'Nephrostomy-free' percutaneous nephrolithotomy: experience in a UK district general hospital.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. 'Tubeless' or 'nephrostomy-free' PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of 'nephrostomy-free' PCNLs compared to standard PCNL over a 4-year period. PATIENTS AND METHODS: Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive 'nephrostomy-free' PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications. RESULTS: 'Nephrostomy-free' PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted 'nephrostomy-free' PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the 'nephrostomy-free' group developed a delayed perirenal haematoma. CONCLUSIONS: 'Nephrostomy-free' percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.

Green tea flavan-3-ols and oligomeric proanthocyanidins inhibit the motility of infective larvae of Teladorsagia circumcincta and Trichostrongylus colubriformis in vitro.

The effects of a hot water infusion and an aqueous acetone extract of green tea (Camellia sinensis) on the motility of infective larvae of the sheep nematodes Teladorsagia circumcincta and Trichostrongylus colubriformis were investigated under in vitro conditions. The infusion and extract dose-dependently inactivated the infective larvae as assessed by the larval migration inhibition (LMI) assay. To determine the components responsible for the inhibitory activity, the hot water infusion and aqueous acetone extract of green tea were fractionated on Sephadex LH-20 and the green tea extract fractions (GTE-I-VIII) characterised by mass spectrometry. The larvae were exposed to increasing concentrations of these GTE fractions. Fractions containing epigallocatechin gallate (EGCG) and proanthocyanidin oligomers were most effective. GTE fractions were more effective against T. circumcincta than T. colubriformis larvae as assessed by the LMI assay.

Effect of flavan-3-ols on in vitro egg hatching, larval development and viability of infective larvae of Trichostrongylus colubriformis.

The effects of flavan-3-ols (the monomer units of condensed tannins (CT)) and their galloyl derivatives on the viability of eggs, the development of first stage (L1) larvae, and the viability of the infective larvae of Trichostrongylus colubriformis were investigated under in vitro conditions. Each of the flavan-3-ol gallates showed some inhibition of egg hatching at 100 microg/ml, and 100% inhibition at 1000 microg/ml, with epigallocatechin gallate being the most effective in the egg hatch (EH) assay. In contrast, none of the flavan-3-ols were able to completely inhibit egg hatching. The flavan-3-ols and galloyl derivatives dose-dependently inhibited the development of infective larvae as assessed by the larval development (LD) assay. A larval migration inhibition (LMI) assay was used to assess the effect of flavan-3-ols and their galloyl derivatives on the motility of the infective third-stage (L3) larvae of T. colubriformis. In general, the flavan-3-ol gallates were more effective than the flavan-3-ols at immobilising the infective larvae as evidenced by their ability to inhibit more (P<0.05-0.01) larvae from passing through the LMI sieves. At 500 microg/ml, epigallocatechin gallate inhibited significantly more (P<0.1) larvae from passing through the sieves than did catechin gallate, epicatechin gallate, or gallocatechin gallate. Comparisons were made between the flavan-3-ols and their galloyl derivatives with the in vitro effects of CT extracts from several forage legumes, which have exhibited effects on parasites in vivo. The forage legumes tested at 200-500 microg/ml reduced the proportion of eggs that hatch, with comparable results to those obtained using the flavan-3-ols. The activities may be influenced by the prodelphinidin: procyanidin (PD:PC) ratios: CT extracts from Lotus pendunculatus and sainfoin have PD:PC ratios of 70:30 and 77:23, respectively, whereas the less active CT extract from Lotus corniculatus has a PD:PC ratio of 27:73. The active CT extracts from forage legumes have epigallocatechin as the dominant flavan-3-ol extender unit, and epigallocatechin is the most active flavan-3-ol in both the EH and LD assays.

Effects of a histamine type 2 receptor antagonist, BMY-26539-01, on equine gastric acid secretion.

A dose-response study was undertaken of the effects of a newly developed histamine type 2 receptor antagonist, BMY-26539-01, on gastric acid secretion in 4 fasted horses. Doses of 0.1 mg/kg, 0.3 mg/kg, 0.5 mg/kg, or placebo were administered in a randomly assigned treatment sequence. Hydrogen ion concentration and pH were variable during baseline measurements in all 4 animals; however, following BMY-26539-01 administration, mean pH increased and hydrogen ion concentration decreased in a dose-related pattern. At the 0.3 mg/kg and 0.5 mg/kg dose levels, pH remained elevated for > 4 h and > 8 h, respectively. No adverse effects were observed. A significant level of 0.01 was used for all statistical methods.

Severe mitral regurgitation in horses: clinical, echocardiographic and pathological findings.

Forty-three horses with mitral regurgitation (MR) and congestive heart failure were examined, using M-mode, 2-dimensional real-time and Doppler echocardiography. There was no breed or sex predisposition when compared to the general hospital population. The mean +/- s.d. age of affected horses was 7.6 +/- 8.1 years. Horses with MR and congestive heart failure had significant increases in mean values for left ventricular chamber size, left atrial size and heart rate and significant decreases in interventricular septal and left ventricular free wall thickness. Significant increases in pulmonary artery diameter were detected compared to aortic diameter. Mean values for fractional shortening were not significantly different from normal. All horses had a Grade 3-6/6 holosystolic or pansystolic murmur with its point of maximal intensity in the mitral to aortic valve area. Atrial fibrillation was found at presentation in 24 horses with MR and congestive heart failure. One horse presented with atrial tachycardia and subsequently developed atrial fibrillation. Seven horses had ventricular premature contractions. Exercise intolerance (n = 34), respiratory signs (n = 31), and fever (n = 21) were the most common presenting signs. Thickening of the left atrioventricular valve leaflets, endocarditis, flail valve leaflets, rupture of a chorda tendineae, and mitral valve prolapse were detected echocardiographically. Doppler echocardiography confirmed the presence of a large systolic regurgitant jet in the left atrium in all horses in which it was used, and in many horses, concurrent tricuspid and pulmonary regurgitation was detected. All horses died or were subjected to euthanasia due to the severity of their MR and/or lack of response to therapy. Post mortem examinations were performed in 35 horses and confirmed the echocardiographic findings. The echocardiographic detection of a flail mitral valve leaflet was significantly associated with the detection of a ruptured chorda tendineae at post mortem examination. There was a significant association between echocardiographic detection of a dilated pulmonary artery and its presence at post mortem examination. M-mode, 2-dimensional real-time, and Doppler echocardiography should be used to accurately characterise the valvular abnormalities and assess the severity of mitral regurgitation. Pulmonary artery dilatation, an echocardiographic indication of severe pulmonary hypertension, should be considered a grave prognostic indicator and may indicate impending pulmonary artery rupture.

Evaluation of a rapid reagent strip test for blood glucose determination in diarrheic calves.

Sixty-three blood samples from 10 diarrheic calves were tested for glucose concentration by two methods. Plasma glucose concentration was measured by the conventional glucose-6-phosphate dehydrogenase method in the clinical laboratory, and the results compared to those obtained using a rapid reagent strip test for blood glucose concentration measurement. The rapid reagent strip test result could not be used to make an accurate prediction of the actual plasma glucose concentration as determined by the conventional method, due to the wide variability in actual plasma glucose concentrations corresponding to each rapid test result.

Tissue and serum concentrations of amikacin after intramuscular and intrauterine administration to mares in estrus.

Concentrations of amikacin in endometrial tissue and plasma were studied in mares in estrus after intrauterine infusion of 1.0 or 2.0 g once a day for 3 consecutive d, and after 9.7 or 14.5 mg/kg body weight (BW) had been injected intramuscularly once a day for 3 consecutive d to determine concentrations of amikacin sulfate in plasma and endometrial tissues, and whether parenteral administration provides any advantages over intramuscular infusion. No amikacin was detected in serum at the 1.0 g dose. At the infusion dose of 2.0 g once a day, very low levels of serum amikacin were detected at 1 and 4 h postinfusion on the 1st treatment day. Amikacin was found to penetrate the endometrium after intramuscular injection; however, the levels attained were not as high as those achieved following intrauterine infusion. Based on the tissue and serum concentrations of amikacin, an intrauterine infusion at a dose of 4.4 mg/kg BW/d would appear to be an appropriate therapeutic regimen for the treatment of gram-negative endometritis.

Evaluation of a commercial enzyme-linked immunosorbent assay for the diagnosis of paratuberculosis in dairy cattle.

The performance of a commercially available ELISA for detection of antibodies to Mycobacterium paratuberculosis was evaluated using sera from 1,146 cows. Samples were from uninfected cattle, infected subclinical cattle shedding low numbers of organism in feces, subclinical heavy shedders, clinical cases, and randomly selected cattle in a slaughterhouse survey for paratuberculosis. The overall sensitivity of the test, using the manufacturer's recommended cutoff was 45% +/- 4.8%, and the specificity was 99% +/- 0.9%. The ELISA result was significantly correlated with the number of colonies of M. paratuberculosis detected by fecal culturing. The sensitivity of the test was highest for clinical cases of paratuberculosis (87% +/- 8.4%), and lowest for subclinical, light-shedding cattle (15% +/- 6.6%). Changing the cutoff point did not improve performance of the test. Evaluating ELISA results with a kinetic-based method reduced plate-to-plate variation in results but did not improve performance of the test based on receiver-operating characteristic curve analysis.

Treatment of atrial fibrillation in horses: new perspectives.

Forty-one horses were treated for atrial fibrillation (AF) with 22 mg/kg quinidine sulfate via nasogastric tube every 2 hours until conversion to sinus rhythm, a cumulative dose of 88 to 132 mg/kg had been administered in 2-hour increments, or the horse had adverse or toxic effects from the drug. Treatment intervals were prolonged to every 6 hours if conversion had not occurred. Digoxin was administered before treatment if the horse had a fractional shortening < or = 27% (3 horses), was prone to tachycardia (resting heart rate > or = 60 beats/min) (1 horse), or had a previous history of sustained tachycardia of over 100 beats/min during prior conversion (3 horses). Digoxin was administered during day 1 of quinidine sulfate treatment if the horse developed a sustained tachycardia of over 100 beats/min during treatment (11 horses) or on day 2 if conversion had not occurred (7 horses). Plasma quinidine concentrations within 1 hour of conversion of AF to sinus rhythm ranged from 1.7 to 7.5 micrograms/mL (mean, 4.05 +/- 1.6) and ranged from 1.7 to 4.7 micrograms/mL in 97% of horses. Most horses (92%) with plasma quinidine concentrations > 5 micrograms/mL exhibited an adverse or toxic effect of quinidine sulfate (clinical or electrocardiographic). There was no statistical association between plasma quinidine concentrations and sustained tachycardia (> 100 beats/min), diarrhea, or colic. Ataxia and upper respiratory tract stridor were significantly associated with plasma quinidine concentrations. In most instances (98%) conversion did not occur while toxic or adverse effects of quinidine sulfate were present or when plasma quinidine concentrations were > 5 micrograms/mL.

Concordance of ultrasonographic and physical findings in cattle with an umbilical mass or suspected to have infection of the umbilical cord remnants: 32 cases (1987-1989).

Medical records of 32 cattle treated for umbilical abnormalities that had undergone ultrasonographic examination of the umbilicus followed by umbilical resection or postmortem examination were reviewed. Thirty of the cattle were between 6 and 240 days old (mean, 73 days); the remaining 2 cattle were a 3-year-old bull and a 5-year-old cow. Thirty (94%) animals had external evidence of infection associated with the umbilicus. Two calves did not have external signs of infection; 1 had an abscess of the urachus and the other was found to be normal. Two-dimensional real-time ultrasonography was used to identify abnormal umbilical cord remnants. Ultrasonographic results were most reliable for the urachus, and the urachus was the most commonly affected internal umbilical cord remnant. Statistical agreement between ultrasonographic and physical (surgical or postmortem) findings was good to excellent for all umbilical structures. Intra-abdominal adhesions were found at surgery in 47% of animals with umbilical abnormalities; however, adhesions were not detected ultrasonographically.

Colour flow mapping in the diagnosis of the calf deep vein thrombosis.

This prospective trial was organized to evaluate further the role of colour flow Doppler ultrasound techniques in the diagnosis of deep vein thrombosis (DVT) with particular reference to the isolated calf lesion. In 100 patients ultrasound was compared against the recognized gold standard of ascending venography. Fifty venograms were positive for DVT compared with 49 on ultrasound, a sensitivity of 98%. The specificity of ultrasound for DVT in the 50 patients without DVT on venography was 100%. Forty-five venograms demonstrated calf thrombus with varying proximal extent. Sixteen proved to be isolated calf lesions and these were all identified by ultrasound (100% sensitivity and specificity respectively for isolated calf DVT). In five of these isolated calf thrombus cases, results suggested that ultrasound better diagnosed the presence of thrombus. Ultrasound diagnosed significant pathology in 13 of the normal venogram patients giving an overall diagnostic yield of 62% as compared to 50% at venography.

Metabolic response of horses to a high soluble carbohydrate diet: effects of low-intensity submaximal exercise and sodium bicarbonate supplementation.

Four mares fed a low fiber, high soluble carbohydrate diet were used in a crossover design to evaluate the effects of dietary sodium bicarbonate (NaHCO3) supplementation during daily low-intensity submaximal working conditions. Mares were fed the diet at 1.7 times the maintenance energy requirement for mature horses at work. The horses tolerated the diet well and had no clinical abnormalities. Resting venous blood bicarbonate (HCO3), standard HCO3, and base excess (BE) concentrations significantly (P less than 0.05) increased with NaHCO3 supplementation, but no significant changes in resting venous blood pH or carbon dioxide tension (PCO2) were recorded. Venous blood HCO3, standard HCO3, BE, hemoglobin, and heart rate were significantly (P less than 0.05) increased and plasma lactate concentration was significantly (P less than 0.05) decreased in the control horses and in the horses given the NaHCO3 supplement during low-intensity submaximal exercise. There were no significant changes in venous blood pH, PCO2, or plasma protein concentration with exercise. Venous blood HCO3, standard HCO3, and BE concentrations were significantly (P less than 0.05) greater during submaximal exercise in horses given the NaHCO3 supplement. There were no significant differences in plasma lactate or total protein concentrations, blood pH, PCO2, or hemoglobin concentration between the 2 groups during exercise.

Ultrasonographic evaluation of horses with thrombophlebitis of the jugular vein: 46 cases (1985-1988).

Medical records of 46 horses with jugular vein thrombophlebitis that were evaluated ultrasonographically were reviewed. The ultrasonographic appearance of the thrombus within the jugular vein was classified as noncavitating if it had uniform low to medium amplitude echoes, or as cavitating if it was heterogenous with anechoic to hypoechoic areas representing fluid or necrotic areas within the thrombus, and/or hyperechoic areas representing gas. Signs of pain on palpation of the affected vein (P less than 0.001), heat over the vein (P = 0.001), and swelling of the vein (P less than 0.05) were significantly associated with the ultrasonographic detection of a cavitating lesion. Ultrasonography also was useful for selecting a site for aspiration of a specimen for bacteriologic culturing and susceptibility testing.

Relative incidence of dorsal metacarpal disease in young Thoroughbred racehorses training on two different surfaces.

The relative incidence of dorsal metacarpal disease was examined in two groups of Thoroughbred racehorses training on dissimilar surfaces (dirt and wood fibre). The horses and training methods appeared to be similar. The incidence of disease was significantly greater in the group training on dirt. There was no significant difference in the age distribution of incidence between the two groups and there was no association of incidence with sex or age within the training group. The number of fast miles worked by the two groups prior to the onset of dorsal metacarpal disease was lower in the group training on dirt.

Relations among synovial membrane histopathologic findings, synovial fluid cytologic findings, and bacterial culture results in horses with suspected infectious arthritis: 64 cases (1979-1987).

A retrospective evaluation of 64 cases of suspected infectious arthritis in horses was undertaken to determine the relations among histopathologic findings in synovial membrane specimens, cytologic findings in synovial fluid samples, and bacterial culture results. Positive cultures were obtained from 55% of the joints, and 18 different bacterial organisms were cultured. Culturing of synovial fluid yielded bacterial growth more often than did culturing of synovial membrane. Histologic evaluation (H&E and Gram stain) of synovial membrane specimens provided little information to help distinguish infected from culture-negative joints. We do not advocate the routine use of closed synovial biopsy in suspected cases of equine septic arthritis.

Evaluation of age, breed, and gender as risk factors for umbilical hernia in horses of a hospital population.

Age, breed, and gender distributions of 168 horses with umbilical hernia treated at the University of Pennsylvania School of Veterinary Medicine were analyzed to determine risk factors for this disease. For the 3 breeds that constituted the largest proportion of hospital and case populations, Thoroughbred, Standardbred, and Quarter Horse, the overall ratio of females to males was 1.63. In a hospital population of the same age group, 0 to 48 months, the female to male ratio was 0.93. Compared with males, females were at significantly higher risk for umbilical hernia after adjustment for breed and age (odds ratio, 2.01; 99% confidence interval, 1.31 to 3.10; P = 0.00002). Of the 2 major breeds, Thoroughbreds were at greater risk than Standardbreds for umbilical hernia, after adjustment for gender and age (odds ratio, 1.80; 99% confidence interval, 1.10 to 2.95; P = 0.0020). The results provide information about a common congenital defect in horses that can be used for future genetic research.

Effects of a histamine type-2 receptor antagonist (BMY-25368) on gastric secretion in horses.

The effects of a potent new histamine-2 (H2) receptor antagonist, BMY-25368, were studied on gastric acid secretion in 5 foals from which food was withheld. Doses of 0.02, 0.11, 0.22, and 1.10 mg/kg of body weight were administered IM in a randomly assigned treatment sequence. Following BMY-25368 administration, hydrogen ion concentration was decreased and mean pH was higher than baseline values in a dose-response pattern. At the 0.22 and 1.10 mg/kg doses, the high pH was sustained for greater than 4 hours. The BMY-25368 thus may be useful for treating gastric ulcer disease in horses.

Effects of furosemide on the racing times of Thoroughbreds.

The effects of furosemide on the racing times of 79 horses without exercise-induced pulmonary hemorrhage (EIPH) and 52 horses with EIPH were investigated. Racing times were adjusted to 1-mile equivalent racing times by 2 speed handicapping methods, and analysis of covariance was used to adjust actual racing times by winning time and distance for each race. All 3 methods of determining racing time indicated that geldings without EIPH had significantly faster racing times (P less than 0.05) when given furosemide before racing than when furosemide was not given before racing. Females and colts without EIPH were determined to have faster racing times when furosemide was given before racing, but the difference was not significant. Geldings with EIPH had significantly faster racing times (P = 0.0231) when given furosemide before racing, as determined by one of the speed handicapping methods. There was a strong correlation (range 0.9314 to 0.9751) between the 1-mile equivalent racing times, as determined by the 2 speed handicapping methods for horses with and without EIPH. Furosemide failed to prevent the development of EIPH in many horses that were previously considered to be EIPH-negative. When given furosemide, 62 (25.3%) of 235 EIPH-negative horses were EIPH-positive after racing. Furosemide had questionable efficacy for prevention of EIPH in known EIPH-positive horses. Thirty-two (61.5%) of 52 EIPH-positive horses given furosemide before a race remained EIPH-positive after that race.

Clinical, ultrasonographic, and surgical findings in foals with umbilical remnant infections.

Infection of umbilical arteries, umbilical vein, and/or urachus was diagnosed ultrasonographically in 33 foals 1 to 90 days old (mean, 17.7 +/- 17.3 days). In these foals, the most common initial problems were umbilical abnormalities, septic arthritis, and/or neonatal septicemia. In 16 foals, abnormalities of the external umbilical stalk were noticed on admission. Abnormalities of the internal umbilical structures were identified when enlargement and echogenic material (fluid and/or gas) were imaged ultrasonographically within these structures. Multiple structures were affected in 23 foals, with the urachus the most commonly affected structure. Surgical findings confirmed ultrasonographic identification of infected umbilical structures in 23 foals. Twenty-two samples from affected umbilical remnants submitted for culture at surgery were positive for bacterial growth. Multiple organisms were isolated in 15 cultures. Escherichia coli and beta-hemolytic streptococci were the most common isolates. Two foals died of late complications associated with surgical resection, 1 foal treated surgically and 3 foals treated medically died or were euthanatized because of other complications, and the remaining 27 foals lived.