Misoprostol is superior to combined omeprazole-sucralfate for the treatment of equine gastric glandular disease.

BACKGROUND: Previous studies have demonstrated a poor response to healing of gastric glandular lesions with oral omeprazole and other medications. OBJECTIVES: To evaluate the efficacy of two novel treatments (misoprostol [M] and combined omeprazole-sucralfate [OS]) in horses for gastric glandular disease. STUDY DESIGN: Prospective, clinical study. METHODS: Sixty-three sports horses with grade >1/4 glandular disease were identified by gastroscopy. Horses received either 5 µg/kg of misoprostol per os BID 1 h prior to feeding or a combination of 4 mg/kg enteric coated omeprazole per os SID and 12 mg/kg sucralfate per os BID where drugs were given 1 h prior to feeding and sucralfate given 60 min after omeprazole; allocation was dependent upon centre. Gastroscopy was repeated at 28-35 days. Evaluators of the gastroscopy images were blinded to the treatments the horses received and images were reviewed independently. RESULTS: The most common presenting sign in both treatment groups was poor performance (Overall - 65.1%; M - 60.5% and OS - 75%). Overall healing (P<0.001; OR = 11 [2.8-45]) and improvement (P = 0.006; OR = 11 [1.9-59]) of lesions were associated with resolution of clinical signs. Misoprostol was shown to be superior to combined omeprazole-sucralfate both for healing (M - 72% [95% CI 43-67] and OS - 20% [95% CI 7-41]; P<0.001) and improvement (M - 98% [95% CI 90-100] and OS - 65% [95% CI 43-83]; P<0.001). MAIN LIMITATIONS: Relatively small, clinical study, reliance on client questionnaire data, clients not blinded to the treatments the horse received, diet could have affected drug pharmacodynamics although mimics clinical practice and no validated scoring system available for glandular lesions. CONCLUSIONS: These results suggest that gastric glandular disease does indeed result in clinical signs. In this population of horses, misoprostol was superior to omeprazole and sucralfate and warrants further evaluation in a large scale, multi-centre trial.

Intrastromal corneal ring segments for low myopia: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes intrastromal corneal ring segments (Intacs) inserts technology and examines the evidence to answer the key question about whether the treatment is safe and effective in correcting low myopia. METHODS: A literature search that was conducted in September 2000 retrieved 13 relevant citations, and the reference lists of these articles were consulted for additional citations. Panel members reviewed this information and articles were rated according to the strength of evidence. RESULTS: Prospective multicenter phase II and III clinical trials (Level II evidence rating) of Intacs inserts for myopia of -1.00 to -3.00 diopters (D), with a maximum of +1.00 D of astigmatism, enrolled a total of 452 subjects, with a total of 454 surgical attempts. The results from phase II and phase III were pooled for much of the analysis. At 1 year, 97% of patients who completed follow-up had 20/40 or better uncorrected visual acuity (UCVA). Seventy-four percent of patients had 20/20 or better UCVA. Ninety-two percent of eyes were within +/-1 D of intended refractive correction, and 69% were within 0.5 D of intended refractive correction. At 3 months, 90% of patients had less than 1.0 D of change from the previous examination performed at 1 month. The ocular complication rate, which was defined as clinically significant events but not resulting in permanent sequelae, was 11% at 12 months. The adverse event rate was 1.1%, defined as a serious event if untreated. Nearly 9% of patients requested to have their inserts removed and a total of 3.8% of patients required a secondary surgical intervention. CONCLUSIONS: To date, evidence suggests that low myopia (-1 to -3 D) in a well-defined group of patients who have a stable manifest refraction and less than +1.0 D of astigmatism can be treated with Intacs inserts with a reasonable assurance of safety and effectiveness. Additional clinical research is needed to determine the long-term effectiveness of treatment and the comparative safety, effectiveness, and costs with other treatment modalities, including laser-assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK).

Estimating the relative roles of top-down and bottom-up forces on insect herbivore populations: a classic study revisited.

Although most ecologists agree that both top-down and bottom-up forces (predation and resource limitation, respectively) act in concert to influence populations of herbivores, it has proven difficult to estimate the relative contributions of such forces in terrestrial systems. Using a combination of time-series analysis of population counts recorded over 16 years and experimental data, we present the first estimates of the relative roles of top-down and bottom-up forces on the population dynamics of two terrestrial insect herbivores on the English oak (Quercus robur). Data suggest that temporal variation in winter moth, Operophtera brumata, density is dominated by time-lagged effects of pupal predators. By comparison, spatial variation in O. brumata density is dominated by host-plant quality. Overall, top-down forces explain 34.2% of population variance, bottom-up forces explain 17.2% of population variance, and 48.6% remains unexplained. In contrast, populations of the green oak tortrix, Tortrix viridana, appear dominated by bottom-up forces. Resource limitation, expressed as intraspecific competition among larvae for oak leaves, explains 29.4% of population variance. Host quality effects explain an additional 5.7% of population variance. We detected no major top-down effects on T. viridana populations. An unknown factor causing a linear decline in T. viridana populations over the 16-year study period accounts for most of the remaining unexplained variance. We discuss the observed differences between the insect species and the utility of time-series analysis as a tool in assessing the relative importance of top-down and bottom-up forces on herbivore populations.

Conservative management of wrist ganglia. Aspiration versus steroid infiltration.

Wrist ganglia were randomly allocated for conservative treatment by either aspiration or aspiration and injection of steroid. Both treatment methods had 33% success rates. Almost all ganglia which recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only a quarter of patients requested surgical treatment.

Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients.

We report on a prospective randomized trial on the effect of wound drains on wound healing following surgery for proximal femoral fractures. One hundred and seventy-seven consecutive patients admitted to Queen's Medical Centre Nottingham, undergoing AO dynamic hip screw (DHS) or hemiarthroplasty were randomized whether or not to receive wound drainage. Wound healing was assessed in terms of ultrasound examination, the ASEPSIS wound score system and overt infection rates. All patients were followed up at 6 weeks and 6 months. Ultrasound examinations showed that drains were indeed ineffective in preventing haematoma formation, the first time this has been demonstrated objectively. However, using drains failed to prevent late seroma formation. Patients who received wound drainage showed statistically better wound healing on the ASEPSIS wound scoring system and a reduced infection rate. The ASEPSIS scores on day 2 and 5 postoperatively proved an accurate predictor of poor wound healing. This study conflicts with previous smaller studies which failed to show an effect of wound drainage upon wound healing, and strongly supports the use of wound drains.

The Seidel locking humeral nail: the Nottingham experience.

The experience of one institution in the use of the Seidel locking intramedullary nail in 23 patients with humeral shaft fractures is reported. The device was used only for cases involving failure of previous treatment, pathological fractures or multiple injuries. Acceptable results were achieved in patients with pathological fractures, but the results in other patients were disappointing with unacceptably high complication rates and poor postoperative shoulder function.

Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients.

We report on the effect of wound drains on wound healing following surgery for proximal femoral fractures. One hundred and seventy-seven patients undergoing AO dynamic hip screw (DHS) or hemiarthroplasty were randomized whether or not to receive wound drainage. Patients who received wound drainage showed statistically better wound healing in terms of the ASEPSIS wound scoring system and a reduced infection rate. This study conflicts with previous smaller studies which failed to show an effect of wound drainage upon wound healing.

Excision of the trapezium for osteoarthritis at the base of the thumb.

We have assessed the results of 34 simple excisions of the trapezium, with no additional soft-tissue procedures, in 30 patients. At a median follow-up of five years (2 to 22), 16 thumbs (47%) were completely painfree and a further 10 (29%) were slightly painful after use. Nineteen thumbs (56%) had no functional disability, but thumb-pinch strength was reduced by about 20%. No patient had painful degeneration at the scaphotrapezial pseudarthrosis.

Ultrasound assessment of the efficacy of wound drains.

We report the use of ultrasound in the assessment of the efficacy of wound drains in preventing wound haematoma. 171 patients with proximal femoral fractures who underwent AO dynamic hip screw or hemiarthroplasty were randomized as to whether or not they should receive wound drainage. Patients then underwent ultrasound examination on the 5th postoperative day to localize and quantify any wound haematomas. Results show that drains are effective in preventing wound collections, but only while in situ; following the removal of drains the size of resulting wound collections is the same whether the wound has been drained or not (Student's t-test; t = 0.19, NS). This study questions current theories on the mechanisms by which wound drainage is thought to influence wound healing.

Injury patterns in motorcycle road racers: experience on the Isle of Man 1989-1991.

We report the first prospective study on the incidence of motorcycle accidents of the world's foremost motorcycle road-racing venue, the Isle of Man. Between 1989 and 1991 there were six meetings during which over 2500 riders took part. Racing on essentially normal country and town roads, the motorcycles can reach speeds in excess of 306 km/h and the average lap record is now 198 km/h. During the study, 175 motorcyclists were injured and 16 were killed (9.1 per cent). The most common injury patterns were soft tissue injury (114 riders), head injury (52) and fractures/dislocations (188), of which one-third were open. The injuries sustained were more frequent and of a greater severity than recreational motorcycling. The casualty rate was 15 times, and the fatality rate 87 times the national figures. Of the 16 fatalities only seven reached hospital alive, despite the use of helicopter air ambulance, and 14 had serious head injuries. No fatality was thought to have been avoidable on review. There were no cervical spine injuries and only two major abdominal injuries. Of the injured riders, 93 (56 per cent) were admitted and there were 170 surgical procedures undertaken on 54 riders.

Helicopter transfer of trauma patients: the Isle of Man experience.

A 10-year study of the helicopter transfer of motorcyclists injured during the International Motorcycle Tourist Trophy races (TT) and the amateur Manx Grand Prix (MGP) is reported. A total of 266 riders was transferred from the scene of the accident to hospital by air. The overall mortality rate for those riders airlifted was 3.38 per cent. The figures are compared with similar emergency helicopter services.

Trauma on the Isle of Man.

The Isle of Man Tourist Trophy motorcycle races remain one of the most popular venues for motorcycle races. This is despite the reduced status of the event. The reason for the loss of world championship and formula one status is the nature of the road racing circuit itself. The twisting narrow roads are only closed to the public at certain times during the practice and race weeks. Motorcycling visitors to the event attempt to emulate their heroes on machines capable of high speeds. Casualties from both visitors and racers are dealt with efficiently by an expanded medical service. This includes the use of an aeromedical evacuation helicopter. Casualties from the visitors exceeded those from the racers themselves during the period reported.

Bacterial endophthalmitis following cataract surgery in an eye with a preexisting Molteno implant.

We describe a patient with a preexisting, functioning Molteno implant in whom acute endophthalmitis developed following cataract extraction. The condition was treated successfully without removing the implant.

Conjunctival involvement in paraneoplastic pemphigus.

Paraneoplastic pemphigus is a recently described autoimmune inflammatory mucocutaneous disease associated with an underlying neoplasm. Although histopathologic and direct immunofluorescence findings of involved skin and mucous membranes are consistent with pemphigus vulgaris, indirect immunofluorescence and immunoprecipitation study results are unique. We treated two patients with non-Hodgkin's lymphoma and paraneoplastic pemphigus. Both patients had bilateral bulbar conjunctival hyperemia and diffuse papillary tarsal conjunctival reactions. One patient had sloughing of conjunctival epithelium and the other had tarsal conjunctival cicatrization and forniceal shortening. Histopathologic findings of conjunctivae obtained from both patients were consistent with pemphigus vulgaris. Diffuse deposition of IgG and C3 in the intercellular substance of the conjunctival epithelium was demonstrated by direct immunofluorescence. Indirect immunofluorescence testing disclosed binding of autoantibodies to rodent bladder and intestinal epithelium. Immunoprecipitation disclosed antibodies reactive to Desmoplakin I (250 kd), bullous pemphigoid (230 kd), Desmoplakin II (210 kd) and 190-kd proteins. Ophthalmologists and pathologists should be aware of the conjunctival changes in paraneoplastic pemphigus.

Secretory reflexes in ileum and jejunum: absence of remote effects.

We have tested the hypothesis that luminal secretagogues initiate neural reflexes that alter ion transport in small intestinal segments proximal or distal to the site of the secretory stimulus. Effects of secretagogues that act by different mechanisms were studied in vitro by measuring short circuit current (ISC) of ileum or jejunum mounted in a unique flux chamber while proximal mucosa in neural continuity with the tissue was perfused with secretagogues (Na deoxycholate. Escherichia coli STa, 5-hydroxytryptamine, theophylline) or was stimulated electrically (EFS). No proximal stimulus affected distal ISC. We also studied in vivo adjacent segments of ileum or jejunum in neural continuity but with unconnected lumens. In anesthetized rabbits, we measured transmural electrical potential difference and fluid movement (Phenol red marker). Stimulation of proximal segments of ileum or jejunum with STa, or of ileum with 5-HT or Na deoxycholate did not affect distal transport. Stimulation of distal segments of ileum and jejunum with STa or 5-HT, or of jejunum with Ha deoxycholate did not affect proximal transport. We conclude that the secretion caused by luminal secretagogues in the rabbit small intestine is limited to the area of stimulation.

Complications of penetrating keratoplasty: graft infections.

Microbial infection of a corneal transplant is a complication that is a bane to all corneal surgeons, the sequelae of which can be devastating. Identified risk factors include exposed, loose, or broken sutures; persistent epithelial defects or severe punctate keratopathy; soft contact lens wear including therapeutic lenses; graft hypoesthesia; kerato-conjunctivitis sicca; previous herpetic eye disease; graft failure; ocular adnexa and lid abnormalities; and ongoing external and corneal infections. Management includes preventive measures, microbiologic diagnostic procedures, and antibiotic therapy. Infectious crystalline keratopathy is a unique corneal infection that predominantly occurs in corneal transplants. It is characterized by the slowly progressive development of needle-like opacities in the corneal stroma and is most commonly caused by streptococcal species. Another group of infections that occur in grafts is recurrence of an infectious process for which the patient was originally grafted. Two notable pathogens in this group include Acanthamoeba and herpes simplex.

Hibiclens keratopathy. A clinicopathologic case report.

A 39-year-old woman developed a painful, red eye immediately following oral surgery associated with preoperative preparation of her face with the antiseptic, Hibiclens. Epithelial and stromal edema was observed 2 weeks after surgery and progressed to diffuse bullous keratopathy. This led to penetrating keratoplasty 10 months later. Light and electron microscopic findings of the cornea included epithelial edema with bullous changes, marked loss of keratocytes, a thickened Descemet's membrane, and an attenuated, disrupted endothelial cell layer. These findings demonstrate the corneal damage that may occur following ocular exposure to Hibiclens.

The results of penetrating keratoplasty for pellucid marginal corneal degeneration.

Over a 14-year period from 1974 to 1988, 12 eyes of 11 patients with pellucid marginal corneal degeneration underwent penetrating keratoplasty. Peripheral corneal thinning required a large eccentric graft in each case. Follow-up ranged from one to eight years (mean, three years). One graft failed because of a persistent epithelial defect with keratolysis of the wound. Although endothelial allograft rejection was common, occurring in seven of 11 (64%) clear grafts, no graft failed because of rejection. Other complications included retinal detachment and a bacterial corneal ulcer. Suture erosion and vascularization of the graft were not problems. Postoperative spectacle correction was dispensed an average of 11 months after surgery. Visual acuity in seven patients without amblyopia, retinal disease, or a previous corneal ulcer at the time of spectacle correction ranged from 20/20 to 20/40 (mean, 20/30). Average final keratometric astigmatism in these patients was 2.46 diopters (range, 0.00 to 5.25 diopters). We believe that penetrating keratoplasty offers an excellent surgical result for patients with pellucid marginal corneal degeneration.

Development of keratoconus after contact lens wear. Patient characteristics.

A retrospective review of 398 eyes of 199 patients with keratoconus revealed 106 eyes of 53 patients with an association between contact lens wear and the development of keratoconus. The absence of keratoconus at the time of contact lens fitting was confirmed by slit-lamp examination, keratometry readings, and manifest refraction. Keratoconus was diagnosed after a mean of 12.2 years of contact lens wear. This group was compared with patients with sporadic keratoconus with either no history of contact lens wear or a history of contact lens wear after the diagnosis. They were older at the time of diagnosis, had central vs decentered cones, and had a tendency toward flatter corneal curvatures. We believe that these patients suggest that long-term contact lens wear is a factor that can lead to keratoconus.

Noradrenergic influence on epithelial responses of rabbit ileum to secretagogues.

Norepinephrine is one of three neurotransmitters that may act directly on enterocytes to enhance absorption; its interaction with secretagogues is of physiological importance. We have studied the influence of norepinephrine on the short-circuit current (Isc) responses to acetylcholine (ACh; 10 microM), vasoactive intestinal polypeptide (VIP; 100 pM-10 nM), peptide histidine isoleucine (PHI; 100 pM-10 nM), histamine (0.1 mM), and to electrical field stimulation (EFS) of rabbit ileum mounted in flux chambers. Tetrodotoxin reduced the response to norepinephrine (10 microM) by 40% and to histamine by 32% but did not affect responses to VIP or PHI. Norepinephrine decreased the ACh response (EC50, 70 nM) and reduced the responses to PHI (less than or equal to 87%), to EFS (less than or equal to 75%), and to histamine (less than or equal to 42%). Norepinephrine decreased the response to VIP (500 pM) but not to higher or lower VIP concentrations. It enhanced the response to VIP (10 nM) and to theophylline (5 mM). We conclude that 1) norepinephrine increases absorption by acting on nerves and enterocytes; 2) the failure of norepinephrine to reduce the Isc response to VIP when the VIP-induced increment in Isc is comparable to that caused by EFS is evidence that VIP does not mediate the EFS response; 3) PHI might mediate the EFS response; and 4) VIP, PHI, and histamine affect enterocytes directly; histamine also affects intrinsic nerves.