Diagnosis and surgical management of ureteral calculi in dogs: 16 cases (1990-2003).

AIMS: To examine the clinical signs, laboratory and radiographic findings, surgical technique, ureterolith composition, and post-operative outcomes in dogs managed surgically for ureterolithiasis to determine whether surgical removal of ureteroliths in dogs resulted in a positive clinical outcome. METHODS: The medical record database of a university veterinary hospital in Pennsylvania, USA, was searched for dogs that underwent surgery to remove obstructive ureteral calculi between 1990 and 2003. Records were reviewed for signalment, clinical history and examination findings, radiographic and laboratory test results, surgical technique, and ureterolith analysis. Follow-up information was obtained from telephone interviews with owners or referring veterinarians, or by reviewing the medical record of subsequent hospital visits. RESULTS: Sixteen dogs were included in this study; ten were neutered females, two intact females and four castrated males. Abdominal radiography revealed ureteral calculi in 14/16 dogs, renal calculi in 8/16, cystic calculi in 8/16, urethral calculi in 1/16, renomegaly in 6/16 and renal mineralisation in 5/16. Ureterolith type included struvite in six dogs, calcium oxalate in five, calcium phosphate in one, and a mix of struvite, calcium phosphate and calcium oxalate in another. Compared to dogs with non-struvite ureteroliths, those with struvite ureteroliths had a higher pre-operative white blood cell (WBC) count (25.6, SD 7 vs 17.6, SD 6 x 103 cells/mul; p=0.046), and were more likely to have a purulent discharge from the ureteral incision noted at the time of surgery (p=0.015). Following discharge, 14/16 dogs were re-evaluated. Median survival time was 904 days (range 2-1,876). Two dogs required additional surgery on the urinary tract. Four dogs died or were euthanised because of azotaemia and clinical signs related to the urinary system or non-specific signs of illness (vomiting, lethargy) at 8, 90, 333 and 904 days post-operatively. CONCLUSIONS: Surgical management of ureteroliths was successful and resulted in good long-term survival in the majority of dogs examined in this small study population. Similar proportions of calcium oxalate and struvite ureteroliths were identified. CLINICAL RELEVANCE: The use of the ureteral surgery may increase as the frequency of diagnosis of ureteroliths in dogs increases.

Assessment of physicians' ability to prescribe parenteral nutrition support in a community teaching hospital.

OBJECTIVE: To assess the knowledge and skill base of the physicians in our hospital in prescribing parenteral nutrition support. DESIGN: Physicians completed parenteral nutrition orders for three mock patients. A range of clinically appropriate responses was established before the survey by the hospital Nutrition Support Team. Each case was scored according to set criteria, and the three case scores were averaged to yield a total score of 0 to 100. SUBJECTS/SETTING: Forty-eight attending, resident, and student physicians in the departments of family practice, internal medicine, and general surgery in a community teaching hospital. STATISTICAL ANALYSIS: Student's t test was used to compare interval data between two groups, and analysis of variance was used to compare interval data among three or more groups. If Bartlett's test for homogeneity of variance showed differences between the groups, the Kruskal-Wallis one-way analysis of variance was used. If analysis of variance revealed a significant difference, the data were reanalyzed using three different multiple-comparison procedures (Tukey, Scheffe, and Bonferroni) to decrease the possibility of a type I error. RESULTS: The mean total score was 48.6 +/- 20.8. Total score differed according to the number of nutrition lectures attended during residency. Total score tended to differ by specialty and number of patients treated with parenteral nutrition; however, these differences did not reach statistical significance. APPLICATIONS/CONCLUSIONS: This tool can be adapted and used by other hospitals, medical schools, and residency programs to assess physicians' knowledge base, design educational programs, and improve the parenteral nutrition ordering process.

Successful treatment of primary aorta-esophageal fistula resulting from aortic aneurysm.

Most aneurysms of the descending thoracic aorta rupture unless treated surgically. Autopsy studies in these patients indicate that rupture occurs into the esophagus in 10% of the cases and constitutes the most common cause of aorta-esophageal fistula. A reasonable literature review has not revealed a previously successful treatment for this condition. Experience in the treatment of patients with aneurysms of the descending thoracic aorta partially obstructing the esophagus without fistula formation indicates that simple graft replacement is curative. When the disease has progressed to actual fistula formation and esophageal bleeding, as illustrated in these two case reports, operation is done to prevent exsanguination. Appropriate management involves control of hemorrhage and treatment of the chronic esophageal perforation. The former is accomplished by resection and graft replacement of the ruptured thoracic aneurysm. Alternatives in dealing with the chronic esophageal defect are planned, staged reconstruction in high-risk patients and immediate resection and intrathoracic esophagogastrostomy in selected patients.

Treatment of aneurysms of the aortic arch. A progress report.

Graft replacement therapy was employed in the treatment of 67 patients with aneurysms of the transverse aortic arch. Patients were divided into three groups according to the extent of the aneurysm, which determined method of treatment and results. Group I consisted of 37 patients with distal aneurysms treated by simple proximal and distal clamping and aortic reconstruction, with survival in 36. Similarly located lesions in three patients in Group II, in whom the aorta could not be clamped proximally, were treated by hypothermia and circulatory arrest without graft inclusion technique, with survival in one. In Group III, the 27 patients, three with recurrent lesions and 19 with extensive aneurysms including the entire aorta in four, were treated by hypothermia, brachiocephalic arterial clamping, graft inclusion, and direct brachiocephalic vessel reattachment. The distal aneurysmal disease was replaced in most cases by a staged operation including total aortic replacement in two patients. Of the 27 patients in this group, 26 survived both the arch and subsequent operations.

The behavior of jaundiced infants undergoing phototherapy.

Ten full-term jaundiced infants were examined with the Brazelton Scale before, during and following phototherapy. They were compared with 10 non-jaundiced control infants examined at the same post-partum ages. All infants were appropriate for gestational age and free of perinatal complications other than hyperbilirubinemia. Differences on the orienting items of the Brazelton examinations (primarily visual orienting) were found prior to the onset of phototherapy or separation, and persisted for the length of the study. The greatest over-all differences were noted during phototherapy and separation from the mother, at which times the treatment group had lower scores on four of the six orienting items. They also had lower scores on muscle tonus, pull-to-sit and cuddliness while undergoing phototherapy, and poorer scores on orienting items, self-quieting and tremulousness were also evident three days following treatment. It is suggested that the differences found in mother-infant interaction following separation for the management of minor medical problems may be related to changes in infant behaviour which are already evident prior to separation. In the cases of jaundiced infants requiring phototherapy, these changes appear to be related primarily to hyperbilirubinemia. The possibility of these effects being prolonged or confounded by phototherapy or separation cannot be discounted.

Progress in treatment of thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries.

This is a report of surgical treatment of thoracoabdominal aortic aneurysms and aneurysms of the abdominal aorta from which the visceral vessels arise during the 18 year period from April 5, 1960, to April 20, 1978. The extent of aneurysm is divided into five groups. Group I (10 patients) involved most of the thoracic and abdominal aorta down to celiac axis. Group II (22 patients) involved most of the thoracic and abdominal aorta distal to left subclavian artery. Group III (20 patients) were those with lesser involvement of the thoracic aorta and most of the abdominal aorta. Group IV (18 patients) with involvement of the entire abdominal aorta and Group V (12 patients) with involvement of lower abdominal aorta and renal arteries. Treatment in the majority of these cases was by graft inclusion technique with visceral vessel reattachment by direct suture of orifice to openings made in the graft. Intercostal and/or lumbar arteries were also reattached in some with the more extensive lesions. Aortic and renal artery occlusion times varied from 15 to 155 minutes. Paraplegia developed in five patients with the more extensive lesions but was reduced to one-third and made less severe by reattaching intercostal and lumbar arteries. Renal dysfunction was mild in four patients and severe in three patients after operation. All these were transient except one who died while recovering from renal failure. The latter cases were those difficult to reattach or were not initially successful and required reoperation. Of the 82 patients, 77 (94%) survived operation and long-term followup was obtained in 95% of cases, 23 performed over five years ago. Actuarial curves were constructed and compared to survival curves following simple infrarenal abdominal aortic resection. The survival rate both immediately and at six years, were the same.

Tendon healing: an experimental model in the dog.

Based upon the studies of the healing process in dogs in which profundus tendons were severed partially by a method in which the cut surfaces remained in contact and the area of division was in an undamaged area of the sheath, it was shown that healing of the tendon took place without evidence of vascular contribution from the sheath. Vascular loop patterns, similar to those seen in synovial lining of joints or on either side of the growth plate of growing bone, were found on the surface of the tendons in the area of mesotenon reflection, the osseotendinous junctions, where the vinculum joined the tendon, and in various areas of the tendon sheath. No other vessels were found. A theory for nutrition of the tendon is proposed analagous to that postulated for maintenance of cartilage, first with the formation of synovial fluid by the vascular loop system and then a diffusion phase dependent upon the repetitive loading and unloading of the tissue to force the fluid into the system of canaliculi in the tendon.