Publications by authors named "Jeremiah T Easley"

33 Publications

Diagnostic prediction of ovine fracture healing outcomes via a novel multi-location direct electromagnetic coupling antenna.

Ann Transl Med 2021 Aug;9(15):1223

Orthopaedic Bioengineering Research Laboratory, Departments of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, CO, USA.

Background: Expedient prediction of adverse bone fracture healing (delayed- or non-union) is necessary to advise secondary treatments for improving healing outcome to minimize patient suffering. Radiographic imaging, the current standard diagnostic, remains largely ineffective at predicting nonunions during the early stages of fracture healing resulting in mean nonunion diagnosis times exceeding six months. Thus, there remains a clinical deficit necessitating improved diagnostic techniques. It was hypothesized that adverse fracture healing expresses impaired biological progression at the fracture site, thus resulting in reduced temporal progression of fracture site stiffness which may be quantified prior to the appearance of radiographic indicators of fracture healing (i.e., calcified tissue).

Methods: A novel multi-location direct electromagnetic coupling antenna was developed to diagnose relative changes in the stiffness of fractures treated by metallic orthopaedic hardware. The efficacy of this diagnostic was evaluated during fracture healing simulated by progressive destabilization of cadaveric ovine metatarsals treated by locking plate fixation (n=8). An ovine comparative fracture study (n=8) was then utilized to better characterize the performance of the developed diagnostic in a clinically translatable setting. In vivo measurements using the developed diagnostic were compared to weekly radiographic images and postmortem biomechanical, histological, and micro computed tomography analyses.

Results: For all cadaveric samples, the novel direct electromagnetic coupling antenna displayed significant differences at the fracture site (P<0.05) when measuring a fully fractured sample versus partially intact and fully intact fracture states. In subsequent fracture models, this technology detected significant differences (P<0.001) in fractures trending towards delayed healing during the first 30 days post-fracture.

Conclusions: This technology, relative to traditional X-ray imaging, exhibits potential to greatly expedite clinical diagnosis of fracture nonunion, thus warranting additional technological development.
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http://dx.doi.org/10.21037/atm-21-1853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8421979PMC
August 2021

Outcomes following single, caudally based bilateral versus unilateral frontonasal sinusotomy for treatment of equine paranasal sinus disease.

Vet Med Sci 2021 Aug 17. Epub 2021 Aug 17.

Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Veterinary Teaching Hospital, Translational Medicine Institute, Colorado State University, Fort Collins, Colorado, USA.

Background: Bilateral sinus disease is relatively uncommon in horses, accounting for 3%-4.5% of horses with sinonasal disease, but may require bilateral paranasal surgery for complete resolution. Complications and recurrence following bilateral sinusotomy have not been reported or compared to those following unilateral procedures.

Objective: To describe clinical features and outcomes in horses undergoing standing single, caudally based bilateral frontonasal sinusotomy compared to unilateral frontonasal surgery.

Methods: Records of horses (n = 37) undergoing surgical treatment for sinus disease (five bilateral, 32 unilateral) were retrospectively reviewed (2010-2017) for signalment, presenting complaint, duration of signs preoperatively, diagnostic imaging, treatments administered, duration hospitalization, complications, and owner satisfaction with the procedure. Mann-Whitney testing was used to compare age, duration of hospitalization, and follow-up time in horses undergoing unilateral or bilateral procedures. Fisher's exact testing was used to determine if sex predilection was present for unilateral or bilateral disease. Survival time and time to recurrence were compared by Kaplan-Meier survival curves and log-rank curve comparison testing. Significance was assessed at p < 0.05.

Results: Length of signs prior to admission did not differ between horses with unilateral and bilateral disease (p = 0.09), but there was a tendency for horses with bilateral disease to have clinical signs for longer. Age (p = 0.19) and hospitalization duration (p = 0.53) did not differ between horses undergoing unilateral versus bilateral procedures. Recurrence or failure to resolve signs was reported in 11/32 (34%) of unilateral and 0/5 bilateral cases (p = 0.07).

Conclusions: The bilateral single, caudally based sinusotomy approach may be considered to effectively treat bilateral paranasal sinus disease without concern for increased risk of life-threatening complications or longer hospitalization duration than would be typical for unilateral sinusotomy procedures.
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http://dx.doi.org/10.1002/vms3.607DOI Listing
August 2021

Outcomes after cervical vertebral interbody fusion using an interbody fusion device and polyaxial pedicle screw and rod construct in 10 horses (2015-2019).

Equine Vet J 2021 Apr 12. Epub 2021 Apr 12.

Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA.

Background: Further development of surgical techniques for equine cervical stabilisation is necessary to make the procedure less technically demanding, reduce complications and improve outcomes.

Objective: To describe clinical outcomes and owner reports in horses undergoing placement of an interbody fusion device and polyaxial pedicle screw and rod construct for cervical vertebral fusion in horses with cervical vertebral compressive myelopathy.

Study Design: Retrospective case series.

Methods: Data were retrieved from medical records of 10 horses undergoing cervical vertebral fusion (2015-2019). Records were evaluated for signalment, duration of clinical signs, number and location of compression sites, grade of ataxia, duration of hospitalisation and complications. Long-term follow-up was obtained through clinical re-evaluation, postoperative radiographs and owner contact.

Results: Breeds were mixed. Median age was 24 (range 12-168) months. There were 2/10 mares, 4/10 geldings and 4/10 stallions. Preoperative grade of ataxia ranged from 1-3/5. Fusion was performed at one (n = 3) or two (n = 7) sites. Two horses were euthanised within the first year. In 6 of 8 horses with ≥1-year follow-up, ataxia improved by 1-3 grades, with an average improvement of 1.25 grades. In four horses, ataxia improved to grade 0-1. In two horses the gait was unaffected, but neck comfort improved. Complications included seroma formation (n = 9), pain (n = 5), fever (n = 4), upper respiratory tract obstruction (n = 2), azotemia (n = 2), screw breakage (n = 2), progression of neurological signs (n = 1), Horner's Syndrome (n = 1), dysphagia (n = 1), hives (n = 1), implant infection (n = 1) and nondisplaced fracture (n = 1).

Main Limitations: Small case series, heterogeneous patient population.

Conclusions: This technique resulted in ≥1 grade gait improvement in 6/10 cases operated and 6/8 cases for which ≥1-year follow-up was available, similar to other methods. Fatal complications related to implant placement did not occur. This technique may represent a safer alternative to current techniques of ventral interbody fusion with similar outcomes.
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http://dx.doi.org/10.1111/evj.13449DOI Listing
April 2021

Polyaxial pedicle screw external fixation to stabilize oblique mandibular fractures in three standing, sedated horses.

Vet Surg 2021 Apr 19;50(3):659-667. Epub 2021 Feb 19.

Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado.

Objective: To report the radiographic, surgical and postoperative features in horses with unstable oblique mandibular fractures secured with polyaxial pedicle screws (PPS) external fixation construct and intraoral wiring.

Animals: Three client-owned horses.

Study Design: Short case series.

Methods: Two horses each had a unilateral fracture, which did not improve after conservative management, and one horse had bilateral fractures. Clinical and radiographic features were documented. Polyaxial pedicle screw external fixators and intraoral tension band wiring were applied in standing horses after combining sedation and regional nerve anesthesia. Intraoral wires were implanted through a lateral buccotomy between teeth (two horses) or burred through exposed crown (one horse) and then secured around the incisors. The PPS were inserted under radiographic guidance to avoid tooth roots. Healing was assessed with radiographic examination. The PPS external fixator rod and intraoral wires were removed first. The mandible was manipulated, and, if it was stable, the PPS were removed.

Results: Implants were removed at 6, 8, or 10 weeks after the mandibles were palpably stable. Complications included broken wires in one horse, bone sequestration in one horse, and infection in one horse. Follow-up communication with the owners 12 to 18 months later confirmed complete healing without further complications of the fractured mandibles or teeth.

Conclusion: Polyaxial pedicle screw external fixation led to fracture healing and a return to function in all three horses. The complications encountered did not preclude a successful outcome.

Clinical Significance: Polyaxial pedicle screw external fixation coupled with intraoral wiring provides an alternative to treat unstable equine mandibular fractures without general anesthesia.
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http://dx.doi.org/10.1111/vsu.13587DOI Listing
April 2021

Laparoscopic Ovariectomy in a Domestic Yak.

Case Rep Vet Med 2020 6;2020:8886670. Epub 2020 Nov 6.

Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523, USA.

Owners of a juvenile domestic yak elected bilateral ovariectomy to prevent future reproduction. The yak was noted to be healthy at presentation. Both ovaries were removed using a laparoscopic approach as follows: after induction and maintenance of general inhalant anesthesia, 15 degrees Trendelenburg positioning was required to view the ovaries. Ovariectomy was conducted within a surgical time of 50 minutes. Due to the small ovarian size, portal enlargement was not necessary for removal. Mild hemorrhage from the left ovarian pedicle was controlled with application of a vessel-sealing device. Postoperative complications were not encountered during hospitalization. At 12 months following surgery, the yak was healthy, and the owner was highly satisfied with the procedure. The described approach was successful for performing laparoscopic ovariectomy in a juvenile yak. Positioning for surgery was similar to other small ruminant species. Further case enrollment is needed to optimize the surgical approach and better describe clinical outcomes.
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http://dx.doi.org/10.1155/2020/8886670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665910PMC
November 2020

Mechanical, biochemical, and morphological topography of ovine knee cartilage.

J Orthop Res 2021 04 4;39(4):780-787. Epub 2020 Sep 4.

Preclinical Surgical Research Laboratory, C. Wayne McIlwraith Translational Medicine Institute, Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado.

The knee is the most common site for translational cartilage research in sheep, though topographic features of articular cartilage across surfaces are unspecified. We aimed to characterize the mechanical, morphological, and biochemical properties of articular cartilage across ovine knee surfaces and document variations between and within surface locations. Regions of interest (ROIs) were delineated across surfaces of 10 healthy ovine knees. Articular cartilage at each ROI was measured for creep indentation, thickness, and glycosaminoglycan (GAG) and collagen content. Variables were compared between surface locations (trochlea, and lateral [LFC] and medial [MFC] femoral condyles) and between ROIs within each surface location. Correlations between variables were also assessed. Articular surface location had a significant effect on creep (P < .0001), thickness (P < .0001), and collagen (P = .0007), but not GAG (P = .28). Significant differences in percent creep between ROIs were found within the LFC (P < .0001), MFC (P < .0001), and trochlea (P = .0002). Cartilage thickness was different between ROIs within the LFC, MFC, and trochlea (all P < .0001). The LFC (P = .002) and trochlea (P = .01) each had significant differences in GAG between ROIs. Collagen content between ROIs was different within the LFC (P = .0003), MFC (P = .0005), and trochlea (P < .0001). Collagen content was correlated with thickness (r = -.55), percent creep (r = .47), and GAG (r = -.21). Percent creep was correlated with thickness (r = -.64) and GAG (r = -.19). Topographic variations in mechanical, morphological, and biochemical properties exist across knee cartilage surfaces in sheep. Recognition of this variability is important to optimize study protocols and improve accuracy of results.
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http://dx.doi.org/10.1002/jor.24835DOI Listing
April 2021

Biomechanical comparison of locking compression plate fixation and a novel pedicle screw external fixation to repair equine mandibular fractures.

Vet Surg 2020 Jul 15;49(5):997-1006. Epub 2020 Apr 15.

Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado.

Objective: To determine the biomechanical properties of pedicle screw external fixation (PDW) for equine mandibular fracture repair and compare PDW to locking compression plates (LCP).

Study Design: Cadaveric study.

Sample Population: Sixteen adult equine mandibles.

Methods: Four mandibles were kept intact, while 12 were osteotomized and stabilized with the LCP or PDW construct (6 mandibles/group). Failure, stiffness, and yield were calculated from quasi-static ramp to failure and compared with previous analysis of mandibular fracture constructs. Tooth root involvement and method of failure were determined from radiographs and videos.

Results: Locking compression plate constructs achieved greater stiffness and load at failure (4656 ± 577 N-m/radian, 558 ± 27 N-m P < .05) compared with PDW constructs (2626 ± 127 N-m/radian, 315 ± 48 N-m). Yield did not differ between types of fixation (369 ± 57 N-m, 193 ± 35 N-m, P = .145). Tooth involvement was noted in two LCP constructs with failure via bone fracture. Pedicle screw external fixation constructs failed via wire unraveling and screw bending.

Conclusion: Locking compression plate fixation increased stiffness and failure of constructs but did not influence yield. It also increased the risk to tooth root involvement relative to fixation with PDW. Compared with another study, PDW offered stiffness and failure similar to an intraoral splint with interdental wires, external fixator (EF), and external fixator with wires (EFW) and yield similar to an EF, an EFW, and a dynamic compression plate.

Clinical Relevance: Pedicle screw external fixation offers biomechanical stability comparable to other relevant mandibular fixation techniques and reduces the risk of tooth root damage compared with LCP fixation.
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http://dx.doi.org/10.1111/vsu.13416DOI Listing
July 2020

Comparison of intravenous anesthetic induction doses and physiologic effects of ketamine or alfaxalone in goats undergoing surgery with isoflurane anesthesia.

Am J Vet Res 2019 Sep;80(9):819-824

Objective: To compare IV doses of alfaxalone and ketamine needed to facilitate orotracheal intubation and assess effects of each treatment on selected physiologic variables in goats undergoing orthopedic surgery with isoflurane anesthesia.

Animals: 18 healthy adult goats.

Procedures: Behavior was assessed before and after sedation with midazolam (0.1 mg/kg, IV) for IV catheter placement. Anesthesia was induced with additional midazolam (0.1 mg/kg, IV) and alfaxalone (n = 9) or ketamine (9) at 2 mg/kg, IV, over 30 seconds. An additional dose of alfaxalone or ketamine (1 mg/kg) was given IV if needed for intubation; anesthesia was maintained with isoflurane in oxygen and IV fluids with ketamine (0.5 to 1 mg/kg/h). Direct systolic (SAP), diastolic (DAP), and mean (MAP) arterial blood pressures; heart rate; and respiratory rate were recorded before induction, immediately after intubation, and during surgery. Qualitative anesthetic induction and recovery characteristics were assessed. Variables were compared within and between groups by statistical methods.

Results: No preinduction variables differed significantly between groups. Postintubation and 30-minute intraoperative SAP, DAP, and MAP were higher for the ketamine group than for the alfaxalone group; within the alfaxalone group, postintubation SAP, MAP, and respiratory rate prior to mechanical ventilation were lower than respective preinduction values. All alfaxalone-group goats were intubated after 1 dose of the induction agent; 5 of 9 ketamine-group goats required an additional (1-mg/kg) dose. Postoperative recovery was good to excellent for all animals.

Conclusions And Clinical Relevance: Both drugs were suitable for induction of anesthesia after sedation with midazolam, but most goats required higher doses of ketamine to allow intubation. For situations in which alfaxalone administration is appropriate, the potential for decreased arterial blood pressures and respiratory rate should be considered.
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http://dx.doi.org/10.2460/ajvr.80.9.819DOI Listing
September 2019

Prospective randomized investigation of topical anesthesia during unilateral laparoscopic ovariectomy in horses.

Vet Surg 2020 Jun 21;49 Suppl 1:O54-O59. Epub 2019 Jun 21.

Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado.

Objective: To compare pain-related responses in mares receiving topical or injected anesthesia of the ovarian pedicle prior to standing unilateral laparoscopic ovariectomy.

Study Design: Prospective randomized, blinded, placebo-controlled study.

Animals: Fifteen healthy research mares.

Methods: Mares were restrained in stocks and administered sedation. A right or left paralumbar ovariectomy was performed by using a laparoscopic portal and two instrument portals. Mares were divided into two treatment groups, and equal volumes of mepivacaine anesthesia were administered either topically (n = 8) or by injection into the ovarian pedicle (n = 7). Saline controls were simultaneously administered topically (n = 7) or by injection (n = 8), and surgeons were blinded to the treatment group. Ovarian removal was performed with traumatic forceps and a blunt tip vessel sealer and divider. Pain responses were measured by operative visual analog scale (VAS) scoring and perioperative serum cortisol response. Visual analog scale and serum cortisol were compared between groups by using Mann-Whitney testing. Serum cortisol concentrations were evaluated using repeated-measures one-way analysis of variance.

Results: Ovaries were removed in all mares by using the described technique without operative complications. Quantity of sedation required to complete the procedure, operative VAS scores, and perioperative cortisol concentrations did not differ between treatment groups.

Conclusion: Application of topical mepivacaine to the ovary provided intraoperative analgesia similar to injection of the ovarian pedicle when performing unilateral standing laparoscopic ovariectomy in mares.

Clinical Significance: Topical anesthesia application to the ovary could provide an alternative to laparoscopic needle use, reducing the risk of inadvertent trauma to the pedicle or other visceral organs during laparoscopic ovariectomy.
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http://dx.doi.org/10.1111/vsu.13264DOI Listing
June 2020

Laparoscopic ovariohysterectomy in goats.

J Am Vet Med Assoc 2019 Jan;254(2):275-281

OBJECTIVE To describe a minimally invasive 3-portal laparoscopic approach for elective ovariohysterectomy and the outcome of that procedure in a population of goats. DESIGN Descriptive clinical study. ANIMALS 16 healthy client-owned goats. PROCEDURES Food but not water was withheld from all goats for 24 hours before the procedure. Goats were anesthetized and positioned in dorsal recumbency. Three laparoscopic portals were created in the caudoventral portion of the abdomen, and the abdomen was insufflated to a maximum pressure of 10 mm Hg. A blunt-tip vessel sealer and divider device was used to transect the left and right mesovarium and mesometrium and uterus, and the resected tissue was removed from the abdomen. After hemostasis was verified, the portals were closed in a routine manner and anesthesia was discontinued. Goats were discharged from the hospital 24 hours after the procedure, and owners were contacted by telephone or email to obtain short- and long-term follow-up information by use of standardized questions. RESULTS All procedures were performed by a surgeon and assistant surgeon. The procedure was not complex and was easily learned. No intraoperative complications were reported, and only 1 goat required rescue analgesia post-operatively. No other postoperative complications were recorded. Median surgery time was 43 minutes (range, 20 to 65 minutes). All owners were satisfied with the outcome of the procedure, and several perceived that the procedure improved goat behavior. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that laparoscopic ovariohysterectomy was a viable alternative for elective sterilization of female goats.
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http://dx.doi.org/10.2460/javma.254.2.275DOI Listing
January 2019

Cervical stabilization with polyaxial pedicle screw and rod construct in horses: A proof of concept study.

Vet Surg 2018 Oct 10;47(7):932-941. Epub 2018 Sep 10.

Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado.

Objective: To evaluate safety and efficacy of a novel technique for cervical stabilization.

Study Design: In vivo experimental.

Animals: Four normal adult quarterhorse crossbreed horses (2-4 years of age, > 250 kg).

Methods: One mid-cervical spinal unit (C3-C4) was distracted with a porous metal interbody fusion device (IFD) and stabilized with a polyaxial pedicle screw and rod construct. Neurologic examinations were performed preoperatively and postoperatively. Radiographs of the fusion site and adjoining vertebrae were obtained preoperatively and monthly. Horses were euthanized at 8 months and spinal units were evaluated for osseointegration and implant safety via micro-computed tomography (CT), histology, and histomorphometry.

Results: The procedure was performed safely in all horses, without severe postoperative complications. Evaluation of radiographs revealed no implant failure, implant migration, or spinal unit instability in any of the horses. The presence of new bone formation around the screw and rod constructs was confirmed via micro-CT. No evidence of inflammation or iatrogenic damage was noted from histology. New bone was present within the IFD in all horses, with variable osseointegration on the cranial and caudal surfaces of the implant in 3 horses.

Conclusion: The novel technique reported in the present study was safely applied to stabilize the C3-C4 spinal unit in the horses tested here and led to variable osseointegration within 8 months.

Clinical Significance: The results of this study justify evaluation of this technique in horses with a diagnosis of cervical vertebral compressive myelopathy.
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http://dx.doi.org/10.1111/vsu.12938DOI Listing
October 2018

Comparison of two techniques for transpharyngeal endoscopic auditory tube diverticulotomy in the horse.

J Vet Sci 2018 Nov;19(6):835-839

Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA.

Auditory tube diverticula, also known as guttural pouches, are naturally occurring dilations of the auditory tube in horses that communicate with the nasopharynx through a small ostium. Infection and select other conditions can result in inflammation and narrowing of the nasopharyngeal ostium, which prevents drainage of fluid or egress of air and can lead to persistent infection or guttural pouch tympany. Auditory tube diverticulotomy allows continuous egress from the auditory tube diverticula and is a feature of disease treatment in horses, in which medical treatment alone is not successful. Transpharyngeal endoscopic auditory tube diverticulotomy was performed using a diode laser either at a single dorsal pharyngeal recess location or bilaterally caudal to the nasopharyngeal ostium in 10 horse head specimens. Both methods resulted in clear communication between the nasopharynx and auditory tube diverticula. Diverticulotomy performed in the dorsal pharyngeal recess required less laser energy and activation time and had a shorter surgical duration than diverticulotomy performed caudal to the nasopharyngeal ostium. Further study related to the clinical application of both techniques is warranted.
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http://dx.doi.org/10.4142/jvs.2018.19.6.835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6265580PMC
November 2018

Reinforced Electrospun Polycaprolactone Nanofibers for Tracheal Repair in an In Vivo Ovine Model.

Tissue Eng Part A 2018 09 10;24(17-18):1301-1308. Epub 2018 May 10.

1 Stephenson School of Biomedical Engineering, University of Oklahoma , Norman, Oklahoma.

Tracheal stenosis caused by congenital anomalies, tumors, trauma, or intubation-related damage can cause severe breathing issues, diminishing the quality of life, and potentially becoming fatal. Current treatment methods include laryngotracheal reconstruction or slide tracheoplasty. Laryngotracheal reconstruction utilizes rib cartilage harvested from the patient, requiring a second surgical site. Slide tracheoplasty involves a complex surgical procedure to splay open the trachea and reconnect both segments to widen the lumen. A clear need exists for new and innovative approaches that can be easily adopted by surgeons, and to avoid harvesting autologous tissue from the patient. This study evaluated the use of an electrospun patch, consisting of randomly layered polycaprolactone (PCL) nanofibers enveloping 3D-printed PCL rings, to create a mechanically robust, suturable, air-tight, and bioresorbable graft for the treatment of tracheal defects. The study design incorporated two distinct uses of PCL: electrospun fibers to promote tissue integration, while remaining air-tight when wet, and 3D-printed rings to hold the airway open and provide external support and protection during the healing process. Electrospun, reinforced tracheal patches were evaluated in an ovine model, in which all sheep survived for 10 weeks, although an overgrowth of fibrous tissue surrounding the patch was observed to significantly narrow the airway. Minimal tissue integration of the surrounding tissue and the electrospun fibers suggested the need for further improvement. Potential areas for further improvement include a faster degradation rate, agents to increase cellular adhesion, and/or an antibacterial coating to reduce the initial bacterial load.
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http://dx.doi.org/10.1089/ten.TEA.2017.0437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150933PMC
September 2018

Vessel sealer and divider instrument temperature during laparoscopic ovariectomy in horses.

Vet Surg 2018 Jun 3;47(S1):O26-O31. Epub 2017 Dec 3.

Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado.

Objective: To determine the temperature of a vessel sealer and divider device during unilateral paralumbar laparoscopic ovariectomy in standing, sedated mares.

Study Design: Prospective study.

Animals: Fifteen healthy research mares.

Methods: Healthy mares with normal ovarian palpation and ultrasonographic appearance were enrolled. Horses were restrained in standing stocks and sedated. A right or left paralumbar ovariectomy was performed with a laparoscopic portal and 2 instrument portals. Ovaries were excised with traumatic forceps and a blunt tip vessel sealer and divider. Temperatures of the vessel sealer and divider were recorded with a thermocouple device adhered to the tip of the instrument. Variables were reported as median and interquartile range (IQR).

Results: Surgical time was 30 minutes (IQR, 25-32) including use of the vessel sealer and the divider for 4.1 minutes (IQR, 3.2-5.8). The tip of the instrument reached temperatures of 77°C (IQR, 72-85) during activation and 64°C (IQR, 61-67) at end cycle. The median increase in end-cycle instrument tip temperature per activation cycle was 2°C (IQR, -1-6). All mares returned to their intended use.

Conclusion: Despite the instrument temperatures observed during unilateral laparoscopic ovariectomy, surgical complications were minimal. The clinical relevance of the increase in instrument tip temperature of the vessel sealer and divider is presently unclear, but surgeons should use the instrument with caution, especially in close proximity to viscera. The increase in temperature observed at the tip of the vessel sealer and divider during unilateral ovariectomy could be associated with morbidity. The clinical relevance of instrument tip heating during other procedures, such as adhesiolysis and intestinal resection, is unknown and should be evaluated.
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http://dx.doi.org/10.1111/vsu.12755DOI Listing
June 2018

An investigation of shock wave therapy and low-intensity pulsed ultrasound on fracture healing under reduced loading conditions in an ovine model.

J Orthop Res 2018 03 11;36(3):921-929. Epub 2017 Aug 11.

Orthopaedic Bioengineering Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Ft Collins, Colorado.

The use of shock wave therapy (SWT) and low-intensity pulsed ultrasound (LIPUS) as countermeasures to the inhibited fracture healing experienced during mechanical unloading was investigated by administering treatment to the fracture sites of mature, female, Rambouillet Columbian ewes exposed to partial mechanical unloading or full gravitational loading. The amount of fracture healing experienced by the treatment groups was compared to controls in which identical surgical and testing protocols were administered except for SWT or LIPUS treatment. All groups were euthanized after a 28-day healing period. In vivo mechanical measurements demonstrated no significant alteration in fixation plate strains between treatments within either partial unloading group. Similarly, DXA BMD and 4-point bending stiffness were not significantly altered following either treatment. μCT analyses demonstrated lower callus bone volume for treated animals (SWT and LIPUS, p < 0.01) in the full gravity group but not between reduced loading groups. Callus osteoblast numbers as well as mineralized surface and bone formation rate were significantly elevated to the level of the full gravity groups in the reduced loading groups following both SWT and LIPUS. Although no increase in 4-week mechanical strength was observed, it is possible that an increase in the overall rate of fracture healing (i.e., callus strength) may be experienced at longer time points under partial loading conditions given the increase in osteoblast numbers and bone formation parameters following SWT and LIPUS. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:921-929, 2018.
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http://dx.doi.org/10.1002/jor.23666DOI Listing
March 2018

Response to early repeat celiotomy in horses after a surgical treatment of jejunal strangulation.

Vet Surg 2017 Aug 29;46(6):843-850. Epub 2017 May 29.

Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida.

Objective: To determine the outcome after early repeat celiotomy in horses operated for jejunal strangulation.

Study Design: Retrospective case series.

Animals: Horses (n = 22) that underwent repeat celiotomy for postoperative reflux (POR) and/or postoperative colic (POC) that did not improve within 48 hours from onset after initial surgical treatment of strangulating jejunal lesions by jejunojejunostomy (n = 14) or no resection (n = 8).

Methods: Medical records were reviewed for clinical signs, duration of signs before repeat surgery, surgical findings and treatment, and outcome. Survival was documented by phone call at long-term follow-up. The influence of POC and POR on timing of surgery were analyzed. Long-term survival was examined by Kaplan-Meier analyses.

Results: Repeat celiotomy was performed at a median of 57 hours after initial surgery and 16.5 hours from onset of signs, and earlier in horses with POC compared with POR (P < .05). A total of 3/22 horses were euthanatized under anesthesia. A total of 9 of 11 horses with initial jejunojejunostomy required resection of the original anastomosis due to anastomotic complications. In 8 horses without resection, second surgery included resection (4) or decompression (4). Repeat celiotomy was successful in 13/16 horses with POR. Repeat celiotomy eliminated POC in all horses (n = 9). A total of 19 horses were recovered from anesthesia and all survived to discharge. Incisional infections were diagnosed in 13/17 horses where both surgeries were performed through the same ventral median approach, and hernias developed in 4/13 infected incisions. Median survival time was 90 months.

Conclusion: Repeat celiotomy can eliminate signs of POR and/or POC, and the additional surgery does not appear to aggravate POR. Criteria for repeat celiotomy in this study could provide guidelines for managing POC and POR after surgery for jejunal strangulation.
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http://dx.doi.org/10.1111/vsu.12670DOI Listing
August 2017

An intravaginal ring for real-time evaluation of adherence to therapy.

PLoS One 2017 6;12(4):e0174729. Epub 2017 Apr 6.

Auritec Pharmaceuticals, Inc., Pasadena, California, United States of America.

Two recent Phase III clinical trials to investigate an intravaginal ring for preventing HIV infection demonstrated that adherence to prescribed device use was a primary driver of efficacy. Surrogate methods for determining adherence in the studies were limited in their inability to monitor temporal patterns of use and allow deconvolution of the effects of adherence and device efficacy on HIV infection rates. To address this issue, we have developed functionality in an intravaginal ring to continuously monitor when the device is being used and maintain a log of adherence that can be accessed by clinicians after it is removed. An electronic module fabricated with common, inexpensive electronic components was encapsulated in a silicone intravaginal ring. The device uses temperature as a surrogate measure of periods of device insertion and removal, and stores a record of the data for subsequent retrieval. The adherence-monitoring intravaginal ring accurately recorded the device status over 33 simulated IN-OUT cycles and more than 1000 measurement cycles in vitro. Following initial in vitro testing in a temperature-controlled chamber, the device was evaluated in vivo in sheep using a predetermined insertion/removal pattern to simulate intravaginal ring use. After insertion into the vaginal cavity of a sheep, the logged data correctly indicated the device status over 29 hours of continuous measurement including three cycles of insertion and removal. The device described here is a promising, low-cost method for real-time adherence assessment in clinical trials involving medicated intravaginal rings or other intravaginal devices.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174729PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5383054PMC
September 2017

Combination Pod-Intravaginal Ring Delivers Antiretroviral Agents for HIV Prophylaxis: Pharmacokinetic Evaluation in an Ovine Model.

Antimicrob Agents Chemother 2016 06 23;60(6):3759-66. Epub 2016 May 23.

Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, USA

Preexposure prophylaxis (PrEP) against HIV using oral regimens based on the nucleoside reverse transcriptase inhibitor tenofovir disoproxil fumarate (TDF) has been effective to various degrees in multiple clinical trials, and the CCR5 receptor antagonist maraviroc (MVC) holds potential for complementary efficacy. The effectiveness of HIV PrEP is highly dependent on adherence. Incorporation of the TDF-MVC combination into intravaginal rings (IVRs) for sustained mucosal delivery could increase product adherence and efficacy compared with oral and vaginal gel formulations. A novel pod-IVR technology capable of delivering multiple drugs is described. The pharmacokinetics and preliminary local safety characteristics of a novel pod-IVR delivering a combination of TDF and MVC were evaluated in the ovine model. The device exhibited sustained release at controlled rates over the 28-day study and maintained steady-state drug levels in cervicovaginal fluids (CVFs). Dilution of CVFs during lavage sample collection was measured by ion chromatography using an inert tracer, allowing corrected drug concentrations to be measured for the first time. Median, steady-state drug levels in vaginal tissue homogenate were as follows: for tenofovir (TFV; in vivo hydrolysis product of TDF), 7.3 × 10(2) ng g(-1) (interquartile range [IQR], 3.0 × 10(2), 4.0 × 10(3)); for TFV diphosphate (TFV-DP; active metabolite of TFV), 1.8 × 10(4) fmol g(-1) (IQR, 1.5 × 10(4), 4.8 × 10(4)); and for MVC, 8.2 × 10(2) ng g(-1) (IQR, 4.7 × 10(2), 2.0 × 10(3)). No adverse events were observed. These findings, together with previous pod-IVR studies, have allowed several lead candidates to advance into clinical evaluation.
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http://dx.doi.org/10.1128/AAC.00391-16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879417PMC
June 2016

Computational characterization of fracture healing under reduced gravity loading conditions.

J Orthop Res 2016 07 8;34(7):1206-15. Epub 2016 Jan 8.

Department of Mechanical Engineering, School of Biomedical Engineering, Orthopaedic Research Laboratory, Colorado State University, Ft Collins, Colorado.

The literature is deficient with regard to how the localized mechanical environment of skeletal tissue is altered during reduced gravitational loading and how these alterations affect fracture healing. Thus, a finite element model of the ovine hindlimb was created to characterize the local mechanical environment responsible for the inhibited fracture healing observed under experimental simulated hypogravity conditions. Following convergence and verification studies, hydrostatic pressure and strain within a diaphyseal fracture of the metatarsus were evaluated for models under both 1 and 0.25 g loading environments and compared to results of a related in vivo study. Results of the study suggest that reductions in hydrostatic pressure and strain of the healing fracture for animals exposed to reduced gravitational loading conditions contributed to an inhibited healing process, with animals exposed to the simulated hypogravity environment subsequently initiating an intramembranous bone formation process rather than the typical endochondral ossification healing process experienced by animals healing in a 1 g gravitational environment. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1206-1215, 2016.
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http://dx.doi.org/10.1002/jor.23143DOI Listing
July 2016

Microsphere-based gradient implants for osteochondral regeneration: a long-term study in sheep.

Regen Med 2015 29;10(6):709-28. Epub 2015 Sep 29.

Department of Chemical & Petroleum Engineering, University of Kansas, Lawrence, KS 66045, USA.

Background: The microfracture technique for cartilage repair has limited ability to regenerate hyaline cartilage.

Aim: The current study made a direct comparison between microfracture and an osteochondral approach with microsphere-based gradient plugs.

Materials & Methods: The PLGA-based scaffolds had opposing gradients of chondroitin sulfate and β-tricalcium phosphate. A 1-year repair study in sheep was conducted.

Results: The repair tissues in the microfracture were mostly fibrous and had scattered fissures with degenerative changes. Cartilage regenerated with the gradient plugs had equal or superior mechanical properties; had lacunated cells and stable matrix as in hyaline cartilage.

Conclusion: This first report of gradient scaffolds in a long-term, large animal, osteochondral defect demonstrated potential for equal or better cartilage repair than microfracture.
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http://dx.doi.org/10.2217/rme.15.38DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4977000PMC
August 2016

Muscle atrophy and fatty infiltration after an acute rotator cuff repair in a sheep model.

Muscles Ligaments Tendons J 2015 Apr-Jun;5(2):106-12. Epub 2015 Jul 3.

Department of Orthopaedic Surgery, University of California, San Francisco, CA, United States.

Introduction: rotator cuff tears (RCTs) are the most common tendon injury seen in orthopedic patients. Muscle atrophy and fatty infiltration of the muscle are crucial factors that dictate the outcome following rotator cuff surgery. Though less studied in humans, rotator cuff muscle fibrosis has been seen in animal models as well and may influence outcomes as well. The purpose of this study was to determine if the rotator cuff would develop muscle changes even in the setting of an acute repair in a sheep model. We hypothesized that fatty infiltration and fibrosis would be present even after an acute repair six months after initial surgery.

Methods: twelve female adult sheep underwent an acute rotator cuff tear and immediate repair on the right shoulder. The left shoulder served as a control and did not undergo a tear or a repair. Six months following acute rotator cuff repairs, sheep muscles were harvested to study atrophy, fatty infiltration, and fibrosis by histological analysis, western blotting, and reverse transcription polymerase chain reaction (RT-PCR).

Results: the repair group demonstrated an increase expression of muscle atrophy, fatty infiltration, and fibrosis related genes. Significantly increased adipocytes, muscle fatty infiltration, and collagen deposition was observed in rotator cuff muscles in the tendon repair group compared to the control group.

Conclusions: rotator cuff muscle undergoes degradation changes including fatty infiltration and fibrosis even after the tendons are repair immediately after rupture.

Level Of Evidence: Basic Science Study.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4496009PMC
August 2015

Implantable microelectromechanical sensors for diagnostic monitoring and post-surgical prediction of bone fracture healing.

J Orthop Res 2015 Oct 29;33(10):1439-46. Epub 2015 Jul 29.

Orthopaedic Bioengineering Research Laboratory, Departments of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, Colorado, 80523.

The relationship between modern clinical diagnostic data, such as from radiographs or computed tomography, and the temporal biomechanical integrity of bone fracture healing has not been well-established. A diagnostic tool that could quantitatively describe the biomechanical stability of the fracture site in order to predict the course of healing would represent a paradigm shift in the way fracture healing is evaluated. This paper describes the development and evaluation of a wireless, biocompatible, implantable, microelectromechanical system (bioMEMS) sensor, and its implementation in a large animal (ovine) model, that utilized both normal and delayed healing variants. The in vivo data indicated that the bioMEMS sensor was capable of detecting statistically significant differences (p-value <0.04) between the two fracture healing groups as early as 21 days post-fracture. In addition, post-sacrifice micro-computed tomography, and histology data demonstrated that the two model variants represented significantly different fracture healing outcomes, providing explicit supporting evidence that the sensor has the ability to predict differential healing cascades. These data verify that the bioMEMS sensor can be used as a diagnostic tool for detecting the in vivo course of fracture healing in the acute post-treatment period.
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http://dx.doi.org/10.1002/jor.22918DOI Listing
October 2015

Laparoscopic inguinal hernioplasty in a ram.

J Am Vet Med Assoc 2015 May;246(10):1118-21

Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523.

Case Description: A 4-month-old Hampshire ram underwent open right inguinal herniorrhaphy and unilateral castration following herniation that developed after a kick injury. Seven months later, the ram was reevaluated because of scrotal swelling of 1 month's duration as well as suspected left inguinal hernia.

Clinical Findings: The ram had marked scrotal swelling. Palpation of the left testicle revealed no abnormalities. Ultrasonographic examination revealed heterogenous tissue within the cranial and medial portions of the scrotum with pronounced accumulation of hypoechoic fluid at the scrotal apex. Examination findings indicated left-sided indirect inguinal herniation of omentum.

Treatment And Outcome: To preserve fertility, left inguinal hernioplasty without castration was performed. The ram was anesthetized and placed in dorsal recumbency, and laparoscopic abdominal evaluation revealed omental entrapment within the left inguinal ring. The omentum was removed, and a polypropylene mesh was secured over the internal inguinal ring with an articulating hernia stapler. Following mesh placement, a dorsally based peritoneal flap was elevated and secured over the mesh repair. The ram recovered well from surgery; there was no repeated herniation following the surgical correction, and the ram was able to breed successfully without complication.

Clinical Relevance: Laparoscopic mesh hernioplasty can be successful in rams with inguinal hernias when preservation of fertility is preferred.
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http://dx.doi.org/10.2460/javma.246.10.1118DOI Listing
May 2015

Partial gravity unloading inhibits bone healing responses in a large animal model.

J Biomech 2014 Sep 7;47(12):2836-42. Epub 2014 Aug 7.

Orthopaedic Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, 1374 Campus Delivery, Fort Collins, CO, USA. Electronic address:

The reduction in mechanical loading associated with space travel results in dramatic decreases in the bone mineral density (BMD) and mechanical strength of skeletal tissue resulting in increased fracture risk during spaceflight missions. Previous rodent studies have highlighted distinct bone healing differences in animals in gravitational environments versus those during spaceflight. While these data have demonstrated that microgravity has deleterious effects on fracture healing, the direct translation of these results to human skeletal repair remains problematic due to substantial differences between rodent and human bone. Thus, the objective of this study was to investigate the effects of partial gravitational unloading on long-bone fracture healing in a previously-developed large animal Haversian bone model. In vivo measurements demonstrated significantly higher orthopedic plate strains (i.e. load burden) in the Partial Unloading (PU) Group as compared to the Full Loading (FL) Group following the 28-day healing period due to inhibited healing in the reduced loading environment. DEXA BMD in the metatarsus of the PU Group decreased 17.6% (p<0.01) at the time of the ostectomy surgery. Four-point bending stiffness of the PU Group was 4.4 times lower than that of the FL Group (p<0.01), while µCT and histomorphometry demonstrated reduced periosteal callus area (p<0.05), mineralizing surface (p<0.05), mineral apposition rate (p<0.001), bone formation rate (p<0.001), and periosteal/endosteal osteoblast numbers (p<0.001/p<0.01, respectively) as well as increased periosteal osteoclast number (p<0.05). These data provide strong evidence that the mechanical environment dramatically affects the fracture healing cascade, and likely has a negative impact on Haversian system healing during spaceflight.
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http://dx.doi.org/10.1016/j.jbiomech.2014.07.031DOI Listing
September 2014

Alterations in trabecular bone microarchitecture in the ovine spine and distal femur following ovariectomy.

J Biomech 2014 Jun 25;47(8):1918-21. Epub 2014 Mar 25.

Tissue Mechanics Laboratory, Bioengineering Graduate Program, and Department of Aerospace and Mechanical Engineering, University of Notre Dame, 147 Multidisciplinary Research Building, Notre Dame, IN 46556, United States. Electronic address:

Osteoporosis is a bone disease resulting in increased fracture risk as a result of alterations in both quantity and quality of bone. Bone quality is a combination of metabolic and microarchitectural properties of bone that can help to explain the increased susceptibility to fracture. Translational animal models are essential to understanding the pathology and for evaluating potential treatments of this disease. Large animals, such as the ovariectomized sheep, have been used as models for post-menopausal osteoporosis. However, long-term studies have not been carried out to observe the effects of ovariectomy after more than one year. This study employed micro-computed tomography to quantify changes in microarchitectural and mechanical parameters in femoral condyles and vertebral bodies of sheep that were sacrificed one or two years following ovariectomy. In the vertebral body, microarchitectural characteristics were significantly degraded following one year of ovariectomy in comparison to controls. The mechanical anisotropy, determined from micro-scale finite element models, was also greater in the ovariectomized groups, although the fabric tensor anisotropy was similar. There was no greater architectural degradation following two years of ovariectomy compared to one. Ovariectomy had minimal effects on the trabecular architecture of the distal femur even after two years. These results indicate that the vertebral body is the preferred anatomic site for studying bone from the ovariectomized sheep model, and that architectural changes stabilize after the first year.
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http://dx.doi.org/10.1016/j.jbiomech.2014.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4042680PMC
June 2014

Standing surgery. Preface.

Vet Clin North Am Equine Pract 2014 Apr 19;30(1):xiii-xiv. Epub 2013 Dec 19.

Surgical Research Laboratory, Department of Clinical Sciences, College of Veterinary Medicine and Biological Sciences, Colorado State University, 300 West Drake Road, Fort Collins, CO 80523, USA. Electronic address:

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http://dx.doi.org/10.1016/j.cveq.2013.11.013DOI Listing
April 2014

Advances in laparoscopic techniques and instrumentation in standing equine surgery.

Vet Clin North Am Equine Pract 2014 Apr 17;30(1):19-44. Epub 2014 Jan 17.

Professional Veterinary Medicine, Colorado State University, 300 W Drake Road, Fort Collins, CO 80523, USA.

Equine standing surgery and laparoscopy are becoming increasingly important aspects of equine surgery. Laparoscopic advancements lag behind the human medical field, mainly due to decreased access to appropriate training and instrumentation. It is nearly impossible to cover the topic of equine standing surgery without discussing advances in laparoscopy, because without such advances, equine standing surgery lacks potential for forward progress. Although novel standing techniques continue to be published, the addition of minimally invasive laparoscopic techniques adds an entirely new dimension and provides a plethora of procedures to surgeons practicing equine standing surgery.
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http://dx.doi.org/10.1016/j.cveq.2013.11.003DOI Listing
April 2014

An in vivo ovine model of bone tissue alterations in simulated microgravity conditions.

J Biomech Eng 2014 Feb;136(2):021020

Microgravity and its inherent reduction in body-weight associated mechanical loading encountered during spaceflight have been shown to produce deleterious effects on important human physiological processes. Rodent hindlimb unloading is the most widely-used ground-based microgravity model. Unfortunately, results from these studies are difficult to translate to the human condition due to major anatomic and physiologic differences between the two species such as bone microarchitecture and healing rates. The use of translatable ovine models to investigate orthopedic-related conditions has become increasingly popular due to similarities in size and skeletal architecture of the two species. Thus, a new translational model of simulated microgravity was developed using common external fixation techniques to shield the metatarsal bone of the ovine hindlimb during normal daily activity over an 8 week period. Bone mineral density, quantified via dual-energy X-ray absorptiometry, decreased 29.0% (p < 0.001) in the treated metatarsi. Post-sacrifice biomechanical evaluation revealed reduced bending modulus (-25.8%, p < 0.05) and failure load (-27.8%, p < 0.001) following the microgravity treatment. Microcomputed tomography and histology revealed reduced bone volume (-35.9%, p < 0.01), trabecular thickness (-30.9%, p < 0.01), trabecular number (-22.5%, p < 0.05), bone formation rate (-57.7%, p < 0.01), and osteoblast number (-52.5%, p < 0.001), as well as increased osteoclast number (269.1%, p < 0.001) in the treated metatarsi of the microgravity group. No significant alterations occurred for any outcome parameter in the Sham Surgery Group. These data indicate that the external fixation technique utilized in this model was able to effectively unload the metatarsus and induce significant radiographic, biomechanical, and histomorphometric alterations that are known to be induced by spaceflight. Further, these findings demonstrate that the physiologic mechanisms driving bone remodeling in sheep and humans during prolonged periods of unloading (specifically increased osteoclast activity) are more similar than previously utilized models, allowing more comprehensive investigations of microgravity-related bone remodeling as it relates to human spaceflight.
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http://dx.doi.org/10.1115/1.4025854DOI Listing
February 2014

New ways to diagnose and treat equine dental-related sinus disease.

Vet Clin North Am Equine Pract 2013 Aug 23;29(2):467-85, vii. Epub 2013 May 23.

Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, 300 West Drake Street, Fort Collins, CO 80523, USA.

The diagnosis and treatment of equine dental-related sinus disease is often challenging. Dental-related sinus disease is common and knowledge of these diseases is becoming increasingly important in veterinary medicine. Diagnostic capabilities are continually improving, leading to early diagnostic and therapeutic successes. With advanced imaging modalities, such as computed tomography and magnetic resonance imaging, understanding of the intimate anatomic relationship between teeth and the paranasal sinuses continues to progress. There are many therapeutic options available for the treatment of these common and challenging disorders. A complete understanding of the disease, therapeutic options, and potential complications is vital to overall successful resolution of clinical signs in equine dental-related sinus disorders.
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http://dx.doi.org/10.1016/j.cveq.2013.04.003DOI Listing
August 2013

Advanced imaging in equine dental disease.

Vet Clin North Am Equine Pract 2013 Aug 28;29(2):397-409, vi. Epub 2013 May 28.

Department of Biosciences and Diagnostic Imaging, University of Georgia, 501 DW Brooks Drive, Athens, GA 30602, USA.

Dental and sinus disorders are relatively common and of major clinical importance in equine medicine. Advanced diagnostic imaging has become an integral part of equine veterinary medicine. Advanced imaging has progressed the understanding, diagnosis, and treatment of dental- and sinus-related diseases. As a clinician, it is important to realize the value of advanced diagnostic imaging. Although computed tomography and magnetic resonance imaging are both significantly more expensive compared with other diagnostic tools, the financial cost of inaccurate diagnosis and treatment can often result in higher overall costs.
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http://dx.doi.org/10.1016/j.cveq.2013.04.009DOI Listing
August 2013
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