Equine “Idiopathic” and Infundibular Caries-Related Cheek Teeth Fractures: A Long-Term Study of 486 Fractured Teeth in 300 Horses

Background: Limited objective information is available on the prevalence of non-traumatic equine cheek teeth fractures, the signalment of affected horses, and the clinical features and treatment of these fractures. Objectives: This study aims to document patterns of idiopathic and infundibular caries-related cheek teeth fractures in a referral population and evaluate associations between fracture patterns and horse age, Triadan position of affected teeth, clinical signs, and deemed necessity for treatment. Study Design: A retrospective case review. Methods: The clinical records at Edinburgh University Veterinary School (2010–2018) were examined for the presence of non-traumatic equine cheek teeth fractures. Variations in the frequencies of different fracture patterns were compared between horse ages, Triadan tooth positions, clinical signs, and deemed necessity for treatment. Results: Records of 300 horses with 486 non-traumatic cheek teeth fractures including 77% maxillary and 23% mandibular teeth with a mean of 1.6 (range 1–10) fractured teeth/horse were available. Fracture patterns included maxillary first and second pulp horn (“slab”) cheek teeth fractures (n = 171), caries-related infundibular fractures (n = 88), other maxillary teeth fracture patterns (n = 92), mandibular first and second pulp horn (“slab”) fractures (n = 44), other mandibular fracture patterns (n = 62), and complete clinical crown loss (n = 29; including 23 maxillary and 6 mandibular teeth). The median age of affected horses ranged from 11 years with maxillary “slab” fractures to 15 years with infundibular caries-related fractures. Triadan 08–10s were the most commonly (86%) fractured maxillary teeth. The Triadan 08 and 09 positions were the most commonly (64%) fractured mandibular teeth. No clinical signs were noted in horses with 48% of the fractured teeth; oral pain/quidding was recorded with 26%, clinical apical infection with 23%, and bitting/headshaking problems with 6%. Treatments included extraction of 40% fractured teeth, extraction of small/loose fragments (10%), and odontoplasty. Stable remnants of 60% of fractured teeth were left in horses without clinical signs. Main Limitations: Long-term follow-up information was not available for all cases. Conclusions: There is increasing recognition of equine non-traumatic cheek teeth fractures, with about half not causing clinical signs. Teeth with apical infection, multiple fractures, or advanced caries require extraction. Other fractured teeth with subclinical endodontic disease may not need exodontia unless they later cause clinical signs

Computed tomographic assessment of individual paranasal sinus compartment and nasal conchal bulla involvement in 300 cases of equine sinonasal disease

Background: Computed tomographic (CT) imaging has allowed new anatomical studies and detailed clinical imaging of the complex, overlapping equine sinonasal structures. Despite the widespread use of CT, no study has specifically identified which compartments are most commonly affected with sinus disorders. CT has also shown the presence of intercurrent, ipsilateral nasal disorders, especially infection of the nasal conchal bullae (NCB) in many cases of sinus disease, but the frequency of intercurrent NCB infections has not been reported. Objectives: To identify which sinus compartments are most commonly affected in horses with clinical sinus disorders and to record the prevalence of NCB involvement in such cases. Study Design: Retrospective examination of CT images of horses with confirmed unilateral sinus disease. Methods: The CT images of 300 horses, from three different equine hospitals with clinically confirmed sinus disease [mainly dental (53%) and primary sinusitis (25.7%)] were retrospectively examined to determine which sinus compartments and NCBs were affected. Results: The rostral, more dependent sinus compartments were most commonly involved, i.e., the rostral maxillary sinus in 284/300 (94.7% affected) and the ventral conchal sinus (87% affected). The caudal maxillary sinus (65.3%), dorsal conchal sinus (52.7%), frontal sinus (26%), ethmoidal sinus (32%) and sphenopalatine sinus (28.7%) were less commonly affected. There was infection or destruction of the ipsilateral NCBs in 56% of horses with sinus disorders, including the ventral NCBs in 42.3%, dorsal NCBs in 29% and both NCBs in 18% of cases. Main Limitations: The horses with sinonasal disease that underwent head CT imaging include more problematic cases and horses of high value, rather than the general horse population. Conclusions: The more dependant (i.e., the RMS and VCS) sinus compartments are most commonly involved in sinus disorders, with the RMS involved in nearly every case. The more dorsally located sinuses (i.e., caudal group) are less commonly involved. Many horses with sinus disease also have disorders of their nasal conchal bullae and so the term sinonasal disease seems appropriate for these disorders

A COMPARISON OF COMPUTED TOMOGRAPHIC, RADIOGRAPHIC, GROSS AND HISTOLOGICAL, DENTAL AND ALVEOLAR FINDINGS IN 30 ABNORMAL CHEEK TEETH FROM EQUINE CADAVERS

BackgroundEquine cheek teeth disorders, especially pulpar/apical infections, can have very serious consequences due to the frequent extension of infection to the supporting bones and/or adjacent paranasal sinuses. Limited studies have assessed the accuracy of computed tomographic (CT) imaging in the diagnosis of these disorders, and no study has directly compared imaging and pathological findings of the alveoli of diseased equine cheek teeth.ObjectiveTo validate the accuracy of CT and radiographic imaging of cheek teeth disorders by comparing CT and radiographic imaging, gross and histological findings in abnormal cheek teeth and their alveoli extracted from equine cadaver heads.Study designEx vivo original study.MethodsFifty-four cadaver heads from horses with unknown histories that had died or been euthanized on humane grounds obtained from a rendering plant had radiography, CT imaging, and gross pathological examinations performed. Based on imaging and gross examination findings, 30 abnormal cheek teeth (26 maxillary and 4 mandibular) identified in 26 heads were extracted along with their dental alveoli where possible, and further CT imaging, gross, and histological examinations were performed. Eight maxillary cheek teeth (including four with attached alveolar bone) from these heads, that were normal on gross and CT examinations, were used as controls.ResultsGross pathological and histological examinations indicated that 28/30 teeth, including two supernumerary teeth, had pulpar/apical infection, including pulpar and apical changes. A further supernumerary and a dysplastic tooth were also identified. Abnormal calcified tissue architecture was present in all three supernumerary and in the dysplastic tooth. CT imaging strongly indicated the presence of pulpar/apical infection in 27 of the 28 (96.4%) pulpar/apically infected teeth, including the presence of intrapulpar gas (N = 19/28), apical clubbing (N = 20), periapical halo (N = 4), root lysis or fragmentation (N = 7), and periapical gas (N = 2). Also present were alveolar bone sclerosis (N = 20), alveolar bone thickening (N = 3), and lytic/erosive changes (N = 8). Radiographic abnormalities strongly indicative of pulpar/apical infection including periapical sclerosis (N = 8/28) and apical clubbing (N = 14/28) were found in 14/28 (50%) of apically infected teeth. Histological changes were present in alveolar bone of all 21 cases of apical infection where alveolus remained attached to the tooth and was marked in 16 cases, all which had CT alveolar changes. Histological changes included disruption of the normal trabecular pattern, increased osteoclastic activity, and the presence of islands of bone with a scalloped profile within the thickened attached periodontal ligament. No gross pathological or histological changes were present in the eight control teeth or their alveoli (N = 4).Main limitationsNo history or breed-related information was available on these cases.ConclusionThere was a 96.4% correlation between a CT diagnosis and confirmative pathological findings in 28 apically infected teeth confirming the accuracy of CT imaging in diagnosing equine pulpar/apical infections. There was also excellent correlation between CT and histological alveolar bone findings

Impact of Chlamydia trachomatis in the reproductive setting: British Fertility Society Guidelines for practice

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified

Rheumatoid arthritis - clinical aspects: 134. Predictors of Joint Damage in South Africans with Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) causes progressive joint damage and functional disability. Studies on factors affecting joint damage as clinical outcome are lacking in Africa. The aim of the present study was to identify predictors of joint damage in adult South Africans with established RA. Methods: A cross-sectional study of 100 black patients with RA of >5 years were assessed for joint damage using a validated clinical method, the RA articular damage (RAAD) score. Potential predictors of joint damage that were documented included socio-demographics, smoking, body mass index (BMI), disease duration, delay in disease modifying antirheumatic drug (DMARD) initiation, global disease activity as measured by the disease activity score (DAS28), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and autoantibody status. The predictive value of variables was assessed by univariate and stepwise multivariate regression analyses. A p value <0.05 was considered significant. Results: The mean (SD) age was 56 (9.8) years, disease duration 17.5 (8.5) years, educational level 7.5 (3.5) years and DMARD lag was 9 (8.8) years. Female to male ratio was 10:1. The mean (SD) DAS28 was 4.9 (1.5) and total RAAD score was 28.3 (12.8). The mean (SD) BMI was 27.2 kg/m2 (6.2) and 93% of patients were rheumatoid factor (RF) positive. More than 90% of patients received between 2 to 3 DMARDs. Significant univariate predictors of a poor RAAD score were increasing age (p = 0.001), lower education level (p = 0.019), longer disease duration (p < 0.001), longer DMARD lag (p = 0.014), lower BMI (p = 0.025), high RF titre (p < 0.001) and high ESR (p = 0.008). The multivariate regression analysis showed that the only independent significant predictors of a higher mean RAAD score were older age at disease onset (p = 0.04), disease duration (p < 0.001) and RF titre (p < 0.001). There was also a negative association between BMI and the mean total RAAD score (p = 0.049). Conclusions: Patients with longstanding established RA have more severe irreversible joint damage as measured by the clinical RAAD score, contrary to other studies in Africa. This is largely reflected by a delay in the initiation of early effective treatment. Independent of disease duration, older age at disease onset and a higher RF titre are strongly associated with more joint damage. The inverse association between BMI and articular damage in RA has been observed in several studies using radiographic damage scores. The mechanisms underlying this paradoxical association are still widely unknown but adipokines have recently been suggested to play a role. Disclosure statement: C.I. has received a research grant from the Connective Tissue Diseases Research Fund, University of the Witwatersrand. All other authors have declared no conflicts of interes

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme