Dynamic obstructions of the equine upper respiratory tract. Part 1: observations during high-speed treadmill endoscopy of 600 Thoroughbred racehorses.

REASONS FOR PERFORMING STUDY AND OBJECTIVE: To review the prevalence of single and complex forms of dynamic airway obstructions within a large group of Thoroughbred horses in training referred for investigation of poor performance. METHODS: Video-endoscopic recordings of the upper respiratory tract made during a standardised treadmill exercise test of 600 Thoroughbred racehorses were reviewed and analysed in real time and slow motion to identify dynamic collapse by the tissues bordering onto the pharyngeal and laryngeal airways. RESULTS: Dynamic collapse within the nasopharynx or larynx was confirmed in 471 of the 600 horses. Dorsal displacement of the soft palate (DDSP; 50%) and palatal instability (33%) were the disorders most frequently identified. It was concluded that deglutition is not a significant event in the triggering of DDSP. Complex forms of dynamic collapse were present in 30% of the horses with upper respiratory tract obstructions. A significant influence of age on the prevalence of DDSP and dynamic laryngeal collapse was identified. There was an increased risk of DDSP in younger horses, and of laryngeal collapse in older horses. No association with gender or format of racing was identified. CONCLUSIONS AND POTENTIAL RELEVANCE: Palatal instability and DDSP comprised the most frequently encountered forms of dynamic collapse within the upper respiratory tract of the Thoroughbred racehorses in this study and are probably expressions of the same nasopharyngeal malfunction. Complex obstructions, i.e. where more than one structure collapses into the airway, occur frequently and therefore treatments that address solitary disorders may often be unsuccessful. Younger horses were found to be at greater risk of sustaining DDSP while older horses seemed more at risk to vocal cord collapse but not to collapse of the arytenoid cartilage itself.

Dynamic obstructions of the equine upper respiratory tract. Part 2: comparison of endoscopic findings at rest and during high-speed treadmill exercise of 600 Thoroughbred racehorses.

REASONS FOR PERFORMING STUDY: The reliability of diagnoses of obstructive conditions of the upper respiratory tract (URT) based on examinations performed at rest vs. at exercise is controversial. OBJECTIVE: To compare diagnosis of URT by endoscopy at rest with that achieved during high-speed treadmill exercise (HSTE). HYPOTHESIS: Endoscopy of URT at rest, when performed in isolation from other simpler techniques is unreliable in the prediction of dynamic respiratory obstructions. METHODS: Endoscopic findings of 600 Thoroughbred racehorses during quiet breathing were compared with findings during high-speed treadmill exercise. Other parameters were also assessed for their specificity in diagnosis. RESULTS: Endoscopy of the resting horse showed low sensitivity (0.15) in the diagnosis of dorsal displacement of the soft palate (DDSP) and palatal instability (PI). When endoscopy and reported noises were taken together there was still a 35% misdiagnosis rate. Although there was significant association between resting laryngeal function score (LFS) and dynamic vocal cord and/or arytenoid cartilage collapse at exercise, 19% of horses with a grade 4/5 LFS were able to attain and maintain full abduction during exercise and 7% of those with 'normal' grades 1 or 2 LFS at rest showed dynamic laryngeal collapse when exerted. Sensitivity of the diagnostic model was greatly increased (80%) when a history of inspiratory noise and palpable intrinsic muscle atrophy were included. CONCLUSIONS AND POTENTIAL RELEVANCE: Endoscopy of the upper respiratory tract of static horses is unreliable in the diagnosis of dynamic obstructions of the URT and should not be used in isolation in surgical decision-making or in the assessment of horses at the time of sale.

Videoendoscopic evaluation of the upper respiratory tract in 93 sport horses during exercise testing on a high-speed treadmill.

REASONS FOR PERFORMING STUDY: Videoendoscopy of the upper respiratory tract (URT) during high-speed treadmill exercise has proved to be invaluable in the assessment of URT dysfunction in racehorses. However, very little information exists regarding dynamic airway collapse in other sport horses used in nonracing equestrian disciplines. OBJECTIVES: To evaluate the videoendoscopic findings at rest and during exercise in a mixed population of sport horses referred for investigation of poor athletic performance and/or abnormal respiratory noise. METHODS: Videoendoscopy of the upper airway was performed at rest and during high-speed treadmill exercise in 93 horses. RESULTS: Dynamic airway obstructions were diagnosed in 77% of horses and were frequently complex in nature. The most common forms of dynamic collapse included soft palate dysfunction (54%), dynamic laryngeal collapse (38%), axial deviation of the aryepiglottic folds (24%) and pharyngeal wall collapse (18%). In the majority of horses, no obvious abnormalities were identified at rest. Enforced poll flexion was found to be a contributing factor in 24% of cases. CONCLUSIONS: Dynamic obstructions of the URT were a common cause of poor performance and/or abnormal respiratory noise in sport horses referred for investigation of performance problems. POTENTIAL RELEVANCE: This study highlights the importance of videoendoscopic evaluation of the URT during exercise in horses utilised for equestrian sports where exercise during competition is submaximal in nature.

Plasma glutamine concentrations in the horse following feeding and oral glutamine supplementation.

REASONS FOR PERFORMING STUDY: Pharmacological benefits of glutamine supplementation have been shown in athletically and clinically stressed human subjects. In the horse, infection and intense exercise have also been shown to significantly decrease plasma glutamine concentrations, but little is known on how best to supplement. OBJECTIVE: To evaluate whether ingestion of different foodstuffs, with or without L-glutamine (G) or a peptide (Pep) containing 31.5% w/w G in a water-stable form, could affect plasma glutamine concentrations (P-GC). MATERIALS AND METHODS: Nine feeds (molassed sugar beet-pulp (mSB); naked oats (nO); commercial mix (CM); mSB with 30 or 60 mg/kg bwt G or the G-molar equivalent of Pep; and CM with 60 mg/kg bwt G or equivalent Pep) were offered to 6 healthy mature horses on different days following overnight food restriction. The changes in P-GC were monitored for 8 h post feeding. RESULTS: After 1.5 h mean +/- s.d. AP-GC were -0.9 +/- 10.2% (mSB), +12.5 +/- 7.1% (nO) and +44.7 +/- 15.9% (CM; P<0.05). deltaP-GC with mSB supplemented with G was +60.9 +/- 30.0% (30 mg; P<0.05) and +156.8 +/- 34.6% (60 mg; P<0.05) at 1 h; deltaP-GC with Pep was 51.0 +/- 31.0% (30 mg equivalent, P<0.05) and +91.1 +/- 9.5% (60 mg equivalent, P<0.05) at 1 h. After 10 days of supplementation with 60 mg/kg bwt G, AP-GC following a further 60 mg/kg bwt G challenge showed a similar increase at 1 h of +154.3 +/- 37.9%; prevalues were unchanged. G and Pep added to CM, increased P-GC by 246.3 +/- 55.3 (+99.2%) and 252.3 +/- 94.2 micromol/l (96.7%) at 1.5 h with concentrations still above prevalues at 8 h (P<0.05). Apart from the CM (with or without supplement), pre P-GC was always regained by 4 h. Plasma NH3 and plasma protein concentrations were unaffected by supplementation with G or Pep. CONCLUSION: P-GC may be modified by appropriate supplementation with no apparent adverse effects. POTENTIAL RELEVANCE: Increasing P-GC through appropriate supplementation may be of benefit in the athletically or clinically stressed horse with lowered plasma glutamine concentrations.

Effect of dorsal displacement of the soft palate on ventilation and airflow during high-intensity exercise.

Dorsal displacement of the soft palate (DDSP) is one of the most common obstructive conditions of the upper respiratory tract in the racehorse. The present study was conducted to determine the effects of intermittent dorsal displacement of the soft palate (DDSP) on ventilation and respiratory airflow during high intensity exercise. Videoendoscopic recordings were made of the nasopharynx and larynx simultaneously with measurements of airflow and respiratory gas exchange, during high-speed treadmill exercise in 9 horses with confirmed intermittent DDSP admitted for clinical investigation of poor racing performance. In all horses, DDSP resulted in a reduction in minute ventilation (VE) (P<0.001), associated with a decrease in tidal volume (VT) (P<0.01) with no change in breathing frequency (f) and a reduction in oxygen consumption (VO2) (P<0.01). Further, DDSP resulted in reduction of expiratory flow parameters, including peak expiratory flow (PEF), EF50, EF25 and EF125 (P<0.01), with no alteration of inspiratory flow. These results confirm that naturally-occurring intermittent DDSP creates a flow-limiting expiratory obstruction. The associated impairment of athletic performance is probably caused, at least in part, by the accompanying decrease of oxygen uptake.

The effect of a tongue-tie in horses with dorsal displacement of the soft palate.

Tongue-ties are frequently used in an attempt to prevent dorsal displacement of the soft palate (DDSP). The aim of this study was to determine the efficacy of a tongue-tie in horses clinically affected with the disorder. Videoendoscopic recordings and measurements of respiratory airflow were made simultaneously during high intensity treadmill exercise in 6 Thoroughbred racehorses with confirmed DDSP, with and without a tongue-tie. DDSP was confirmed in all 6 horses without the tongue-tie but occurred in only 4 horses with the tongue-tie in place. In one horse the palate displaced only on slowing down after intense exercise and in the other horse DDSP did not occur although palatal instability remained. The presence of the tongue-tie did not result in any significant alteration in run-time to fatigue or in any of the respiratory variables measured. The results suggest that the use of a tongue-tie may prevent DDSP in individual horses although it is not effective in the majority, consistent with the widely accepted anecdotal reports of success rates for its use. Where DDSP was not prevented, application of a tongue-tie did not improve ventilation.

Ambient temperature and relative humidity influenced packed cell volume, total plasma protein and other variables in horses during an incremental submaximal field exercise test.

Thermoregulation may limit exercise performance under hot and humid conditions. This study compared heart rate (HR), respiratory rate (RR), rectal temperature (Tr), packed cell volume (PCV) and total plasma protein concentration (TPP) during a submaximal incremental field exercise test under high vs. low ambient temperature and relative humidity. Ten horses were tested 3 times in summer (July) and 3 times in autumn (September). Heart rate was measured continuously, the other variables at rest and immediately after 4 min at 3.5, 4.5 and 7.0 m/s, separated by 3 min rest intervals, and after 5 and 10 min recovery. Data for all variables were significantly greater during exercise and recovery in the hot vs. cool conditions, respectively: after 4 min at 7.0 m/s, HR was 135+/-1 and 123+/-1/min (P<0.0001), Tr was 39.0+/-0.06 and 38.0+/-0.05 degrees C (P<0.0001), RR was 99+/-3 and 50+/-3/min (P<0.0001), PCV was 48.8+/-0.06 and 42.1+/-0.3% (P<0.0001) and TPP was 7.7+/-0.14 and 7.6+/-0.12 g/l (P = 0.026). These data reflect the thermal burden during submaximal exercise under hot conditions in the field. The greater relative PCV increase in the heat probably conferred a thermoregulatory advantage and reflected a greater circulating red cell volume increase rather than a decrease of plasma volume. This study illustrates how differences in environmental conditions can affect assessment of exercise responses and how these factors must be considered in monitoring progress during fitness and acclimatisation regimes in the field.

Plasma ammonia and lactate responses using incremental and constant speed exercise tests.

Plasma NH3, formed during intense exercise, results principally from the deamination of AMP in muscle. Its formation during exercise may be influenced both by the pool of fibres recruited and by changes in the intracellular environment affecting ADP homeostasis. This study compared incremental and constant speed exercise as possible protocols for the investigation of plasma NH3 accumulation with intense exercise. Six trained Thoroughbred horses, one of which had recently been operated on for recurrent laryngeal neuropathy, undertook a step-wise treadmill test with 1 min incremental steps of 6, 8, 10, 11 and 12 m/s (7.5% incline). Two and 4 weeks later horses performed a constant-speed, maximum-exercise tolerance test at 115% VO2max (7.5% incline). Blood samples from the jugular vein were drawn at 20 s intervals in all 3 tests, for plasma NH3 and lactate. There were marked differences between and within horses in their time dependant lactate and NH3 responses to exercise. Three of the 6 horses studied showed a distinct threshold for onset of plasma NH3 accumulation with incremental exercise. Distinct thresholds for the onset of NH3 accumulation were apparent also in 5 of the 6 horses during exercise at constant rate. The present study demonstrates clearly the practicality of measuring NH3 concentration curves, even during a short incremental step test which has the advantage that other measures relating to cardiovascular and respiratory functions can be measured simultaneously.

Plasma glutamine status in the equine at rest, during exercise and following viral challenge.

The variation over 24 h of plasma glutamine concentration in nonexercising horses was studied in 3 Thoroughbreds (TB) fed at 1600 h and 0700 h. This indicated a small but regular change associated with feeding. Starting at a mean of 482 mumol/l at 1600 h the concentration increased to 522 mumol/l at 2000 h, falling to 476 mumol/l at 1600 h and increasing again to 525 mumol/l at 2000 h. 'Normal' values were established in 19 part-bred TB horses, lacking clinical signs or remarkable pathology and in light training, by sampling weekly at 1000 h over a 10 week period. The mean concentration was 491 mumol/l. Values were normally distributed with 95% confidence range between horses of 469-512 mumol/l. The s.d. of values within-horse was 28 mumol/l. The acute effect of exercise was investigated in 5 TB horses during i) an exercise simulating the road and tracks phase of a 3-day-event and ii) a sustained high-intensity exercise test (115% VO2max until the pace was no longer maintained). In both tests a transient increase was produced as a direct result of exercise, followed by a decline to a nadir at approximately 3 h post exercise. Pre-exercise resting concentrations, following either test, were approaching pre-values by 24 h recovery. The effect of viral challenge was studied in 6 TB horses exposed to an aerosol of equine influenza virus, subtype H3N8 (A/equine-2 subtype) which caused mild clinical signs. A significant fall in the 1000 h plasma glutamine concentration from a mean of 463 to 342 mumol/l by the 6th day was seen in 5 horses. A more gradual decline was observed in the 6th horse. These findings indicate a similar response to viral challenge in the horse to that in man.

A general population survey of rest cramps.

Two hundred and eighteen subjects, out of 250 individuals taken from a general practice register, returned completed questionnaires giving details about rest cramps, and a further 15 were contacted by telephone. The overall prevalence of rest cramps in the survey population was 37%. The symptom was more prevalent in older subjects. Rest cramps were most commonly experienced in the muscles of the leg, in 83% of the 86 cramp sufferers. Symptoms were usually present at night (73%). On average cramp episodes lasted for 9 min (95%CI 6.7-11.2). Most cramps sufferers experienced symptoms infrequently, but 40% had cramp episodes more than three times per week and 6% complained of at least one episode per day or night. Twenty-one per cent of cramp sufferers described their symptoms as very distressing. A minority, 32% of the 86 cramp sufferers, had reported the symptoms to a general practitioner although the 86 subjects self-rated their health more negatively than the individuals without muscle cramps. There was a significant, positive association between rest cramps and symptoms of angina or intermittent claudication although these two factors only accounted for 12% of the variance, suggesting that peripheral vascular disease may play a relevant but limited role in the aetiology of rest cramps.

Commodes: inconvenient conveniences.

OBJECTIVES: To investigate use of commodes and attitudes of users and carers to them. DESIGN: Interview with semi-structured questionnaire of subjects supplied with commodes from Leeds community appliance centre. SUBJECTS: 140 users of a commode and 105 of their carers. RESULTS: Main reasons for being supplied with a commode were impaired mobility (130 subjects), difficulty in climbing stairs (128), and urinary incontinence (127). Main concerns of users and carers were lack of privacy (120 subjects felt embarrassed about using their commode, and 96 would not use it if someone was present); unpleasant smells (especially for 20 subjects who were confined to one room); physical appearance of commode chair (101 users said it had an unfavourable appearance, and 44 had tried to disguise it); and lack of follow up after commode was supplied (only 15 users and carers knew who to contact if there were problems). Users generally either had very positive or very negative attitudes to their commodes but most carers viewed them very negatively, especially with regard to cleaning them. CONCLUSIONS: Health professionals should be aware of people's need for privacy when advising them where to keep their commode. A standard commode is inappropriate for people confined to one room, and alternatives such as a chemical toilet should be considered. Regular follow up is needed to identify any problems such as uncomfortable or unsafe chairs. More thought should be given to the appearance of commodes in their design.

Equine plasma and blood volumes decrease with dehydration but subsequently increase with exercise.

The effects of dehydration and 40 min of exercise at approximately 40% of maximal O2 consumption on plasma volume (PV) and blood volume (BV) were studied in six horses. Horses were exercised while euhydrated (C); 4 h after administration of furosemide (1.0 mg/kg i.v.; FDH), which induced isotonic dehydration; and after 30 h without water (DDH), which caused hypertonic dehydration. Dehydration resulted in decreases of 6.3 and 9.9% for PV and BV, respectively, with FDH and 10.7 and 8.5%, respectively, with DDH. During exercise in C, PV and BV increased by 12.7 and 20.0%, respectively; during exercise with FDH, they increased by 11.7 and 26.1%, respectively; and during exercise with DDH, PV decreased by 1.3% from predehydration values, while BV increased by 18.7%. Hematocrit and total plasma protein concentration rose to higher values throughout exercise in FDH and DDH than in C; plasma [Na+] was higher in DDH than in FDH and C, [Cl-] was higher in DDH and lower in FDH than in C, and [K+] was lower in FDH and DDH than in C through exercise and recovery. From these results, we conclude that increases in PV and BV are normal features of low-intensity exercise in the horse. The increases in BV not only augment O2 carriage but also help maintain circulating volume. These increases can be modified by preexercise dehydration, the nature of which affects the extent of modification.

Effects of dehydration on thermoregulatory responses of horses during low-intensity exercise.

Effects of dehydration on thermoregulatory and metabolic responses were studied in six horses during 40 min of exercise eliciting approximately 40% of maximal O2 consumption and for 30 min after exercise. Horses were exercised while euhydrated (C), 4 h after administration of furosemide (FDH; 1.0 mg/kg i.v.) to induce isotonic dehydration, and after 30 h without water (DDH) to induce hypertonic dehydration. Cardiac output was significantly lower in FDH (144.1 +/- 8.0 l/min) and in DDH (156.6 +/- 6.9 l/min) than in C (173.1 +/- 6.2 l/min) after 30 min of exercise. When DDH, FDH, and C values were compared, dehydration resulted in higher temperatures in the middle gluteal muscle (41.9 +/- 0.3, 41.1 +/- 0.2, and 40.6 +/- 0.2 degrees C, respectively) and pulmonary artery (40.8 +/- 0.3, 40.1 +/- 0.2, and 39.7 +/- 0.2 degrees C, respectively). Temperatures in the superficial thoracic vein and subcutaneous sites on the neck and back and peak sweating rates on the neck and back were not significantly different in DDH and C. In view of higher core temperatures during exercise after dehydration and decrease in cardiac output without concomitant increases in peripheral temperatures or reduced sweating rates, we conclude that the impairment of thermoregulation was primarily due to decreased transfer of heat from core to periphery.

Correction of cellular zinc depletion by oral zinc supplementation in elderly subjects.

Immune function declines with age, and has been implicated in the increased incidence of cancer and infections in the elderly. In this hospital, many elderly patients have evidence of zinc depletion. In the present study, we supplemented those elderly patients who had depressed polymorphonuclear cell (PMNC) zinc levels with 135 mg oral zinc sulphate for 4 weeks. Plasma and PMNC zinc increased markedly but the percentage of peripheral blood T-lymphocytes expressing the surface markers CD3, CD4 and CD8 were unchanged. Plasma concentrations of vitamins A and E also remained constant. This study confirms the 25-30% incidence of cellular zinc depletion in this patient population, and demonstrates that zinc concentrations can be brought back to within normal limits by oral zinc supplements, but with no effect on T-cell phenotypes.

Intracellular free Ca2+ fluxes and responses to phorbol ester in T lymphocytes from healthy elderly subjects.

A group of healthy elderly subjects (greater than or equal to 75 years) was selected by the strict criteria of the SENIEUR protocol, and compared with healthy young (less than or equal to 35 years) volunteers. Mitogenic responses of peripheral blood mononuclear cells to phytohaemagglutinin and anti-CD3 were significantly reduced in the elderly (P less than 0.0002), thereby confirming that even though in perfect health, elderly individuals show impaired cell-mediated immunity. However, no abnormality of intracellular free Ca2+ fluxes could be detected in purified T cells from the elderly subjects when stimulated with anti-CD3 antibody. Nevertheless, both the proliferative responses of purified T cells to phorbol ester and calcium ionophore (Ionomycin) and the phorbol ester-induced inhibition of the Ca2+ response were defective in the elderly subjects (P less than 0.003 and P less than 0.0002, respectively). These data suggest that signal transduction and the generation of second messengers proceed normally in T cells from the elderly, but downstream events mediated by activation of protein kinase C are dysfunctional.

Test/inform/retest: a useful technique in undergraduate rheumatology teaching.

Twenty final year medical students had their ability to interpret rheumatological physical signs tested by 10 multiple choice questions (MCQ) on days 1 and 4 of an educational study. Ten theory questions were used as controls. They were then given an information sheet on the interpretation of physical signs, and repeated the MCQ on day 26. There was a progressive improvement in the theory scores but no improvement in clinical scores until after the information sheet was available. The improvement in clinical scores was significantly greater than the improvement in theory scores (P less than 0.001). We suggest that the use of an information sheet in conjunction with an MCQ paper can improve undergraduates' ability to interpret physical signs when used in the pattern test/inform/retest.

Surgical collars: a survey of their prescription and use.

We report the results of a questionnaire survey of 124 orthopaedic, rheumatology, medical and accident and emergency outpatients prescribed a surgical collar during a 3-month period. Of these, 99 (80%) returned the questionnaire. Instructions received about when to wear the collar differed widely, especially between specialties. Most patients (76%) found benefit in wearing the collar. Pain was the symptom helped most (78%) whilst dizziness was helped least (40%). Problems with the collars were common, many being too hot (69%) and uncomfortable (48%). A third had difficulty putting the collar on. Despite these problems, compliance was good with 19 patients discontinuing collars for reasons other than recovery or medical advice. We believe this study highlights further areas for research and stimulates a re-evaluation of collar usage.