Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings.

BACKGROUND: Transanal hemorrhoidal dearterialization (THD) is a recently developed procedure to minimize postoperative pain from hemorrhoidectomy. This technique utilizes Doppler signals to aid ligation of hemorrhoidal arteries followed by mucopexy of redundant mucosa if needed. The aim of the present study was to assess patient satisfaction after THD. METHODS: This is a retrospective cohort study of patients who underwent THD at three different sites from April 2007 through October 2010. All procedures were performed in ambulatory settings according to protocol. Telephone surveys were conducted after a minimum of 1-month follow-up to assess patients' satisfaction on a scale of 1-10. Patients were asked whether the procedure had alleviated their symptoms. Patients were asked to recall duration of pain and time from surgery to return to work. RESULTS: Between April 2007 and October 2010, 216 patients with grade III-IV hemorrhoids underwent THD. There were 165 males and 61 females. Average age was 52.2 ± 14.2 years. All patients were discharged the same day after meeting ambulatory surgery center discharge criteria. Postoperative difficulty urinating occurred in 37 (17 %) patients, and six of them required temporary urinary catheterization. Transitory postoperative bleeding was reported by 38 (18 %) patients. Transitory incontinence to stool and flatus occurred in 18 (9 %) and 16 patients (8 %), respectively. Pelvic muscle spasms occurred in 21 (10 %) patients. Median follow-up was 23 months (range 1-42 months) with 143 (66 %) having at least 9 months between procedure and interview. Mean patient satisfaction was 8.5 ± 0.7 (on a scale of 1-10 with 10 being the best), and 91.5 % of patients felt the procedure had "helped" them. Average number of days with discomfort was 6.7 ± 2.1. Patients returned to work after an average of 10.3 ± 3.2 days. Our study is limited by lack of long-term follow-up and by retrospective complication assessment. CONCLUSIONS: Patient satisfaction with THD performed in ambulatory settings is high. Our data support performance of this procedure in an ambulatory setting.

Masseter myodegeneration as a cause of trismus or dysphagia in adult horses.

The medical records of eight horses with histological evidence of myodegeneration of the masseter muscles were examined. While they were alive their most common clinical signs had included difficulty in eating or opening their mouths, weight loss, difficulty in moving, and noticeable atrophy of the masseter muscles. The serum activities of muscle enzymes were abnormally high in all of the horses. Whole blood and/or liver selenium and vitamin E concentrations were less than the reference ranges in some of the horses. The lesions varied with the stage of the disease and consisted of swelling and discoloration, or muscle atrophy and fibrosis. Histologically, the muscle changes ranged from acute to subacute degeneration, with regenerative changes accompanying ongoing degeneration, to chronic degeneration with fibrotic replacement of muscle tissue. There were changes in the masseter muscle of all the horses, but some had widespread lesions in skeletal muscle, and a few also had myocardial lesions.

Effect of oral administration of excessive iron in adult ponies.

OBJECTIVE: To evaluate the potential of excess dietary iron to cause hepatic lesions similar to those described in horses with suspected iron toxicosis or hemochromatosis. DESIGN: Prospective study. ANIMALS: 6 adult male ponies. PROCEDURE: 4 ponies received 50 mg of iron/kg (22.7 mg/lb) of body weight each day by oral administration of ferrous sulfate, which contained 20% elemental iron; 2 ponies received only the carrier (applesauce). Complete blood counts, serum biochemical analyses, and hepatic tissue biopsies were performed, and serum iron concentrations were measured. Blood and tissue samples were obtained at days 0 and 2, and at the end of weeks 1, 3, 6, and 8 after administration of iron was initiated. Treatment was discontinued after 8 weeks, and hepatic iron concentrations were measured at 28 weeks. RESULTS: Hepatic iron concentrations, serum iron concentrations, percentage saturation of transferrin, and serum ferritin concentrations were increased, compared with baseline and control concentrations, by week 8. Adverse clinical signs or histologic lesions in the liver were not detected in any ponies. At 28 weeks, hepatic iron concentrations had decreased. CONCLUSIONS AND CLINICAL RELEVANCE: Histologic lesions were not seen in the hepatic biopsy specimens obtained from the ponies treated with ferrous sulfate. It was concluded that it would be unlikely for iron toxicosis to develop in adult ponies or horses during a period of < 8 weeks when food or water contained increased amounts of iron. It is suspected that previous reports of hepatopathies in animals with hemosiderin accumulation may represent a primary hepatopathy with secondary hemosiderin accumulation, especially if the only source of iron is via oral consumption.

Pancreatic necrosis in New World camelids: 11 cases (1990-1998).

OBJECTIVE: To determine clinical, clinicopathologic, and postmortem abnormalities in New World camelids with pancreatic necrosis. DESIGN: Retrospective study. ANIMALS: 10 llamas and 1 alpaca. PROCEDURES: Medical records of animals in which a diagnosis of pancreatic necrosis had been made on the basis of histologic examination of necropsy specimens or on the basis of clinical signs and results of clinicopathologic testing were reviewed. RESULTS: The initial owner complaint varied, and various other conditions were diagnosed. Clinical and clinicopathologic abnormalities were vague. Amylase activity was higher in abdominal fluid than in serum in 5 of 7 animals, and lipase activity was higher in abdominal fluid than in serum in all 7. Four animals survived, and 7 died or were euthanatized. Only 1 of the animals that died had marked inflammation of the pancreatic parenchyma. All 7 had necrosis and saponification of fat in and surrounding the pancreas. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that pancreatic necrosis may develop in New World camelids, but clinical signs are vague, and the condition may easily be confused with other diseases. The only laboratory test that appeared to be helpful in the antemortem diagnosis of pancreatic necrosis was comparison of amylase and lipase activities in abdominal fluid and serum.

Normal reference intervals and the effects of time and feeding on serum bile acid concentrations in llamas.

Fifty clinically healthy llamas, 0.5-13 years of age (22 intact males, 10 neutered males, 18 females), with no biochemical evidence of liver disease or hematologic abnormalities, were selected to establish serum bile acid reference intervals. Serum samples submitted to the clinical pathology laboratory were analyzed using a colorimetric enzymatic assay to establish bile acid reference intervals. A nonparametric distribution of llama bile acid concentrations was 1-23 micromol/liter for llamas >1 year of age and 10-44 micromol/liter for llamas < or = 1 year of age. A significant difference was found between these 2 age groups. No correlation was detected between gender and bile acid concentrations. The reference intervals were 1.1-22.9 micromol/liter for llamas >1 year of age and 1.8-49.8 micromol/liter for llamas < or = 1 year of age. Additionally, a separate group of 10 healthy adult llamas (5 males, 5 females, 5-11 years of age) without biochemical or hematologic abnormalities was selected to assess the effects of feeding and time intervals on serum bile acid concentrations. These 10 llamas were provided fresh water and hay ad libitum, and serum samples were obtained via an indwelling jugular catheter hourly for 11 hours. Llamas were then kept from food overnight (12 hours), and subsequent samples were taken prior to feeding (fasting baseline time, 23 hours after trial initiation) and postprandially at 0.5, 1, 2, 4, and 8 hours. In feeding trials, there was no consistent interaction between bile acid concentrations and time, feeding, or 12-hour fasting. Prior feeding or time of day did not result in serum bile acid concentrations outside the reference interval, but concentrations from individual llamas varied within this interval over time.

Cyclical etidronate: its effect on bone density in patients with acute spinal cord injury.

OBJECTIVE: To compare the effects of a 30-week trial of cyclical etidronate therapy (starting within 6 weeks of spinal cord injury [SCI] and conventional rehabilitation without etidronate treatment on the bone density of the lumbar spine and lower extremities of SCI patients. DESIGN: Prospective, randomized control trial. SETTING: Tertiary care, inpatient rehabilitation center. PATIENTS: Acute SCI, within 6 weeks of injury. Thirteen SCI subjects were recruited; 6 were assigned randomly to receive etidronate and 7 to receive conventional treatment. INTERVENTION: Etidronate, 800 mg orally, once per day for 2 weeks of 15 weeks, repeated once. MAIN OUTCOME MEASURES: Dual X-ray absorptiometry of the spine, hip, distal femur, and proximal tibia measured at baseline, 6 months, and 12 months. RESULTS: A significant interaction between etidronate treatment and ambulatory status over time was observed in the bone density of the patients after SCI (p = .0003). The patients who became ambulatory and received etidronate treatment had a preservation of bone density as compared to all other patients who showed a loss of bone density over time. The loss of bone density occurred in the leg bones, not the spine. Cyclical etidronate treatment was tolerated well without adverse or side effects. CONCLUSION: Cyclical etidronate is a feasible treatment and may prevent osteoporosis associated with SCI in patients who eventually walk.

Pharmacokinetics of ceftriaxone in healthy horses.

Five healthy Equidae (4 horses and one pony) were given a single i.v. dose of ceftriaxone (50 mg/kg bwt) to determine the pharmacokinetics and concentration in cerebrospinal fluid (CSF). Blood was drawn from an i.v. jugular catheter and CSF from a pre-placed, intrathecal catheter. Serum and CSF concentrations were determined by high performance liquid chromatography. The mean serum concentration of ceftriaxone was 144.7 micrograms/ml 15 min after injection and declined to 0.3 microgram/ml 10 h after injection. The elimination rate constant (lambda 2) was 0.63 +/- s.e. 0.23/h, the elimination half-life (t 1/2) was 1.62 +/- s.e. 0.42 h and the apparent volume of distribution at steady state (Vd(ss)) was 330.8 +/- 11.8 ml/kg bwt. Clearance was 312.7 +/- 38 ml/h/kg bwt and mean residence time was 1.13 +/- 0.14 h. Mean CSF concentration was 0.60 +/- 0.14 microgram/ml at 3 h after injection and 0.4 +/- 0.31 microgram/ml at 8 h. Ceftriaxone may be useful in the treatment of bacterial infections in horses. Its ability to penetrate the CSF should make it effective in the treatment of bacterial meningitis.

Atypical pneumonia associated with ryegrass staggers in calves.

A group of 6- to 8-month-old calves developed head tremors, stiff gait, and staggering after consuming ryegrass straw that contained 3,711 micrograms of lolitrem-B/ kg. Signs were consistent with ryegrass staggers syndrome. At necropsy, all calves examined had atypical interstitial pneumonia, with marked emphysema and bullae. Infectious organisms and pneumotoxins were not identified. Experimentally, feeding the same ryegrass straw to age-matched calves induced similar neurologic signs, but did not result in pneumonic lesions. The high concentration of lolitrem-B in the straw or other, undefined factors, such as feed changes, may have contributed to the atypical interstitial pneumonia in the naturally exposed calves.

Evaluation of liver function tests in neonatal calves.

OBJECTIVE: To evaluate the efficacy of tests for hepatic disease in young calves. DESIGN: Prospective case-control study. ANIMALS: 28 clinically normal calves and 47 calves with histologically proven hepatic disease. PROCEDURE: Liver function tests and serum activity of liver-derived enzymes were determined on 28 clinically normal calves at birth and at 2 weeks of age. These values were compared with the results from 47 calves with hepatic disease verified by histologic examination. Upper limit of confidence interval was determined for the results on the clinically normal calves, and Student's t-test was used to identify significant differences in the data from calves of various age-groups. RESULTS: None of the results of the common tests for liver damage or function (measurement of bilirubin, gamma-glutamyltransferase, glutamate dehydrogenase [GMD], alkaline phosphatase, L-lactate dehydrogenase, aspartate transaminase, or alanine transaminase) were clinically useful when used alone for detection of hepatic disease in calves less than 6 weeks old. Sensitivity of gamma-glutamyltransferase, GMD, aspartate transaminase, and alkaline phosphatase as indicators of hepatic disease in this population of calves was 0, 59, 80, and 9%, respectively. Direct bilirubin (sensitivity, 87%) was more sensitive than total bilirubin (sensitivity, 66%). Serum enzyme activity of most enzymes (P < 0.01), total bilirubin concentration (P < 0.001), and sulfobromophthalein sodium clearance half-life were significantly higher (P < 0.001) in newborn calves than in 2-week-old calves. CLINICAL IMPLICATIONS: Clinical findings that indicate hepatic disease in calves that are less than 6 weeks old could be confirmed by measurement of serum activity of GMD or concentrations of total serum bile acids or direct bilirubin. Percutaneous liver biopsy may still be needed and may provide the most information.

Megaesophagus in 15 llamas: a retrospective study (1985-1993).

Megaesophagus was diagnosed in 15 llamas on the basis of survey and contrast radiography. Age of onset ranged from 13 months to 9.5 years. Clinical signs varied, with salivation being the most common; regurgitation or dysphagia were noted in only 33% of the cases. Duration of the disorder ranged from 1 week to 5 years. Organophosphate toxicity was the cause of megaesophagus in 1 llama. While most cases were of unknown etiology, the 3 with histological abnormalities included 1 with vagal neuropathy and 2 with a degenerative myopathy of esophageal muscles. The causes in most were undetermined.

Use of electromyography in a cow with esophageal paralysis.

Electromyography of the esophageal musculature of a cow that had been regurgitating and losing weight after correction of an esophageal obstruction was suggestive of unilateral denervation. Radiography before and after oral administration of barium sulfate revealed a dilated terminal portion of the thoracic esophagus, suggestive of a focal motility problem. Electromyography was performed on the esophageal musculature by positioning the electrode through the rumen fistula and into the thoracic esophagus and by positioning the electrode percutaneously with the aid of a tube placed in the cervical esophagus. Numerous fibrillation potentials and sharp epsilon-positive waves were detected in the muscles of the left side of the distal portions of the cervical and thoracic esophagus. During hospitalization, the cow was given alfalfa pellets, ground corn, and sodium bicarbonate through the rumen fistula 3 times each day for several weeks to maintain body weight.

Third compartment ulcers in the llama.

The diagnosis of third compartment ulcers in the llama and alpaca is largely one of exclusion. Clinical signs may include mild to severe colic, inappetence, decreased fecal output, bruxism, and depression. Abdominocentesis results are usually unremarkable if C3 perforation has not occurred but reflective of a generalized peritonitis if full thickness ulceration has occurred. The H-2 receptor antagonists cimetidine and ranitidine do not suppress C3 acid production for a significant period of time and are of questionable efficacy in the management of C3 ulcers.

Polycythemia in a llama.

The PCV of a llama increased from 50.8 to 74.0% during a 19-month period. The llama remained clinically normal unless stressed, when it would become dyspneic and tachypneic. Thoracic auscultation revealed sounds consistent with pneumonia, but were probably attributable to pulmonary congestion resulting from polycythemia. A diagnosis of secondary absolute polycythemia was made on the basis of high serum erythropoietin concentrations and no evidence of hypoxia. Necropsy revealed congestion of the lungs and liver. Cause of the polycythemia was not determined. Polycythemia should be considered as a differential diagnosis in a llama with exercise intolerance and harsh bronchovesicular sounds.

Hepatic cirrhosis and hemochromatosis in three horses.

Hemochromatosis, an iron storage disease, was diagnosed in 3 horses with hepatic cirrhosis. Each horse had bridging portal fibrosis and abundant iron deposits in the cytoplasm of hepatocytes. Serum concentrations of liver-derived enzymes and total bile acids were high. However, serum iron concentration was not high, and iron binding capacity was only 46% saturated in the 1 horse in which it was measured. However, the concentration of iron in the liver of this horse was 20 times the reference limits. Hemochromatosis is common in mynah birds and human beings. There are several types of this iron storage disease. In human beings, there is a familial disease with iron absorption inappropriate for the level of stored iron. Hemochromatosis also occurs secondary to cirrhosis of the liver, and in certain anemia diseases. Another type of hemochromatosis is seen in association with dietary iron overload. These horses were not related, and there was not any evidence of high dietary iron intake.

Variability of serum bile acid concentrations over time in dairy cattle, and effect of feed deprivation on the variability.

Twelve nonlactating dairy cows, free of signs of liver disease and with normal serum activities of liver-derived enzymes and normal liver biopsy tissue, were examined over a 72-hour period for serum total bile acid concentrations. The cattle were fed hay twice daily, and blood samples were obtained every hour for 24 hours, every other hour for 24 hours, then every hour for 24 hours. After 3 weeks, the study was repeated on 6 of the cattle, thus providing data for eighteen 72-hour periods. Serum bile acid concentration varied greatly over the 72 hours, with the range being from one third to 3 times the median. There were variations by as much as 60 mumol/L from 1 hour to the next. After another 3 weeks, 8 of the cattle were deprived of hay for 48 hours and then fed hay morning and afternoon of the third (last) day of the study. There was no significant reduction in bile acid concentration after withholding the hay, but the variability was reduced (P = 0.02) during the last 20 hours of the hay-deprivation period. In 3 ancillary studies, serum bile acid concentrations were examined over a 48-hour period in 2 cows in early lactation, 3 cows in midlactation, and two 6-month-old heifers. The cows were fed hay and grain twice daily, and the heifers were fed only hay twice daily. In comparison with values for the 12 nonlactating cows fed hay twice daily, mean serum bile acid concentration in the recently freshened cows was significantly (P < 0.002) higher (62.9 vs 22.0 mumol/L).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum bile acid concentrations in clinically normal cattle: comparison by type, age, and stage of lactation.

Serum total bile acid concentrations were determined for various types and ages of cattle. There was extreme variability among all the cattle, but the variance was twice as large (0.50 vs 0.22 in logarithmic scale) for beef cattle than for dairy cattle. There was no significant difference in serum total bile acid concentrations between beef cattle and dairy cattle in midlactation. Values for calves < 6 weeks old and for 6-month-old heifers were significantly (P = < 0.05) lower than values for lactating dairy cows. The 5th to 95th percentile range of values (mumol/L) for beef cattle was 9 to 126; for lactating dairy cattle, 15 to 88; and for 6-month-old dairy heifers, 11 to 64.

Serum liver enzyme and histopathologic changes in calves with chronic and chronic-delayed Senecio jacobaea toxicosis.

Progressive changes in serum enzyme activity and liver histologic features were monitored in calves fed tansy ragwort (Senecio jacobaea)-contaminated pellets. The experiments were designed to simulate natural intoxicant ingestion conditions in relationship to the dose and duration of exposure to the toxic plant to correlate early laboratory diagnostic changes with the natural progression of the disease, thereby facilitating early diagnosis and intervention by veterinary clinicians. Eight calves were fed tansy ragwort and 4 additional calves served as controls. In group 1, 4 calves were continuously fed dried tansy ragwort mixed in a pelleted feed at a 5% concentration by dry weight until terminal liver disease developed. Serum liver enzyme (alkaline phosphatase, glutamate dehydrogenase, and gamma-glutamyltransferase) activities were monitored at weekly intervals in these calves and in the 2 controls. In group 2, 4 calves were fed the same contaminated feed for only 60 days, with return to normal feed for the duration of the trial. Two additional calves served as controls. Their liver enzyme activities were monitored every other week in conjunction with percutaneous liver biopsies. All 8 calves fed tansy ragwort-contaminated pellets developed terminal hepatopathy in either a chronic pattern (n = 6) or a chronic-delayed pattern (n = 2), with the onset of a moribund state or sudden death at 11 to 17 weeks and 27 to 51 weeks, respectively. The calves were euthanatized when classic terminal signs of hepatic encephalopathy first became evident. The clinicopathologic patterns of chronic and chronic-delayed toxicoses were typical of over 5,000 cases of field tansy toxicosis diagnosed at the diagnostic laboratory. Serum glutamate dehydrogenase was the first enzyme to increase in most animals, with a short-term increase to peak values followed by a rapid return to normal. This enzyme change was followed by increases in alkaline phosphatase and gamma-glutamyltransferase. Serum enzyme changes preceded development of recognizable histologic lesions. Vacuolar changes in hepatocyte nuclei, biliary hyperplasia, and fibrosis sequentially developed in liver biopsy specimens from each animal, whereas megalocytosis was not a predominant feature until necropsy. On the basis of our findings, we suggest that the optimal tests for diagnosis of pyrrolizidine alkaloid intoxication should consist of liver biopsy and determination of concurrent serum liver-enzyme activities.

Liver failure attributable to pyrrolizidine alkaloid toxicosis and associated with inspiratory dyspnea in ponies: three cases (1982-1988).

Of 41 equids referred to a veterinary teaching hospital in the Pacific northwest because of dyspnea and inspiratory noise, 3 ponies were diagnosed as having liver failure, most likely attributable to pyrrolizidine alkaloid toxicosis. Dyspnea appeared to be caused by laryngeal and/or pharyngeal paralysis. It is proposed that this paralysis was a manifestation of hepatic encephalopathy. Although these clinical signs are not common for pyrrolizidine toxicosis, practitioners should be aware of the possibility so that misdiagnosis of other causes of inspiratory dyspnea may not be made.

Erythrocyte dyscrasia, anemia, and hypothyroidism in chronically underweight llamas.

A syndrome characterized by anemia, erythrocyte dyscrasia, low body weight, and hypothyroidism was observed in 8 llamas (Lama glama). At initial examination (1 to 23 months of age; median, 7.5 months), llamas (3 males, 5 females) were markedly underweight (29 to 55 kg; median, 36 kg) and anemic (PCV, 12.9 to 25.5% [median, 19%]). Five of the llamas became progressively more anemic over time; in 2 of them, PCV decreased to less than 10%. Erythrocyte changes included severe poikilocytosis, anisocytosis, asymmetric distribution of hemoglobin within the cytoplasm, and cytoplasmic extensions from one or both poles. Six llamas had moderate to severe valgus deformities of the carpus. All llamas had low baseline serum thyroxine concentration and diminished response to thyrotropin administration. Baseline and post-thyrotropin triiodothyronine concentrations did not have consistent patterns. Five llamas were hypophosphatemic and 7 had low serum iron concentration (iron concentration was not determined in 1 llama). Orally administered iron supplementation did not induce clinical improvement. Because 3 of the affected llamas were full sisters, a genetic basis for the problem has to be considered. It was not possible to evaluate the familial relationship of the other 5 affected llamas. Although the underlying cause of the problem was not established, the prognosis for affected llamas is guarded to poor.