statistically when measured caudally of lesion epicenter being higher in dogs without MFR compared to dogs with MFR (P = .023). Logistic regression analysis revealed significance in FA values measured caudally of the lesion epicenter (P = .033, area under the curve = 0.72). Using a cutoff value of FA = 0.660, the technique had a sensitivity of 80% and a specificity of 55%. Evaluation of DPP had a sensitivity of 73.3% and specificity of 75% (P = .007). CONCLUSIONS AND CLINICAL IMPORTANCE: Evaluation of DPP showed a similar sensitivity and a better specificity predicting early MFR than quantitative magnetic resonance imaging.

Correlation between severity of clinical signs and transcranial magnetic motor evoked potentials in dogs with intervertebral disc herniation.

Transcranial magnetic motor evoked potentials (TMMEPs) can assess the functional integrity of the spinal cord descending motor pathways. In intervertebral disc herniation (IVDH), these pathways are compromised to varying degrees reflected by the severity of neurological deficits. The hypotheses of this study were as follows: (1) TMMEPs differ in dogs with IVDH and healthy control dogs; (2) TMMEPs reflect different severities of neurological signs; and (3) TMMEPs can document functional motor improvement and therefore monitor recovery of function. TMMEPs were recorded in 50 dogs with thoracolumbar IVDH. Clinical signs ranged from spinal hyperesthesia to non-ambulatory paraparesis in 19 dogs and paraplegia with/without deep pain sensation in 31 dogs. In these 31 paraplegic dogs, transcranial magnetic stimulation (TMS) was repeated during follow-up examinations. Ten healthy Beagle dogs served as controls. There was a significant increase in onset latency and decrease in peak-to-peak amplitude in the pelvic limb TMMEPs of dogs with spinal hyperesthesia to severe paraparesis compared to control dogs. Waveforms in dogs with IVDH were predominantly polyphasic in contrast to the biphasic waveforms of the control dogs. TMMEPs could not be generated in the pelvic limbs of paraplegic dogs. However, TMMEPs with markedly increased onset latencies and decreased peak-to-peak amplitudes reappeared in the pelvic limbs of dogs that were paraplegic before surgery and showed functional motor improvement during follow-up. The severity of neurological deficits was reflected by TMMEP findings, which could be used to document functional motor recovery in IVDH. TMS could therefore be used as an ancillary test to monitor response to therapy in dogs during rehabilitation.

Transcranial magnetic stimulation with acepromazine or dexmedetomidine in combination with levomethadone/fenpipramide in healthy Beagle dogs.

The aim of this study was to evaluate the influence of two sedation protocols on transcranial magnetic motor evoked potentials (TMMEPs) after transcranial magnetic stimulation in medium sized dogs. Onset latencies and peak-to-peak amplitudes, elicited in the extensor carpi radialis and cranial tibial muscles, were analysed in 10 healthy Beagles that received either acepromazine or dexmedetomidine in combination with levomethadone/fenpipramide, in a crossover design. Similar TMMEP recordings could be made using both sedation protocols at 80-90% stimulation intensity; however, there were significantly shorter onset latencies with the acepromazine-levomethadone/fenpipramide protocol at 100% stimulation intensity. Reference values were established and it was concluded that both drug combinations are feasible for measuring TMMEPs in medium sized dogs.

The actual development of European aviation safety requirements in aviation medicine: prospects of future EASA requirements.

Common Rules for Aviation Safety had been developed under the aegis of the Joint Aviation Authorities in the 1990s. In 2002 the Basic Regulation 1592/2002 was the founding document of a new entity, the European Aviation Safety Agency. Areas of activity were Certification and Maintenance of aircraft. On 18 March the new Basic Regulation 216/2008, repealing the original Basic Regulation was published and applicable from 08 April on. The included Essential Requirements extended the competencies of EASA inter alia to Pilot Licensing and Flight Operations. The future aeromedical requirements will be included as Annex II in another Implementing Regulation on Personnel Licensing. The detailed provisions will be published as guidance material. The proposals for these provisions have been published on 05 June 2008 as NPA 2008- 17c. After public consultation, processing of comments and final adoption the new proposals may be applicable form the second half of 2009 on. A transition period of four year will apply. Whereas the provisions are based on Joint Aviation Requirement-Flight Crew Licensing (JAR-FCL) 3, a new Light Aircraft Pilot Licence (LAPL) project and the details of the associated medical certification regarding general practitioners will be something new in aviation medicine. This paper consists of 6 sections. The introduction outlines the idea of international aviation safety. The second section describes the development of the Joint Aviation Authorities (JAA), the first step to common rules for aviation safety in Europe. The third section encompasses a major change as next step: the foundation of the European Aviation Safety Agency (EASA) and the development of its rules. In the following section provides an outline of the new medical requirements. Section five emphasizes the new concept of a Leisure Pilot Licence. The last section gives an outlook on ongoing rulemaking activities and the opportunities of the public to participate in them.

Legal background of aviation medicine in Europe and its future development.

European aviation is moving into an exciting phase now, the administrative structure is changing. Aviation rules and aviation medicine will get a new structure as well. The nature of air traffic required an international scope in rulemaking--especially in such a confined continent as Europe with 41 countries, about 380 Million inhabitants and 317 billion person kilometres flown each year. For economic reasons it became necessary to develop common standards for certification of aircraft in the beginning of the 1970ies, maintenance followed later on. The Cyprus arrangement of 01 July 1990 created the JAA (Joint Aviation Authorities). Joint Aviation Requirements were drafted to replace existing national provisions and have been implemented from the end of the 1990s. The areas of air operations and pilot licensing have been covered as well. The latter comprises of aviation medicine as well. The implementation of JAR-FCL 3, which covers the medical requirements for pilots, started from 1999 on in the several JAA member states. A detailed overview about development and structure of JAA, tools for harmonisation, rulemaking and amendment of requirements, medical standards, review procedures for contentious or marginal cases is described. Shortcomings were the fact that implementation was left to the discretion of the member states and that JAA had no executive power. This resulted in differences in safety and the EU commission concluded that aviation safety had to be regulated by the EU commission. After adoption of EU regulation 1592/2002 in 2002 common and binding requirements were to be drafted and a European aviation agency to be founded. EASA (European Aviation Safety Agency) started its work in September 2003. Finally it will take over the role of JAA completely. Whereas Certification and Maintenance were in the focus first, Flight Operations and Licensing are going to be covered as well in the near future. Essential Requirements have been drafted, outlining - inter alia - the scope of Licensing and of aeromedical aspects. However, the legislative process will most probably last at least until the end of 2007. Implementing Rules - being based on existing JAR-FCLs will be drafted soon and are going to be implemented as soon as EASA is operative for Licensing. JAR-FCL 3 will be the basis for the Implementing Rules concerning aeromedical fitness. An overview about the structure of the Agency, rulemaking procedures, philosophy of medical provisions and the transition from JAA to EASA is described.

Future aeromedical assessment in general aviation: a contribution to the actual discussion.

The past years saw a transition of competencies from the Joint Aviation Authorities (JAA) to the European Aviation Safety Agency (EASA), which was founded in 2003, based on EU Regulation 1592/02. EASA started its work in the fields of Airworthiness and will soon its competencies inter alia to Flight Operations and Flight Crew Licensing, the latter including the requirements for aeromedical assessment. The appropriate new EU Regulation will most probably be published in April. It includes the Essential Requirements for Licensing and aeromedical certification. A proposal for a new Commission Regulation promulgates the Implementing Rules for Personnel Licensing, detailing--inter alia--the Medical Requirements (Annex II to the Regulation). The specific rules, numeric standards are published as Acceptable Means of Compliance (AMC) and Guidance Material (GM). The provisions are based on JAR-FCL 3 and have been transposed to the format choosen by EASA by a small working group of aeromedical experts (FCL.001). Comments received by the European Aviation Safety Agency (EASA) prompted the agencys statement that the JAR-FCL 3 requirements for private pilots were excessive and too demanding and that a better regulation in General Aviation had to be developed. Another working group (MDM.032), including one aeromedical specialist, was tasked to draft a set of lighter requirements for non-complex aircraft used in non-commercial operations. In this context a much lighter form of aeromedical assessment - involving self-declaration by the pilot and general practitioners as asessors - has been proposed.

[Traveler's thrombosis. Who is at risk--how to prevent it?]. / Reisethrombose. Wer ist gefährdet--wie können Sie vorbeugen?

"Traveller's thrombosis" is defined as a deep venous thrombosis of the leg that develops no later than two weeks following a journey lasting at least five hours. According to the WHO, traveller's thrombosis affects in particular persons with additional risk factors. These include obesity, age, such prior diseases as malignant tumours, previous surgery, use of oral contraceptives, and such inborn risk factors as antithrombin III deficiency and homozygous factor V Leiden mutation. In such patients, the (air) journey is merely the triggering event. Prophylactic measures should include counseling of high-risk patients. Depending on the risk profile, recommended general measures are compression and low-molecular-weight heparin. The much discussed use of acetylsalicylic acid, in contrast, is no certain prophylaxis.