Rates, costs, return to work and reoperation following spinal surgery in a workers' compensation cohort in New South Wales, 2010-2018: a cohort study using administrative data

BACKGROUND

Internationally, elective spinal surgery rates in workers' compensation populations are high, as are reoperation rates, while return-to-work rates following spinal surgery are low. Little information is available from Australia. The aim of this study was to describe the rates, costs, return to work and reoperation following elective spinal surgery in the workers' compensation population in New South Wales (NSW), Australia.

METHODS

This retrospective cohort study used administrative data from the State Insurance Regulatory Authority, the government organisation responsible for regulating and administering workers' compensation insurance in NSW. These data cover all workers' compensation-insured workers in New South Wales (over 3 million workers/year). We identified a cohort of insured workers who underwent elective spinal surgery (fusion or decompression) between January 1, 2010 and December 31, 2018. People who underwent surgery for spinal fracture or dislocation, or who had sustained a traumatic brain injury were excluded. The main outcome measures were annual spinal surgery rates, cost of the surgical episode, cumulative costs (surgical, hospital, medical and physical therapy) to 2 years post-surgery, and reoperation and return-to-work rates 2 years post-surgery.

RESULTS

There were 9343 eligible claims (39.1 % fusion; 59.9 % decompression); claimants were predominantly male (75 %) with a mean age of 43 (range 18 to 75) years. Spinal surgery rates ranged from 15 to 29 surgeries per 100,000 workers per year, fell from 2011-12 to 2014-15 and rose thereafter. The average cost in Australian dollars for a surgical episode was $46,000 for a spinal fusion and $20,000 for a decompression. Two years post-fusion, only 19 % of people had returned to work at full capacity; 39 % after decompression. Nineteen percent of patients underwent additional spinal surgery within 2 years of the index surgery, to a maximum of 5 additional surgeries.

CONCLUSION

Rates of workers' compensation-funded spinal surgery did not rise significantly during the study period, but reoperation rates are high and return-to-work rates are low in this population at 2 years post- surgery. In the context of the poor evidence base supporting lumbar fusion surgery, the high cost, increasing rates, and the increased likelihood of poor outcomes in the workers' compensation population, we question the value of this procedure in this setting.

An equivalence study: Are patient-completed and telephone interview equivalent modes of administration for the EuroQol survey?

Background

To determine if the EuroQol Health Related Quality of Life survey produces equivalent results when administered by phone interview or patient-completed forms.

Methods

People awaiting hip or knee arthroplasty at a major metropolitan hospital participated. They were randomly assigned to receive the EuroQol Health Related Quality of Life survey via telephone, followed by a patient completed form 1 week later, or vice versa. Equivalence was determined using two one-sided tests (TOST) based on minimal clinically-important differences for the visual analogue scale (VAS) and the summary Utility Index. Cohen’s Kappa scores were computed to determine agreement for the individual EuroQoL Likert scale items.

Results

Seventy-six from 90 (84%) participants completed the survey twice. Based on limits set at ±7 and ±0.11 for the VAS and Utility Index, respectively, equivalence was established between the two methods of administration for both the VAS (mean difference 0.05 [90% CI −3.76–3.67]) and the Utility Index (mean difference 0.06 [90% CI 0.02–0.11]). Varying levels of agreement, ranging from slight to substantial (κ = 0.17–0.67), were demonstrated for the individual health domains. The order of telephone and patient-completed survey administration had no significant effect on results.

Conclusions

Equivalent results are obtained between telephone and patient-completed administration for the VAS and Utility Index of the EuroQol Survey in people with advanced hip or knee osteoarthritis. The limits of agreement for the individual health domains vary which prevents the accurate interpretation of real change in these items across modes.

Minimal important improvement thresholds for the six-minute walk test in a knee arthroplasty cohort: triangulation of anchor- and distribution-based methods

Background

The 6-minute walk test (6MWT) is a commonly used metric for measuring change in mobility after knee arthroplasty, however, what is considered an improvement after surgery has not been defined. The determination of important change in an outcome assessment tool is controversial and may require more than one approach. This study, nested within a combined randomised and observational trial, aimed to define a minimal important improvement threshold for the 6MWT in a knee arthroplasty cohort through a triangulation of methods including patient-perceived anchor-based thresholds and distribution-based thresholds.

Methods

Individuals with osteoarthritis performed a 6MWT pre-arthroplasty then at 10 and 26 weeks post-surgery. Each rated their perceived improvement in mobility post-surgery on a 7-point transition scale anchored from “much better” to “much worse”. Based on these responses the cohort was dichotomised into ‘improved’ and ‘not improved’. The thresholds for patient-perceived improvements were then identified using two receiver operating curve methods producing sensitivity and specificity indices. Distribution-based change thresholds were determined using two methods utilising effect size (ES). Agreement between the anchor- and distribution-based methods was assessed using kappa.

Results

One hundred fifty-eight from 166 participants in the randomised cohort and 222 from 243 in the combined randomised and observational cohort were included at 10 and 26 weeks, respectively. The slightly or more patient-perceived improvement threshold at 26 weeks (an absolute improvement of 26 m) was the only one to demonstrate sensitivity and specificity results both better than chance. At 10- and 26-weeks, the ES based on the mean change score divided by the baseline standard deviation (SD), was an absolute change of 24.5 and 37.9 m, respectively. The threshold based on a moderate ES (a 0.5 SD of the baseline score) was a change of 55.0 and 55.4 m at 10- and 26-weeks, respectively. The level of agreement between the 26-week anchor-based and distribution-based minimal absolute changes was very good (k = 0.88 (95 % CI 0.81 0.95)).

Conclusion

A valid threshold of improvement for the 6MWT can only be proposed for changes identified from baseline to 26 weeks post-surgery. The level of agreement between anchor- and distribution-based methods indicates that a true minimal or more threshold of meaningful improvement following surgery is likely within the ranges proposed by the triangulation of all four methods, that is, 26 to 55 m.

Mail versus telephone administration of the Oxford Knee and Hip Scores

Telephone and postal methods of administration of the Oxford Knee Score (OKS) and the Oxford Hip Score (OHS) were compared on 85 and 61 patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA), respectively. The test for equivalence was significant for both the knee (P<0.001) and hip participants (P<0.001) indicating that the modes of administration yielded similar results. The ICCs of the OKS and OHS were 0.79 (95% Confidence Interval (CI) 0.70, 0.86) and 0.87 (0.79, 0.92) respectively. The 95% limits of agreement were wide for both scores (OKS LOA, -8.6, 8.2; OHS LOA, -7.7, 5.3). The two modes of administration of the OKS and OHS produce equivalent survey responses at a group level but the same method of administration should be constant for individual monitoring in a clinical setting.

Serum D-lactate concentrations in cats with gastrointestinal disease

BACKGROUND

Increased D-lactate concentrations cause neurological signs in humans with gastrointestinal disease.

HYPOTHESIS/OBJECTIVES

To determine if serum D-lactate concentrations are increased in cats with gastrointestinal disease compared to healthy controls, and if concentrations correlate with specific neurological or gastrointestinal abnormalities.

ANIMALS

Systematically selected serum samples submitted to the Gastrointestinal Laboratory at Texas A&M University from 100 cats with clinical signs of gastrointestinal disease and abnormal gastrointestinal function tests, and 30 healthy cats.

METHODS

Case-control study in which serum D- and L-lactate concentrations and retrospective data on clinical signs were compared between 30 healthy cats and 100 cats with gastrointestinal disease. Association of D-lactate concentration with tests of GI dysfunction and neurological signs was evaluated by multivariate linear and logistic regression analyses, respectively.

RESULTS

All 100 cats had a history of abnormal gastrointestinal signs and abnormal gastrointestinal function test results. Thirty-one cats had definitive or subjective neurological abnormalities. D-lactate concentrations of cats with gastrointestinal disease (median 0.36, range 0.04-8.33 mmol/L) were significantly higher than those in healthy controls (median 0.22, range 0.04-0.87 mmol/L; P = .022). L-lactate concentrations were not significantly different between the 2 groups of cats with gastrointestinal disease and healthy controls. D-lactate concentrations were not significantly associated with fPLI, fTLI, cobalamin, folate, or neurological abnormalities (P > .05).

CONCLUSIONS AND CLINICAL IMPORTANCE

D-lactate concentrations can be increased in cats with gastrointestinal disease. These findings warrant additional investigations into the role of intestinal microbiota derangements in cats with gastrointestinal disease, and the association of D-lactate and neurological abnormalities.

Preparing students for careers in food-supply veterinary medicine: a review of educational programs in the United States

The real and/or perceived shortage of veterinarians serving food-supply veterinary medicine has been a topic of considerable discussion for decades. Regardless of this debate, there are issues still facing colleges of veterinary medicine (CVMs) about the best process of educating future food-supply veterinarians. Over the past several years, there have been increasing concerns by some that the needs of food-supply veterinary medicine have not adequately been met through veterinary educational institutions. The food-supply veterinary medical curriculum offered by individual CVMs varies depending on individual curricular design, available resident animal population, available food-animal caseload, faculty, and individual teaching efforts of faculty. All of the institutional members of the Association of American Veterinary Medical Colleges (AAVMC) were requested to share their Food Animal Veterinary Career Incentives Programs. The AAVMC asked all member institutions what incentives they used to attract and educate students interested in, or possibly considering, a career in food-supply veterinary medicine (FSVM). The problem arises as to how we continue to educate veterinary students with ever shrinking budgets and how to recruit and retain faculty with expertise to address the needs of society. Several CVMs use innovative training initiatives to help build successful FSVM programs. This article focuses on dairy, beef, and swine food-animal education and does not characterize colleges' educational efforts in poultry and aquaculture. This review highlights the individual strategies used by the CVMs in the United States.

Infusion of sodium bicarbonate in experimentally induced metabolic acidosis does not provoke cerebrospinal fluid (CSF) acidosis in calves

In a crossover study, 5 calves were made acidotic by intermittent intravenous infusion of isotonic hydrochloric acid (HCl) over approximately 24 h. This was followed by rapid (4 h) or slow (24 h) correction of blood pH with isotonic sodium bicarbonate (NaHCO(3)) to determine if rapid correction of acidemia produced paradoxical cerebrospinal fluid (CSF) acidosis. Infusion of HCl produced a marked metabolic acidosis with respiratory compensation. Venous blood pH (mean ± S(x)) was 7.362 ± 0.021 and 7.116 ± 0.032, partial pressure of carbon dioxide (Pco(2), torr) 48.8 ± 1.3 and 34.8 ± 1.4, and bicarbonate (mmol/L), 27.2 ± 1.27 and 11 ± 0.96; CSF pH was 7.344 ± 0.031 and 7.240 ± 0.039, Pco(2) 42.8 ± 2.9 and 34.5 ± 1.4, and bicarbonate 23.5 ± 0.91 and 14.2 ± 1.09 for the period before the infusion of hydrochloric acid and immediately before the start of sodium bicarbonate correction, respectively. In calves treated with rapid infusion of sodium bicarbonate, correction of venous acidemia was significantly more rapid and increases in Pco(2) and bicarbonate in CSF were also more rapid. However, there was no significant difference in CSF pH. After 4 h of correction, CSF pH was 7.238 ± 0.040 and 7.256 ± 0.050, Pco(2) 44.4 ± 2.2 and 34.2 ± 2.1, and bicarbonate 17.8 ± 1.02 and 14.6 ± 1.4 for rapid and slow correction, respectively. Under the conditions of this experiment, rapid correction of acidemia did not provoke paradoxical CSF acidosis.

Practice variation in common fracture presentations: a survey of orthopaedic surgeons

BACKGROUND

Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation.

MATERIALS AND METHODS

A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored.

RESULTS

358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures).

CONCLUSIONS

Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.

Factors associated with the career path choices of veterinarians in western Canada

This second of 2 articles, relating to the veterinary profession in western Canada, explores the factors associated with veterinarians' career path choices. Among other factors, companion animal (small animal and equine) (CA) practitioners were less likely to have been raised in, or near to, a small center (< or = 10 000), were more concerned with their workload (hours of work and number of nights on-call), and preferred to work in progressive practices. Food animal (FA) practitioners were more likely to be male, have been raised in a small center, have been raised in the Province of Saskatchewan, and to have self-assessed themselves as having an above average knowledge of agriculture at the time they applied for admission to veterinary college. Mixed animal (MA) practitioners had more factors in common with FA than with CA practitioners. Three main factors were associated with leaving mixed or food animal practice: hours of work and too many nights on-call, the level of remuneration, and lack of support and mentorship.

Demographic survey of veterinarians employed in western Canada

The objective of this study was to generate demographic data on veterinarians working in western Canada. A sample of 551 veterinarians was randomly selected from a population of 2474 veterinarians employed in western Canada, 425 (77.1%) of whom responded to the survey. The respondents were evenly split between males (53.1%) and females (46.9%). More than half (58.0%) of the private practitioners practised exclusively on companion animals (small animals and horses), while 2.9% devoted 100% of their time to food animals. There were 351 respondents who had had > or = 2 employers since graduation; 80% of those who had begun their careers in companion animal (CA) practice had remained in this type of practice, while 54.3% of those who had begun their careers in mixed animal practice had switched to CA practice. Analyses of wage and workload data from 85 full-time veterinary employees showed that CA practitioners worked the fewest hours/week (47.0), had the least number of evenings on-call/month (3.7), and earned the highest hourly wage (35.79 dollars) as compared with non-CA practitioners.

Factors affecting the career path choices of graduates at the Western College of Veterinary Medicine

The objective of this study was to describe the demographics of the Class of 2006, Western College of Veterinary Medicine, and to determine which factors influenced the graduates' career path choices. Data were collected via an on-line survey and the response rate was 95.7% (67/70). The majority (57%) of graduates were starting their veterinary career in a food animal-related (FAR) job. Two factors were significantly associated with this choice: 1) those raised in, or near, a small center (population < 10 000) were 3.4 times (P = 0.03) more likely to accept a FAR position than were those raised in a large center (> 10 000), and 2) graduates with a bachelor of science in agriculture (BSc Ag) were 4.5 times (P = 0.04) more likely to begin their career as a FAR practitioner than were those without such a degree. However, 9 of the 16 graduates having a BSc Ag had an urban upbringing.

D-Lactic acid-induced neurotoxicity in a calf model

Lactic acidosis (DAC) occurs as a complication of short-bowel syndrome in humans and in a variety of other gastrointestinal disorders in monogastrics and ruminants. DAC is associated with signs of impaired central nervous system (CNS) function including ataxia and coma. The objective of this experiment was to determine whether either acidification of nervous tissue or d-lactic acid is responsible for decreased neurological function. Eight Holstein calves (32 +/- 11 days, 70 +/- 10 kg) were surgically catheterized with indwelling intravenous jugular and atlanto-occipital space cerebrospinal fluid (CSF) catheters and infused for 6 h in random order with isomolar dl-lactic acid (dl-LA), l-lactic acid (l-LA), hydrochloric acid (HCl), or saline. dl-LA induced ataxia after 4 h of infusion and produced the greatest obtunding of CNS function (at 7 h, score 8.0 +/- 0.4), whereas the other infusions caused neither ataxia nor scores over 1.5 (P < 0.01 from dl-LA). dl-LA induced significantly less acidemia than HCl (at 6 h pH 7.13 +/- 0.06 and 7.00 +/- 0.04, base excess -16 +/- 1 and -23 +/- 3 mmol/l, bicarbonate 11 +/- 1 and 8 +/- 1 mmol/l respectively, all P < 0.01) but greater than l-LA and saline (P < 0.01). CSF changes followed a similar but less pronounced pattern. Although HCl infusion produced a severe acidemia and CSF acidosis, only minor effects on neurological function were evident suggesting that d-lactate has a direct neurotoxic effect that is independent of acidosis. Conversely, l-LA produced only minor neurological changes.

The effects of feeding and fasting on gastrointestinal sounds in adult horses

The effect of changes in feed intake on auscultatable gastrointestinal sounds has not been systematically studied. Disagreement also is present in the literature about variation in sounds according to the quadrant of auscultation. Gastrointestinal sounds were recorded over the center of the left dorsal, left ventral, right ventral, and right dorsal quadrants and over the middle of the right abdominal flank. During 24 hours (n = 4) or 48 hours (n = 5) of fasting, there was a reduction in the intensity of gastrointestinal sounds as assessed by analysis of sound recordings. There was also a reduction in the number of mixing-like and propulsive-like sounds heard by 2 blinded observers. After refeeding, there was a marked increase in sound. Sound intensity varied among abdominal quadrants, but blinded observers did not notice significant differences in the number of mixing-like sounds. The left dorsal quadrant was quieter than others during fasting and refeeding. The right ventral quadrant appeared to be least affected by fasting, and sounds were louder over the right ventral and right middle quadrants than over the others. The blinded observers' perceptions of sound correlated poorly with one another and with objective measures of sound intensity. This experiment demonstrates the effectiveness of computerized analysis of abdominal sound in detecting a reduction in the intensity of gastrointestinal sounds during fasting and their return during refeeding. The left dorsal quadrant was quieter than other quadrants, likely because of its position over the small colon. There was considerable observer variation in the number of intestinal sounds heard.

Obstruction of the small intestine by a trichobezoar in cattle: 15 cases (1992-2002)

OBJECTIVE

To determine historical and clinical findings, treatment, and outcome for cattle with small intestinal obstruction caused by a trichobezoar.

DESIGN

Retrospective case series.

ANIMALS

15 cattle.

PROCEDURES

Medical records of cattle with a diagnosis of small intestinal obstruction by a trichobezoar from 1992 to 2002 were reviewed. Information pertaining to various aspects of diagnosis, treatment, and outcome was collected from records.

RESULTS

Trichobezoars were more common in young cattle, and affected cattle did not deteriorate clinically as rapidly as cattle with other types of intestinal obstruction. The most common initial owner complaints included decreased or absent fecal output, inappetance, abdominal distension, and signs of abdominal pain. Common clinical findings were dehydration, decreased or absent rumen motility, signs of depression, splashing sounds during succussion of the abdomen, and a pinging sound on percussion of the abdomen. The jejunum was obstructed in 10 cattle. Hypochloremic metabolic alkalosis and chronic inflammation were common laboratory findings. All 4 cattle that underwent abdominocentesis had peritonitis. The obstructing trichobezoar was removed surgically in 9 cattle, of which 7 survived and 2 died. The 6 cattle treated medically died or were euthanized.

CONCLUSIONS AND CLINICAL RELEVANCE

Obstruction of the small intestine by a trichobezoar is uncommon, but it should be considered as a differential diagnosis in cattle with signs of intestinal obstruction, particularly if they are younger than 4 years of age and have a history of nonacute signs of intestinal obstruction. Surgical removal appears to be a favorable method of treatment and should be considered when this condition is suspected.

Lactobacillus GG does not affect D-lactic acidosis in diarrheic calves, in a clinical setting

D-lactate, produced by gastrointestinal fermentation, is a major contributor to metabolic acidosis in diarrheic calves. Lactobacillus rhamnosus GG survives gastrointestinal transit in the neonatal calf and does not produce D-lactate. To determine whether this probiotic reduces gastrointestinal D-lactate production or severity of diarrhea or both, 48 calves (mean, 11 days old; range, 2-30 days) admitted to the clinic for treatment of diarrhea were randomly allocated to 2 groups. The experimental group was given Lactobacillus rhamnosus GG (1 x 10(11) cfu/d) PO, dissolved in milk or oral electrolyte solution, in addition to clinic treatment protocols; the other group served as a control. Serum and fecal samples were obtained at admission and at 24 and 48 hours after initial administration of Lactobacillus rhamnosus GG. All samples were analyzed for D- and L-lactate by using high-pressure liquid chromatography. Feces were also analyzed for pathogens, Lactobacillus rhamnosus GG recovery, and dry matter. D-lactic acidemia (>3 mmol/L) was present in 37/48 calves at admission. Lactobacillus rhamnosus GG was recovered in the feces of 13 experimental calves and 0 control calves 24 hours after administration. No difference in serum or fecal D- or L-lactate between the groups was detected at any time point. After therapy, D-lactic acidosis was absent at 48 hours in all but 1 calf. No relation between fecal pathogen (viral, bacterial, or protozoal) and degree of D-lactic acidosis was observed. The reduction in mortality and greater fecal dry matter in Lactobacillus rhamnosus GG-treated calves was not statistically significant.

Lactobacillus GG does not affect D-lactic acidosis in diarrheic calves, in a clinical setting

D‐lactate, produced by gastrointestinal fermentation, is a major contributor to metabolic acidosis in diarrheic calves. Lactobacillus rhamnosus GG survives gastrointestinal transit in the neonatal calf and does not produce D‐lactate. To determine whether this probiotic reduces gastrointestinal D‐lactate production or severity of diarrhea or both, 48 calves (mean, 11 days old; range, 2–30 days) admitted to the clinic for treatment of diarrhea were randomly allocated to 2 groups. The experimental group was given Lactobacillus rhamnosus GG (1×10¹¹ cfu/d) PO, dissolved in milk or oral electrolyte solution, in addition to clinic treatment protocols; the other group served as a control. Serum and fecal samples were obtained at admission and at 24 and 48 hours after initial administration of Lactobacillus rhamnosus GG. All samples were analyzed for D‐and L‐lactate by using high‐pressure liquid chromatography. Feces were also analyzed for pathogens, Lactobacillus rhamnosus GG recovery, and dry matter. D‐lactic acidemia (>3 mmol/L) was present in 37/48 calves at admission. Lactobacillus rhamnosus GG was recovered in the feces of 13 experimental calves and 0 control calves 24 hours after administration. No difference in serum or fecal D‐ or L‐lactate between the groups was detected at any time point. After therapy, D‐lactic acidosis was absent at 48 hours in all but 1 calf. No relation between fecal pathogen (viral, bacterial, or protozoal) and degree of D‐lactic acidosis was observed. The reduction in mortality and greater fecal dry matter in Lactobacillus rhamnosus GG‐treated calves was not statistically significant.

Evaluation of traditional instruction versus a self-learning computer module in teaching veterinary students how to pass a nasogastric tube in the horse

OBJECTIVE

To evaluate the effectiveness of a self-learning computer module (SLCM) versus traditional instruction in teaching how to pass a nasogastric tube (NG) in the horse.

DESIGN

A double-blind, monocentric study.

SAMPLE POPULATION

52 third-year students in the DVM program were randomly assigned to two groups: traditional instruction (N = 25) or SLCM instruction (N = 27).

PROCEDURE

Traditional instruction consisted of an instructor and live demonstration; SCLM students were given a CD-ROM each. Both sessions lasted one hour. The students were then united in one session to practice passing the NG tube. Their performance was videotaped and evaluated by two evaluators. Students were then given a multiple-choice knowledge quiz. One week later, a second demonstration of the same procedure by the two methods was administered, and students were allowed to choose either method of instruction. A Likert-scale questionnaire about their comfort, their confidence, and the appropriateness of the teaching method was given after the second demonstration. Data were analyzed by non-parametric tests. A focus-group study was conducted to determine students' perception of each teaching method. Nine participants in the experiment volunteered for these focus-group sessions. The sessions were audiotaped and transcribed.

RESULTS

Students in the SLCM group performed significantly better on the test of knowledge than traditionally instructed students. The questionnaire found significant perceived benefits to computer-based instruction, including a preference for the computer-based module, better learning, and greater preparedness. In hands-on skill, time to pass the NG tube on the successful attempt was significantly shorter in the SLCM group than in the traditionally instructed group. The data from focus-group sessions suggest that while participants expressed satisfaction with both modes of instruction, the SLCM group reported somewhat higher levels of confidence in their skills prior to performing the procedure. Whereas the traditional group reported a strong preference for continued live demonstrations of the procedure, the SLCM group stated that the computer-assisted module alone provided them with effective instruction.

CONCLUSION

Computer-assisted learning is an acceptable and effective method of training students to pass an NG tube with potential welfare, proficiency, and knowledge advantages.

Comparison of surgical versus medical treatment of nephrosplenic entrapment of the large colon in horses: 19 cases (1992-2002)

OBJECTIVE

To compare the outcome of horses with nephrosplenic entrapment of the large colon (NSELC) treated surgically or medically by rolling, administration of phenylephrine hydrochloride (or both), and exercise.

DESIGN

Retrospective study.

ANIMALS

11 medically treated horses and 8 surgically treated horses with NSELC.

PROCEDURE

Medical records of horses with nephrosplenic entrapment between 1992 and 2002 were reviewed. Medically treated horses were included if diagnosis and outcome of treatment of nephrosplenic entrapment were confirmed via transrectal examination and ultrasonographic examination. Surgically treated horses were included if the diagnosis was confirmed by exploratory laparotomy. Horses in which the large colon was entrapped between the spleen and body wall were not included.

RESULTS

Significant differences in mean age, heart rate, and duration of colic prior to treatment were not detected between horses treated surgically or medically. Ten medically treated horses recovered without complications, and 1 died. In the surgically treated group, 6 of 8 horses recovered without complications and 2 died. Mortality rate did not differ between treatments. Duration of hospitalization for medically treated horses was significantly shorter and the cost significantly less than for surgically treated horses.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that medical treatment of horses with NSELC via administration of phenylephrine hydro-chloride, rolling during general anesthesia, or both appears to be as effective as and less expensive than surgical treatment.

D-lactate in human and ruminant metabolism

D-lactate is normally present in the blood of mammals at nanomolar concentrations due to methylglyoxal metabolism; millimolar d-lactate concentrations can arise due to excess gastrointestinal microbial production. Grain overload in ruminants, short-bowel syndrome in humans, and diarrhea in calves can all result in profound D-lactic acidemia, with remarkably similar neurological manifestations. In the past, D-lactate was thought to be excreted mainly in the urine, and metabolized slowly by the enzyme d-alpha-hydroxy acid dehydrogenase. More recent studies reported that mammals have a relatively high capacity for D-lactate metabolism and identified a putative mammalian D-lactate dehydrogenase. A growing body of literature is also emerging describing subclinical elevation of D-lactate as an indicator of sepsis and trauma. This article describes advances in the understanding of D-lactate metabolism, D-lactic acidosis in ruminants and humans, and subclinical elevation of d-lactate.

A retrospective study of the diagnoses and survival of elk admitted to a large animal referral clinic

Information for veterinarians regarding diseases of farmed elk remains scarce despite an increase in the size of the industry. This retrospective study examines all (n=245) elk cases admitted to the Western College of Veterinary Medicine over an 11-year period (1991 to 2001). Age, gender, date of admission, diagnosis, and outcome were examined. Diarrhea, fractures, and other musculoskeletal problems were most common. Most (76%) cases involved elk under 1 y of age; these were more commonly diagnosed with fractures or diarrheal disease. Elk older than 1 y of age tended to be diagnosed with fractures or noninfectious diseases. Overall, the most common diagnosis was fractures, which were seen mostly as traumatic catastrophic long bone fractures. Fractures and other musculoskeletal problems occurred towards the end of summer and into the fall, while diarrhea and other infectious diseases were diagnosed in young elk in the spring and summer. The in-hospital case fatality rate was 33.5%.

D-lactate production and excretion in diarrheic calves

The origin of D-lactate, the most important acid contributing to metabolic acidosis in the diarrheic calf, is unknown. We hypothesized that because D-lactate is produced only by microbes, gastrointestinal fermentation is the source. The objective of this study was to determine whether D-lactate production occurs in the rumen, colon, or both, and to measure D- and L-lactate concentrations in urine. Fecal, rumen, blood, and urine samples were obtained from 16 diarrheic and 11 healthy calves. Serum electrolyte concentrations were measured in both groups, and blood gas analyses were performed for diarrheic calves. All samples were analyzed for D- and L-lactate by high performance liquid chromatography (HPLC). Diarrheic calves were generally hyperkalemic with high serum anion gap, depressed serum bicarbonate, and low blood pH. L-lactate was markedly higher in rumen contents (22.7 mmol/ L [median]) and feces (8.6 mmol/L) of diarrheic calves than healthy calves (0.5 mmol/L and 5.1 mmol/L, respectively), but not different in serum or urine. Rumen, fecal, serum, and urine D-lactate concentrations were all significantly higher (P < .05) in diarrheic calves (17.0, 25.4, 13.9, and 19.2 mmol/L, respectively) than in healthy calves (0.5, 9.1, 1.4, and 0.5 mmol/L, respectively). Higher D-lactate concentrations in the rumen and feces of diarrheic calves suggests these sites as the source of D-lactate in blood and urine.

Lactobacillus rhamnosus strain GG is a potential probiotic for calves

Diarrhea is a common occurrence in neonatal calves. Several veterinary probiotics claiming to prevent or treat calf diarrhea are available, but have not been well studied. This study assessed the capability of Lactobacillus rhamnosus strain GG (LGG) to maintain viability in the gastrointestinal tract of calves. We also determined whether LGG can be administered in an oral rehydration solution (ORS) without compromising the efficacy of the ORS or the viability of LGG, and whether LGG produces D-lactate or not. To investigate the intestinal survival of LGG, 15 calves were randomized into 3 groups and LGG was administered orally with their morning milk feeding on 3 consecutive days at a low (LD), medium (MD), or high (HD) dosage. Fecal samples were collected on days 0 (control), 1, 2, 3, 5, and 7 and incubated for 72 h on deMan, Rogosa, Sharpe agar. Twenty-four hours after the 1st feeding, LGG was recovered from 1 out of 5 calves in the LD group, 4 out of 5 calves in the MD group, and 5 out of 5 calves in the HD group. To determine if LGG caused the glucose levels in the ORS to drop below effective levels, 1.5 L of the ORS was incubated with LGG for 2 h at 37 degrees C and the glucose concentration was measured every 20 min using a glucose meter. This ORS was then further incubated for 10 h and aliquots analyzed by high performance liquid chromatography to determine if D-lactate was produced by LGG. Glucose concentrations did not change over the 2 h of incubation, and no D-lactate was produced after 48 h. The LGG maintained viability in ORS. Therefore, this study demonstrated that LGG survives intestinal transit in the young calf, produces no D-lactate, and can be administered in an ORS.

High-performance liquid chromatographic assay of lactic, pyruvic and acetic acids and lactic acid stereoisomers in calf feces, rumen fluid and urine

To facilitate clinical investigation of metabolic acidosis, a high-performance liquid chromatographic method was adapted and validated for the chiral separation of D-(-) and L-(+)-lactic acid in calf feces, rumen fluid and urine. A non-chiral method was also adapted and validated for the separation of pyruvic, acetic and DL-(+/-)-lactic acids in calf feces and DL-(+/-)-lactic and pyruvic acids in rumen fluid. Separation and quantification were achieved using a reversed phase sulphonated polystyrenedivinylbenzene analytical column for pyruvic, acetic and racemic lactic acids and by a 3 microm octadecylsilane (ODS) packed analytical column coated with N,N-dioctyl-L-alanine as the chiral selector for the separation of lactic acid enantiomers with Cu(II)-containing eluents by stereoselective ligand exchange chromatography. Endogenous analytes were present in validation samples over a range of concentrations (0.2-14.8 mmol/l). For the stereoselective assay, mean intra-day accuracy ranged from 90.6 to 108.4% and intra-day precision from 0.3 to 13.8%. For the non-stereoselective assay, mean intra-day accuracy ranged from 90.4 to 108.8% and intra-day precision from 1.5 to 11.1%. The limit of quantitation was 1.0 mmol/l for D- and L-lactic acid, 0.06125 mmol/l for pyruvic acid, 1.0 mmol/l for DL-lactic acid and 1 mmol/l for acetic acid. These assays can be used to study the role of the gastrointestinal tract and kidney in metabolic acidosis.

Clinical West Nile virus infection in 2 horses in western Canada

Two horses had a history of ataxia and weakness or recumbency. One recovered and was diagnosed with West Nile virus (WNV) infection by serologic testing. The other was euthanized; it had meningoencephalomyelitis, WNV was detected by polymerase chain reaction. West Nile virus infection is an emerging disease. Year 2002 is the first year in which cases have been seen in Saskatchewan.

Jejunal hemorrhage syndrome in 2 Canadian beef cows

Two beef cows were presented with a history of anorexia and abdominal pain. Both cows were euthanized. Necropsy revealed the presence of a segmental area of ulceration, necrosis, and intraluminal blood clots in the jejunum. Jejunal hemorrhage syndrome is an emerging disease and has not been reported previously in beef cattle.

Anion Gap Correlates with Serum D- and DL-Lactate Concentration in Diarrheic Neonatal Calves

The objective of this study was to investigate the relationship between serum D- and L-lactate concentrations, and anion gap (AG) in neonatal calves. The association of AG with lactic acidosis in diarrheic calves has only been investigated by measurement of L-lactate in calves with experimentally induced diarrhea. D-lactate has recently been reported to be present in high concentrations in the serum of some diarrheic neonatal calves. The contribution of this acid to AG is not reported. The relationship between AG and L- and D-lactate concentrations was examined in 24 healthy calves and 52 calves with naturally occurring infectious diarrhea with metabolic acidosis. AG was calculated as [Na+ + K+] - [Cl- + HCO3-]. D- and L-lactate were quantified using high-performance liquid chromatography. There was no correlation between L-lactate and AG, contrary to previous reports in the literature. Moderate correlations between D-lactate concentration and AG (r = .74, P < .0001), and between DL-lactate and AG (r = .77), P < .0001) were detected. No differences existed due to the age or sex of the calf. This study indicates that AG provides information on the nature of acidosis in the diarrheic, neonatal calf and reinforces the importance of investigating clinical, in addition to experimental, populations.

β-Adrenergic stimulated lipolysis in pony adipocytes is exclusively via a β2-subtype and is not affected by lactation

Catecholamines are important lipolytic agents in horses and ponies but the nature of the adrenergic receptor subtype distribution in their adipocytes is uncertain. A first objective was to identify the beta-adrenergic receptor subtype(s) present in adipocytes from horses and ponies. A second objective was to evaluate if the lipolytic responsiveness of isolated adipocytes to beta-adrenergic agonists is altered during lactation, a condition known to affect markedly maternal fat metabolism. Isoproterenol and salbutamol elicited strong lipolytic responses in adipocytes isolated from horse and pony subcutaneous adipose tissue. There were weak lipolytic responses to norepinephrine, dobutamine and BRL37344. The weak lipolytic response to NE compared to isoproterenol or salbutamol suggests an antilipolytic action from alpha2-adrenergic receptors. The relative order of potency for the beta-adrenergic agonists was isoproterenol>/=salbutamol>>dobutamine=BRL37344. There was expression of beta2-adrenergic receptor mRNA in pony and horse adipose tissues, as estimated by relative RT-PCR, but no expression of mRNAs for beta1- or beta3-adrenergic receptors. Early lactation did not alter the lipolytic responses to beta-adrenergic agonists, nor the expression of beta2-adrenergic receptor mRNA. Thus, these results indicate a dominant if not exclusive presence of beta2-adrenergic receptors in pony and horse adipocytes that is not affected by lactation.

An assessment of the terminology used by diplomates and students to describe the character of equine mitral and aortic valve regurgitant murmurs: correlations with the physical properties of the sounds

Twenty students and 16 diplomates listened to 7 recordings made from 7 horses with either aortic (n = 3) or mitral valve (n = 4) regurgitant murmurs. A total of 30 different terms were used to describe the character of these murmurs. However, only 4 terms were used in a repeatable and consistent manner. Most people described the character of a given mitral or aortic valve murmur with 1 or 2 terms. Diplomates drew from a pool of terms that was about half the size of that used by students--8.1 +/- 2.0 terms for diplomats (mean +/- 1 SD) versus 13.1 +/- 1.8 terms for students (P > .001). Only blowing, honking, buzzing, and musical were markedly associated with the recording played. Frequency analysis of the murmurs allowed them to be classified as containing harmonics (n = 4) or not containing harmonics (n = 3). Blowing was used to describe murmurs without harmonics on 39 of 48 occasions and corresponds to the term noisy used in some older descriptions of equine murmurs. Honking, musical, and buzzing were markedly associated with murmurs that contained harmonics; these terms were used 23, 13, and 12 of a possible 64 times, respectively. The frequency of buzzing and honking murmurs (72.7 +/- 9.3 and 88.4 +/- 46.3 Hz, respectively) was markedly lower than that of musical murmurs (156.8 +/- 81.1 Hz) (all P values < .01). Honking murmurs (0.392 +/- 0.092 seconds) were shorter than those described as buzzing or musical (0.496 +/- 0.205 and 0.504 +/- 0.116 seconds, respectively). The data suggest that the terminology for the character of aortic and mitral regurgitant murmurs should be restricted to 4 terms: blowing, honking, buzzing, and musical. Honking, buzzing, and musical describe murmurs with a peak dominant frequency and harmonics; blowing describes murmurs without a peak frequency. Effective communication could be enhanced by playing examples of reference sounds when these terms are taught so that nomenclature is used more uniformly.

Metabolic acidosis: separation methods and biological relevance of organic acids and lactic acid enantiomers

Metabolic acidosis can result from accumulation of organic acids in the blood due to anaerobic metabolism or intestinal bacterial fermentation of undigested substrate under certain conditions. These conditions include short-bowel syndrome, grain overfeeding of ruminants and, as recently reported, severe gastroenteritis. Measuring fermentation products such as short-chain fatty acids (SCFAs) and lactic acid in various biological samples is integral to the diagnosis of bacterial overgrowth. Stereospecific measurement of D- and L-lactic acid is necessary for confirmation of the origin and nature of metabolic acidosis. In this paper, methods for the separation of SCFAs and lactic acid are reviewed. Analysis of the organic acids involved in carbohydrate metabolism has been achieved by enzymatic methods, gas chromatography, high-performance liquid chromatography and capillary electrophoresis. Sample preparation techniques developed for these analytes are also discussed.

An assessment of the ability of diplomates, practitioners, and students to describe and interpret recordings of heart murmurs and arrhythmia

The ability of clinicians, ie, 10 veterinary students, 10 general practitioners, and 10 board certified internists, to describe and interpret common normal and abnormal heart sounds was assessed. Recordings of heart sounds from 7 horses with a variety of normal and abnormal rhythms, heart sounds, and murmurs were analyzed by digital sonography. The perception of the presence or absence of the heart sounds S1, S2, and S4 was similar for clinicians irrespective of their level of training and was in agreement with the sonographic interpretation on 89, 82, and 78% of occasions, respectively. However, practitioners were less likely to correctly describe the presence of S3. The heart rhythm was correctly described as being regular or irregular on 89% of occasions, and this outcome was not affected by level of training. Differentiation of the type of irregularity was less reliable. The perception of the intensity of a heart murmur was accurate and correlated with the grade assigned in the living horses, R2 = .68, and with sonographic measurements of the murmur's intensity, R2 = .69. Clinicians overestimated the duration of cardiac murmurs, particularly that of the loud systolic murmur. Only diplomates could reliably differentiate systolic from diastolic murmurs. The ability to diagnose the underlying cardiac problem was significantly affected by training; diplomates, practitioners, and undergraduates made the correct diagnosis on 53, 33, and 29% of occasions, respectively. The poor diagnostic ability of practitioners and the lack of improvement in diagnostic skill after the 2nd year of veterinary school emphasizes the need for better teaching of these skills. Digital sonograms that combine sound files with synchronous visual interpretations may be useful in this regard.

Both L- and D-lactate contribute to metabolic acidosis in diarrheic calves

Diarrhea in neonates is often complicated by metabolic acidosis. We used blood gas analysis and HPLC to determine whether bacterial fermentation might contribute to acidosis in diarrheic calves. Diarrheic calves (n = 21) had significantly lower pH, PCO(2), HCO(3)(-) and a higher anion gap than healthy calves (n = 21). Serum concentrations (mean +/- SD, mmol/L) of DL-, L- and D-lactate were also significantly higher in diarrheic (8.9 +/- 5.1, 4.1 +/- 3.4 and 5.2 +/- 5.7) than in healthy calves (1.7 +/- 1.2, 2.0 +/- 1.1 and too low to quantify). D- and L-lactate accounted for 64% anion gap increase in diarrheic calves. Fecal D- and L-lactate concentrations were also significantly higher in diarrheic calves (9.4 +/- 3.0 and 11.9 +/- 2.7 mmol/L) than healthy calves (1.1 +/- 0.1 and 1.6 +/- 0.1 mmol/L). The elevated concentrations of serum and fecal D-lactate suggest gut bacterial fermentation contributes to the development of acidosis in diarrhea.

A comparison of pH determination methods in food animal practice

The accuracy of a portable pH meter in measuring blood pH in neonatal calves, urine pH, and ruminal fluid pH in cows has been assessed. Thirty-five diarrheic and 15 healthy beef calves were used for blood gas analysis; 57 healthy dairy cows provided voided urine samples; and ruminal fluid samples were obtained from 10 dairy cows with ruminal fistulas on 4 separate days. Measurements of blood pH were obtained from an automated blood gas analyzer and the portable pH meter. Measurements of urine and ruminal fluid pH were determined with the benchtop pH meter, urinalysis strips, narrow range pH paper, and the portable pH meter. The portable pH meter was more accurate in measuring urine pH and ruminal fluid pH in cows than blood pH in neonatal calves. The urinalysis strips and the narrow range pH paper were found adequate to evaluate urine and ruminal pH.

Laminitis in a mature elk hind (Cervus elaphus)

Laminitis should be considered as a differential diagnosis in elk presenting with shifting leg lameness, reluctance to move, recumbency and hoof wall ridging. Eliminating the underlying cause and corrective trimming lead to a good prognosis for recovery.

Oral rehydration solution therapy in the management of children with rotavirus diarrhea

Rotavirus infections are the most common cause of gastroenteritis among children younger than 3 years of age and are associated with sporadic outbreaks of diarrhea in elderly and immunocompromised patients. Oral rehydration solutions (ORS) are formulated to correct dehydration and acidosis. Currently, ORS do not promote intestinal healing; however, investigators are examining the role of nutrition in promoting intestinal healing. This article reviews the composition of several ORS in human medicine and summarizes our current knowledge of the nutritional treatment of rotavirus diarrhea and intestinal healing.

Hypernatremia in neonatal elk calves: 30 cases (1988-1998)

OBJECTIVE

To characterize hypernatremia in neonatal elk calves, including clinical signs, incidence, physical examination findings, and possible causes.

DESIGN

Retrospective case series.

ANIMALS

26 neonatal elk calves were examined; 4 calves were evaluated twice, for a total of 30 examinations.

PROCEDURE

Medical records were reviewed for signalment, history, physical examination findings, results of diagnostic tests, and response to treatment. Hypernatremia was defined as serum sodium concentration > 153 mEq/L.

RESULTS

Hypernatremia was diagnosed in 14 calves and was significantly associated with diarrhea, high WBC count, high anion gap, and high serum concentrations of albumin, chloride, creatinine, and urea. Hypernatremia was not significantly associated with survival, but high serum albumin concentration and rectal temperature were significantly associated with survival of calves. Animals given antibiotics and electrolyte solutions orally prior to evaluation were significantly more likely to die than those untreated. Dehydration was a common reason for evaluation but was not significantly associated with survival.

CONCLUSIONS AND CLINICAL RELEVANCE

Hypernatremia was significantly associated with diarrhea. Treatment of diarrheic elk calves is often the same as that used in bovine calves with diarrhea; however, bovine calves are commonly hypo- or normonatremic. Our experience suggests that treatment protocols used in bovine calves are unsatisfactory for elk calves. The rate at which serum sodium concentration is reduced should be < 1.7 mEq Na/L/h to avoid development of neurologic signs associated with iatrogenically induced cerebral edema.

Oral electrolyte therapy

Diarrhea is a common condition in neonatal calves and can be caused by a wide variety of infections and noxious agents. Oral electrolyte therapy is a simple and economical method of treating diarrheic calves. Oral electrolyte solutions can correct dehydration and acidosis, and they may also have a role in preventing or alleviating mucosal damage. Indications, the principles of administration, and choosing an electrolyte product are discussed with examples.

Primary distension of the guttural pouch lateral compartment secondary to empyema

A 6-year-old, 420-kg quarter horse gelding was presented with a 2-month history of difficulty swallowing and dyspnea. The horse was diagnosed with a right guttural pouch empyema with many large chondroids. Two surgeries were required to completely remove all the chondroids from what proved to be a primary distension of the guttural pouch lateral compartment.

A simple formula for predicting claw volume of cattle

The object of this study was to develop a simple method for accurately calculating the volume of bovine claws under field conditions. The digits of 30 slaughterhouse beef cattle were examined and the following four linear measurements taken from each pair of claws: (1) the length of the dorsal surface of the claw (Toe); (2) the length of the coronary band (CorBand); (3) the length of the bearing surface (Base); and (4) the height of the claw at the abaxial groove (AbaxGr). Measurements of claw volume using a simple hydrometer were highly repeatable (r(2)= 0.999) and could be calculated from linear measurements using the formula:Claw Volume (cm(3)) = (17.192 x Base) + (7.467 x AbaxGr) + 45.270 x (CorBand) - 798.5This formula was found to be accurate (r(2)= 0.88) when compared to volume data derived from a hydrometer displacement procedure. The front claws occupied 54% of the total volume compared to 46% for the hind claws.