Global Edition. Diagnostics Focus. Also in this issue:

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1 Diagnostics Focus NAVC Global Edition The Official Publication of Penile Discharge in Dogs Feline Tracheal Tumors: Uncommon or Overlooked? Ophthalmic Examination Made Simple Laboratory Evaluation in Dogs & Cats with Chronic Kidney Disease A Peer-Reviewed Journal May 2015 Volume 13 Number 5 cliniciansbrief.com THE OFFICIAL PUBLICATION OF THE NAVC Also in this issue: Top 5 Leukogram Patterns Determining Canine Estrus Stage via Vaginal Cytology Open & Laparoscopic-Assisted Incisional Gastropexy

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3 Global Edition Advisory Board From the Global Editor Colin F. Burrows, BVetMed, PhD, Hon FRCVS, DACVIM Global Editor of Clinician s Brief Laurent Findji, DMV, MS, MRCVS, DECVS Fitzpatrick Referrals Senior Surgeon, Oncology & Soft Tissue Surrey, United Kingdom Boyko A. Georgiev, DVM, PhD Bulgarian Academy of Sciences, Associate Professor Sofia, Bulgaria Takuo Ishida, DVM, PhD, DJCVP Akasaka Animal Hospital, Medical Director Tokyo, Japan Walasinee Moonarmart, DVM, PhD Mahidol University, Deputy Dean for Education Affairs Bangkok, Thailand Ellen F. K. van Nierop de Fierro, DVM Ecuavet, Co-owner & Practitioner Quito, Ecuador Nicole Rego, BVSc, MVSc Happy Tails Veterinary Specialty, Associate Veterinarian Mumbai, India Welcome to the May issue, which contains a fascinating cross section of practical information. This month s specially commissioned global article is on the choice and use of basic surgical instruments. This may sound very basic to some readers, but acting on the advice of our global advisory board we thought it would be of much use to readers in some countries (and there are some) who were never exposed to this information in veterinary school. Indeed, there are some schools where small animal medicine and surgery is not even on the curriculum. Another great article is Top 5 Leukogram Patterns. A stress leukogram is common in patients, and it is good to keep this in mind when looking at numbers. An inflammatory leukogram is also so important: I never liked to see one, especially in IBD patients as it meant severe disease. This piece also includes a good review of the causes of eosinophilia, one of which is hypoadrenocorticism. I once backed into this diagnosis in a patient with normal electrolytes but an unexplained eosinophilia and lymphocytosis. Additional articles include a review by Dr. Greg Grauer on chronic kidney disease so common in our older patient populations. Also, no thorough physical exam is complete without a systematic ophthalmic exam. Dr. Ron Ofri takes us through one in a well-illustrated guide. Couple all this with a Diagnostic Tree on the all-toocommon problem of penile discharge and a practical description of how to determine estrous stage by vaginal cytology and you have a wealth of material. Last but not least, two life-saving, prophylactic gastropexy techniques for gastric dilatation-volvulus are well described by Drs. Brad Case and Alexander Fox-Alvarez. This issue contains something for every practitioner good reading. Dr. Colin Burrows WSAVA President Editor, Global Edition There are some schools where small animal medicine and surgery is not even on the curriculum. May 2015 Clinician s Brief 1

4 THE OFFICIAL PUBLICATION OF THE NAVC Clinician s Brief is a peer-reviewed journal J. Scott Weese, DVM, DVSc, DACVIM Editor in Chief dr.weese@briefmedia.com NAVC Clinician s Brief Advisory Board Katherine S. Gloyd, DVM President ELEVATE DVM Wilmington, Delaware Douglas Mader, MS, DVM, DABVP (Canine & Feline, Reptile & Amphibian), DECZM (Herpetology) Co-owner Marathon Veterinary Hospital Marathon, Florida Gregg K. Takashima, DVM WSAVA Global Nutrition Committee Co-Chair President AAH-ABV CEO Animal Care Group of Lake Oswego, Oregon Gregory F. Grauer, DVM, MS, DACVIM Professor & Jarvis Chair of Small Animal Internal Medicine Kansas State University College of Veterinary Medicine Howard B. Seim, III, DVM, DACVS Associate Professor Colorado State University College of Veterinary Medicine Todd Tams, DVM, DACVIM Chief Medical Officer VCA Antech VCA West Los Angeles Animal Hospital Los Angeles, California Justine A. Lee, DVM, DACVECC, DABT CEO & Founder VetGirl Minneapolis, Minnesota David F. Senior, BVSc, DACVIM, DECVIM (Companion Animal) Professor Emeritus Louisiana State University School of Veterinary Medicine Alexander Werner, VMD, DACVD Owner Animal Dermatology Center Studio City, California NAVC Board of Directors & Staff Chief Executive Officer Thomas M. Bohn, MBA, CAE President Christine Navarre, DVM, MS, DACVIM (Large Animal) Immediate Past President Charlotte Lacroix, DVM, JD President-Elect Melinda Merck, DVM Vice President Gail Gibson, VMD Secretary-Treasurer Laurel Kaddatz, DVM Directors Paige Allen, MS, RVT Cheryl Good, DVM Susan Klein, DVM, DACVIM K. Leann Kuebelbeck, DVM, DACVS To Contact NAVC Speakers Susan Woodard swoodard@navc.com Exhibits & Sales Mia Cary, DVM mcary@navc.com Marketing Meghan R. Golden, MBA mgolden@navc.com VetFolio Bobby Lee blee@navc.com All Other Inquiries Go to NAVC.com Call info@navc.com 2 cliniciansbrief.com May 2015

5 PUBLISHER OF NAVC CLINICIAN S BRIEF NAVC Clinician s Brief (ISSN ) is published monthly by Brief Media, an Educational Concepts company, 2021 S Lewis Avenue, #760, Tulsa, OK Chief Veterinary Officer & Editor Indu Mani, DVM, ScD, FNAP dr.indu@briefmedia.com President Elizabeth Green beth@briefmedia.com Account Services Coordinator Maria Logan maria@briefmedia.com Editorial Director Michelle N. Munkres, MA michelle@briefmedia.com Director, Finance Cheryl Sutton cheryl@briefmedia.com Account Services Partner, Account Services John O Brien john@briefmedia.com Director, Account Services Kristen Holder kristen@briefmedia.com Account Services Managers Chelsea Elbert chelsea@briefmedia.com Whitney Hewitt whitney@briefmedia.com Naomi Murray, DVM dr.naomi@briefmedia.com Jillian Smith jillian@briefmedia.com Custom Media Manager Shelley Hurley shelley@briefmedia.com Account Services Associate James Jordan james@briefmedia.com Marketing Marketing Manager Jennifer Beltran jennifer@briefmedia.com Marketing Project Coordinator Jessica Stephens jessica@briefmedia.com Marketing Coordinator Chelsea Hise chise@briefmedia.com To subscribe or for subscription inquiries: cliniciansbrief.com/subscribe Domestic subscription rate: $65.00 per year. Single copy: $8.00. Payments by check must be in US funds on a US branch of a US bank only; credit cards also accepted. Copyright 2015 Brief Media, an Educational Concepts company. All rights reserved. Reproduction in whole or in part without expressed written permission is prohibited. POSTMASTER: Send address changes to Brief Media, PO Box 3617, Northbrook, IL Canada Post publications mail agreement # : Return undeliverable Canadian mailings to Circulation Dept; 7496 Bath Rd, Unit #2; Mississauga, ON L4T 1L2. Periodicals postage paid at Tulsa, OK, and at additional mailing offices. Managing Editor Spring L. Harris, MA spring@briefmedia.com Editorial Assistants Jessie Foley jessie@briefmedia.com Drue A. Gindler drue@briefmedia.com Susan H. Rose susan@briefmedia.com Stevie St. John stevie@briefmedia.com Global Editor & Emeritus Editor in Chief Colin F. Burrows, BVetMed, PhD, Hon FRCVS, DACVIM cfb@briefmedia.com Editor & Director of Nursing Kara M. Burns, MS, MEd, LVT, VTS (Nutrition) Editor at Large Antoinette Passaretti toni@briefmedia.com Videographer Christopher Howell chris@briefmedia.com Design/Production Mistretta Design Group, LLC jeanne@mistrettadesigngroup.com Interactive Media & Operations Director, Operations Nikki Howell nikki@briefmedia.com Interactive Medical Editor Amy Mohl, DVM dr.amy@briefmedia.com Director of Education & Medical Editor Jennifer L. Schori, VMD, MS dr.jen@briefmedia.com Interactive Managing Editor Lindsay Reese lindsayreese@briefmedia.com Interactive Editorial Assistant Jenny Dahl jenny@briefmedia.com Manager, Interactive Design & Development Mickael Lucchini mickael@briefmedia.com Front-end Developers Kyle Smith kyle@briefmedia.com Aaron Mays aaron@briefmedia.com Interactive Project Manager Becca Thompson becca@briefmedia.com Interactive Project Coordinator Courtnie Smith courtnie@briefmedia.com Audience Development Coordinator Allix Rawls allix@briefmedia.com Account Services, Administrative, Content, & Operations Offices BRIEF MEDIA 2021 S Lewis Avenue #760 Tulsa, OK T F briefmedia.com info@briefmedia.com May 2015 Clinician s Brief 3

6 THE OFFICIAL PUBLICATION OF THE NAVC FOCUS ON DIAGNOSTICS DIAGNOSTIC TREE 20 Penile Discharge in Dogs Cheryl Lopate, DVM, MS, DACT TOP 5 22 Top 5 Leukogram Patterns Sarah Schmidt, DVM, DACVP (Clinical Pathology) COMPARATIVE IMAGERY 25 Determining Canine Estrus Stage via Vaginal Cytology Autumn P. Davidson, DVM, MS, DACVIM PROCEDURES PRO 28 Ophthalmic Examination Made Simple Ron Ofri, DVM, PhD, DECVO ASK THE EXPERTS 33 Feline Tracheal Tumors: Uncommon or Overlooked? James Howard, DVM M. Katherine Tolbert, DVM, PhD, DACVIM Glomerular capillary tuft showing afferent arteriole dilation and efferent arteriole constriction (see page 49) ASK THE EXPERT 49 Laboratory Evaluation in Dogs & Cats with Chronic Kidney Disease Gregory F. Grauer, DVM, MS, DACVIM PROCEDURES PRO 54 Open & Laparoscopic-Assisted Incisional Gastropexy W. Alexander Fox-Alvarez, DVM J. Brad Case, DVM, MS, DACVS Contact us at editor@cliniciansbrief.com Articles archived on cliniciansbrief.com/journal 4 cliniciansbrief.com May 2015

7 On the Web cliniciansbrief.com This month s clinical features available only online. 36 CAPSULES The latest from the literature. Featuring select commentaries from articles in such esteemed publications as: n AM J VET RES n CASE REPORTS IN VET MED n EMERG INFECT DIS n EVID BASED COMPLEMENT ALTERNAT MED n J PHARMACOL EXP THER n J SMALL ANIM PRACT n J VET BEHAV n JVECC n JAAHA n JAVMA n OPEN J VET MED n RES VET SCI n VET ANAESTH ANALG n VET J n VET SURG To Cut or Not to Cut: Inappetence in a Cat Jean K. Reichle, DVM, MS, DACVR cliniciansbrief.com/article/cut-or-not-cutinappetence-cat 17 OUR AUTHORS 46 SYMPOSIUM CAPSULES Western Veterinary Conference 59 PRACTICE HOTLINE The latest in products and services 60 QUIZ CORNER Test your knowledge Video: Common Tapeworm Proglottids of Dogs and Cats Chris Adolph, DVM, MS cliniciansbrief.com/article/common-tapewormproglottids-dogs-and-cats 60 POLLING PLACE Experience More Discover our web-exclusive content by scanning this page with the Layar App on your smartphone or tablet. May 2015 Clinician s Brief 5

8 Global Edition Global Perspectives Diagnostics: A Tool for the Sleuth Ellen F. K. van Nierop de Fierro, DVM Clinician s Brief Global Advisory Board Co-owner & Practitioner, Equavet Quito, Ecuador Every veterinarian is a bit of a sleuth. It is an exciting game to get from the ill patient with its clinical signs to a diagnosis especially when the diagnosis needs to be made quickly and/or resources are limited. Information from the client may help or may actually make things more complicated. Laboratory testing is a wonderful resource, as are imaging techniques and other diagnostics. Lamentably, many veterinarians have to do without many of these, as dictated by limited availability and economics. In South America, for example, histopathology is only just becoming available in most countries; testing for parathyroid or adrenocorticotropic hormone is still unavailable in most. As more veterinarians realize the utility of these tests, and manage to convince pet owners of the need, more laboratories are likely to find a way to cater to the demand. The Value of the Basics Luckily, a few standard, easy, and in- expensive laboratory tools provide well for the most common diseases of our patients. Apart from a thorough physical examination, a simple microscope is often an eye opener for dermatology and gastroenterology patients, as is a urine sample for some renal, hormonal, and liver diseases. It is important to know the techniques, which can be learned. The WSAVA Continuing Education program, providing lectures and practical training by leading veterinarians in their field, goes a long way in this regard. This Global Edition of Clinician s Brief is also an extremely important tool for WSAVA members; the step-by-step procedures and diagnostic trees are invaluable. Treating the Patient Having many diagnostics at hand can, however, be a double-edged sword. It can be tempting to treat DIAGNOSTIC TESTS ARE SEEN AS A MAP, BUT JUST BECAUSE THINGS SEEM OBVIOUS ON THE MAP DOESN T MEAN THEY WILL BE CLEAR-CUT. the laboratory results instead of the patient. One way to avoid this pitfall is to remind oneself what is being looked for when each test is submitted. If a complete blood count is submitted, what is the clinician hoping to confirm or rule out? If serum blood chemistry is requested, which values and why? If a patient is sent for ultrasonography, what is the expected discovery? Diagnostic tests are seen as a map, but just because things seem obvious on the map, doesn t mean they will be clear-cut. The clinical eye, though often somewhat biased, is still an important factor. In the end, the most important outcome is not that laboratory values go back to normal but rather that the patient feels better, and the client does too. 6 cliniciansbrief.com May 2015

9 Global Edition Call For Help Nepal Earthquake Disaster Dear Colleagues: Most of you will have heard about the devastating earthquake in Nepal and have seen the distressing images of the death and destruction it has caused. The grim statistics of numbers killed, injured, and displaced increase daily. We have friends and colleagues in the country and, as far as we know, they at least survived. For this, we are grateful. It is impossible to remain unmoved by suffering on such a scale, both among the Nepalese people and among the animals on which so many of them rely. We are a global veterinary community and we must help. To this end, the Executive Board is working with the WSAVA Foundation Board to redirect some of the funds we expect to raise during the forthcoming Bangkok Fun(d) Run to both human and animal charities that are delivering emergency aid to Nepal. If you are joining us in Bangkok and have not yet registered to take part in the Fun(d) Run/Walk, please do so now because the more participants we have, the more funds we will raise both for Nepal and for our on-going projects to combat rabies. Canadians should note that participation in this event, which is a registered Canadian charity, will capitalize on the Government of Canada program that will match every dollar donated through the Fun(d) Run to the Nepal Earthquake Relief Fund. For more information about the Fun(d) Run, go to: wsava2015.com/congressinformation/fun(d)-run. If you would like to offer a further donation, you can do so through reputable charities on the ground now. Thank you and please give generously. Sincerely, Dr. Colin Burrows WSAVA President Dutourdumonde Photography / Shutterstock.com On the Ground Now The Rotary Club of Patan, where I have been involved, has begun providing supplies of rice, lentils, sugar, salt, and tea to some 200 residents in the village of Lubhu in the Laliptur district. It also plans to extend these efforts to another village, Panga near Kirtipur. Both these locations are within the Kathmandu valley. Depending on available resources, the club intends to expand its support to other areas over time. To ensure that its efforts directly reach the affected communities at zero overhead cost, the group has established a committee to oversee its relief and rehabilitation work. As with all of its projects, the Rotary Club will closely manage and monitor the distribution and use of its funds. If you would like to support these efforts, the club is accepting donations from all interested individuals, groups, and communities from Nepal and abroad to the following account: Rotary Club of Patan Savings Account No Nepal Investment Bank Pulchowk Branch SWIFT Address: NIBLNPKT All donations will be recorded and donors will be apprised on a regular basis about how the funds are being used. Your generous support will be highly appreciated Mukti N. Shrestha, President, VPAN WSAVA Nepal Representative Kathmandu, Nepal dr.mnshrestha@gmail.com May 2015 Clinician s Brief 7

10 Global Edition In The Press Asian H3N2 Canine Influenza Strain in the United States A current outbreak in the Midwest United States of canine influenza has been attributed to a virus that is closely related to the H3N2 strain. This strain of influenza virus is native to Asia and differs from the H3N8 typical in North America in that it seems to be more transmissible, as supported by the widespread and ongoing nature of the outbreak. Vaccine for the latter that is readily available in the U.S. probably does not afford protection against H3N2. Although it is not known how this Asian strain arrived in the North American dog population, some experts point to a steady influx of rescue dogs from Asia, notably from Korea. Clinician s Brief Editor in Chief Dr. Scott Weese, microbiologist at the University of Guelph Centre for Public Health and Zoonosis, recommends a number of steps for both veterinary practices and pet owners to combat the spread of the infection. In endemic areas, practices should: 1. Ask about the health status of every dog for which an appointment is being scheduled for the next few days or week. If the dog has signs consistent with influenza, it can be handled differently when it arrives. 2. Encourage vigilance from front-office staff in regard to the disease. If a dog arrives and seems ill from an unknown cause, the animal should be designated and handled as a suspect influenza case. 3. Post a sign on the front door asking clients to leave their pet in the car or to call from their cell phone if they are bringing in a dog with a cough or if it may have been exposed to canine influenza. 4. Establish a written plan for handling dogs suspected to be infected. Do not let suspect dogs in the waiting room. Admit them directly to isolation from a back or side door. 5. Handle the dog from its arrival using enhanced protective clothing that will not be used with other patients and institute solid general infection control strategies. 6. If a dog with possible influenza must be hospitalized, keep it in isolation. 7. If H3N8 influenza is also present in the area, considering canine influenza vaccination; however, the canine influenza vaccine likely offers no protection against H3N2 influenza. Although H3N2 probably does not pose a human risk, the above cautionary measures are important in regard to zoonotic spread should the virus evolve. Owners should be instructed to keep their pets away from other dogs if they are sick and to avoid travel with their dogs to an endemic region or if your practice is in an endemic region, ask clients to avoid taking their dogs when traveling to unaffected areas. To protect uninfected pets, owners in areas where the virus is active should be advised to avoid taking their dogs to places where they are likely to encounter other dogs, such as dog parks and pet stores. Everyone should avoid importing dogs from shelters, puppy mills, or other such facilities in areas where H3N2 is active. ALTHOUGH IT IS NOT KNOWN HOW THIS ASIAN STRAIN ARRIVED IN THE NORTH AMERICAN DOG POPULATION, SOME EXPERTS POINT TO A STEADY INFLUX OF RESCUE DOGS FROM ASIA, NOTABLY FROM SOUTH KOREA. Modified from Worms & Germs Blog. Subscribe for free at wormsandgermsblog.com 8 cliniciansbrief.com May 2015

11 PetPlan, Computers4Africa Support AFSCAN; Unwanted IT Equipment Needed The African Small Companion Animal Network (AFSCAN) has received its first donation supporting its program to promote small animal clinical research relevant to Africa. The pledge by David Simpson, Chair of Trustees at the PetPlan Charitable Trust, donated 5,000 to the funding of such a project as well as a 1,000 bursary slated to assist an African veterinary student to undertake a placement in a research laboratory. The new AFSCAN clinical research program will provide veterinarians working in African universities with funding to undertake locally relevant investigations related to small animal disease or welfare. Additional funding will be allocated to encourage students to spend time in research laboratories through the extramural bursary scheme. AFSCAN is an initiative of the WSAVA Foundation meant to advance standards of veterinary care across Africa through education and facilitation of a sustainable network of companion animal veterinarians, associations, and specialist groups. Five countries in sub-saharan Africa are currently participating: Kenya, Namibia, Nigeria, Tanzania, and Uganda. At this year s BSAVA Congress, AFSCAN called for support for its Scientific Projects program. Pet- Plan Charitable Trust immediately offered its assistance. Foundation, said: Our Scientific Projects Programme will address an unmet need in the African academic community and help improve our knowledge base of diseases affecting small companion animals in Africa. We hope it will also foster the next generation of veterinary researchers and highlight the importance of investigating diseases in these species. He added: We hope that the research funding provided by AFSCAN will be matched by further donations for each selected project and are absolutely delighted that the Petplan Charitable Trust has already stepped forward to offer funding for a research project and a student bursary. We would, of course, be very happy to hear from other potential sponsors. Education remains a key focus for AFSCAN, and its Distance Learning for Colleagues in Africa project is now working to increase the availability of high-quality CE resources across the continent. As accessibility of these resources depends on Internet access, U.K.-based charity Computers 4Africa is repurposing unwanted devices and shipping them to Africa for use by AFSCANparticipating practices. Its work is supported by the BSAVA, which has called on its members to donate unneeded equipment. Veterinary practices in the U.K. wishing to donate redundant computers, tablets, smartphones, and other IT equipment are asked to: Contact Computers4Africa, which will arrange to collect the equipment free of charge for a minimum of 10 computers plus other items. (See computers 4africa.org.uk) Take it to a donation center around the U.K. (See computers4africa.org.uk/ appeals/index.php) Contact Vetstream to deliver it to its offices near Cambridge. (See vetstream.com) Left to right: Sharon Roberts, Computers4Africa; Adebowale Ajao, veterinarian; Dr. Gabriel Varga, Chair of AFSCAN Board; Olufunke Adebayo, veterinarian; Professor Michael Day, member of AFSCAN Board; Paschal Umeakuana, veterinarian; Martin Lassen, Kruuse. Professor Michael Day, AFSCAN Board member and Vice-President of the WSAVA May 2015 Clinician s Brief 9

12 CAPSULES THE CURRENT LITERATURE IN BRIEF Anesthetics, Analgesia, & Alfaxalone Alfaxalone is a synthetic neurosteroid anesthetic used in many countries as an IV induction agent. Similar to propofol in regard to good quality of anesthetic induction and cardiopulmonary variables, it may be given IV to effect or as a continuous rate infusion. It is unclear, however, if alfaxalone provides any analgesia. Ketamine and medetomidine are often used in cats in combination for premedication and induction. This combination is known to provide good anesthesia and some postoperative analgesia. The objective of this prospective, blinded study was to compare physiologic parameters and postoperative pain in cats undergoing ovariohysterectomy (OHE) using alfaxalone vs ketaminemedetomidine anesthesia. Twenty-one cats were randomly divided into 2 groups. One group received alfaxalone at 5 mg/ kg IV, followed by 2 mg/kg IV boluses given if response to surgical stimuli or a 20% increase in blood pressure over anesthetic baseline were noted. The second group received medetomidine at 30 µg/kg IM followed by ketamine at 5 mg/ kg IV; 2 mg/kg IV ketamine was given as described for alfaxalone. All cats received meloxicam at 0.2 mg/kg IV postoperatively. Postoperative physiologic parameters, sedation, and pain were assessed at multiple times. Results showed that ketamine-medetomidine produced better analgesia after OHE than alfaxalone. Both groups, however, developed a primary hyperalgesia. The authors suggest that alfaxalone is appropriate for the induction and maintenance of anesthesia for OHE in cats but that additional sedatives and analgesics should be given. Global Commentary Few studies assess the contribution of general anesthetics to postoperative analgesia probably because most, if not all, only produce unconsciousness and some muscle relaxation but not analgesia. Controversially, alfaxalone exhibited pre-emptive analgesic effects in rats, but it remains unclear if alfaxalone could provide some analgesia in a clinical setting. In this study, premedication was excluded to assess the effect of alfaxalone on postoperative pain and to mimic practice conditions, where a single drug injection protocol is often preferred for short procedures. However, I always try to combine sedatives with opioids in my premedication protocols. I keep in mind the invasiveness of the surgery, not its duration, to select the type of opioid and dose. This study showed that cats receiving ketamine and medetomidine had better post-surgical analgesia than alfaxalone cats but, more importantly, that neither anesthesia protocol prevented primary hyperalgesia. These results show the importance that premedication plays in anesthesia, particularly for providing the patient with a suitable, long-lasting, and, ideally, preemptive analgesic regimen. Francisco Laredo, BVSc, PhD, Cert. VA, MRCVS (Anesthesia & Analgesia), Spain Source Alfaxalone or ketamine-medetomidine in cats undergoing ovariohysterectomy: A comparison of intra-operative parameters and post-operative pain. Guerrero KSK, Reichler IM, Schwarz A, et al. Vet Anaesth Analg 41: , Diagnostic Value of Lymph Node FNA Lymph node (LN) cytology is an accessible, inexpensive test with good sensitivity and specificity, albeit with intrinsic limitations. This retrospective study aimed to describe common indications for LN fine needle aspirates (FNA) and reported cytological diagnoses as well as frequency and explanations for nondiagnostic samples from dogs and cats. FNA sample records were evaluated for sampling, sample quality, diagnosis achieved, and reason for nondiagnostic samples. It was hypothesized that samples with clinical history provided and greater number of slides submitted would increase likelihood of diagnosis. In the 1473 records reviewed, the most common reasons for aspirate submission were investigation of lymphadenopathy or tumor staging. In dogs, 72.8% of samples were diagnostic; in cats, 85.9%. In dogs, the most common diagnosis was lymphoma, followed by reactive hyperplasia. In cats, most common was reactive hyperplasia, followed by lymphoma; however, only 50% of these lymphoma cases were confidently diagnosed, compared with 73% in dogs. The most common causes of nondiagnostic samples were absence of nucleated cells, cell disruption, and low cell yield. Submission of clinical history did not correlate with likelihood of reaching diagnosis. In dogs, submission of a higher number of slides was correlated with a higher likelihood of a diagnostic sample and cytological 10 cliniciansbrief.com May 2015

13 Splenectomy & Short-Term Survival In dogs, splenic masses are common and possibly life-threatening. Although there is information available about long-term survival in dogs undergoing splenic surgery, less is available regarding short-term survival. In this retrospective study, the medical records of 539 dogs were reviewed. All had undergone splenectomy for known splenic mass at a large academic referral hospital. The most common malignant tumor was hemangiosarcoma (n = 228); the most common non-neoplastic lesion was hematoma (n = 104). Perioperative mortality rate was 41/539 (7.6%). Twenty-one dogs died following cardiopulmonary arrest, and 20 were euthanized because they were considered moribund. Causes of death included uncontrollable hemorrhage (n = 10), known or suspected portal system thrombosis (n = 9), suspected pulmonary thromboembolism (n = 4), known or suspected pneumonia (n = 4), and known or suspected disseminated intravascular coagulation (n = 3). For each decrease in platelet count of 10,000 platelets/ µl at admission, odds of death increased 6%. Platelet counts may serve as a valuable gauge of overall coagulation status in smaller practices where coagulation testing may not be readily available. Dogs with a PCV <30% or dogs that developed cardiac arrhythmia during surgery were twice as likely to die as dogs with a PCV >30% or dogs that did not develop arrhythmia. Results indicate that reductions in perioperative mortality rate could potentially be achieved through improved recognition and treatment of hemorrhage and thrombotic and coagulopathic syndromes. Global Commentary Splenic masses are a common disease in general practice. Most cases are probably asymptomatic until there is acute blood loss caused by splenic mass rupture, which is why the survival of these cases is challenging. This study found 3 risk factors for perioperative death; whether the mass was neoplastic was not a risk factor. That is a key point in decision making not only for practitioners but also for pet owners. For them, it is difficult to authorize surgery in cases where long-term prognosis is guarded. In this paper, we see that the risk factors for peri-operative death are the same in neoplastic and non-neoplastic lesions, and all surgeons know that a mass with neoplastic aspects can be a hematoma or vice versa. The risk factors reported here can be useful in clinical cases, and our efforts need to be focused on preoperative stabilization and monitoring to reduce the perioperative mortality rate. Esteban Pujol, DVM, DECVS, Spain Source Risk factors for perioperative death in dogs undergoing splenectomy for splenic masses: 539 cases ( ). Wendelburg KM, O Toole TE, McCobb E, et al. JAVMA 245: , diagnosis. Educating practitioners on improved sample collection, smearing technique, and in-house sample examination before submission may increase diagnostic value of LN FNA. Global Commentary This study, which involved submission of nonstained samples with the standard staining in the laboratory, clearly demonstrates that LN cytology is highly diagnostic. Nondiagnostic samples were the result of either sampling or smear-preparation technique. In most clinical settings, slightly more nondiagnostic samples may be expected because of poor staining. There is no reason, however, to consider that the LN cytology is of low diagnostic yield. If the result is nondiagnostic because of the sample preparation, a clinician can repeat the procedure for better sampling. If it is nondiagnostic because of the nature of the lesion, the clinician can turn to surgical resection and histopathology. This is a low-risk, high-return procedure. Takuo Ishida, DVM, PhD, DJCVP, Japan Source The diagnostic utility of lymph node cytology samples in dogs and cats. Amores-Fuster I, Cripps P, Graham P, et al. J SMALL ANIM PRACT 56: , May 2015 Clinician s Brief 11

14 Global Council This protocol for the management of pain for pregnant or lactating patients is part of a continuing series in Clinician s Brief gleaned from the WSAVA Global Pain Treatise, issued by the Global Pain Council (GPC). The treatise is available in full in the GPC pages at WSAVA.org. WSAVA Global Pain Council Pain Management Protocol The following pain management protocol is tiered to ensure a global relevance, recognizing that not all analgesic modalities are available to veterinary practitioners and vary from region to region around the world. Its implementation will be guided by the various analgesic modalities available along with the needs of the individual patient requiring treatment. This protocol is reproduced from the WSAVA Global Pain Treatise, a succinct yet comprehensive review of pain assessment, various pain modalities, and the treatment of various clinically painful scenarios in both dogs and cats. The WSAVA GPC Pain Treatise published in the Journal of Small Animal Practice and is available for open access at the GPC pages of Pregnant or lactating patients Very little information is available about the pharmacology of analgesic drugs in dogs and cats during pregnancy and lactation; some information is presented from studies in humans and laboratory species. Pregnancy Physiological changes associated with the maternal-placental-foetal unit alter drug pharmacodynamics, pharmacokinetics and distribution to the foetus. The maternal factors that may alter drug absorption are decreased gastrointestinal motility, oesophageal reflux and vomiting; and an increased cutaneous blood flow, which may enhance absorption of transdermally administered drugs. Increased total body water, increased total body fat, reduced serum albumin, altered hepatic enzymatic activity and increased renal function are all factors that may alter the response of pregnant animals to analgesic drugs. The placental barrier is considered to be a lipoprotein, therefore drugs with high lipid solubility are permeable. Drugs that are polar, ionized, protein-bound or water soluble are less likely to cross the placenta into the foetus. Opioids: Currently, opioids are commonly used for analgesia in pregnant dogs and cats. Methadone, morphine and hydromorphone are used during pregnancy in humans. Fentanyl, pethidine (meperidine), butorphanol and nalbuphine are more lipid soluble, and therefore may reach higher concentrations in the foeti. Opioids are frequently used preoperatively for caesarian section, and most puppies and kittens are successfully delivered and are vigorous. If the puppies or kittens are depressed after delivery, alongside provision of warmth, stimulation, and oxygen and application of suction as required, a drop of naloxone placed sublingually should reverse these effects; however repeat dosing may be required. Buprenorphine resulted in lack of milk production in animal studies, which may be a problem following casesarian. NSAIDs: Due to possible teratogenicity and development-interfering effects, it is advised that NSAIDs are not administered to pregnant animals. Ketamine: Ketamine rapidly crosses the placenta; however, no foetal effects have been observed during organogenesis and near delivery in rats, mice, rabbits and dogs. Ketamine increases uterine tone and should be avoided during pregnancy. An in-depth review of caesarean section in dogs is available. Alpha 2 adrenoceptor agonists: Reduce uterine blood flow. Xylazine should not be used during pregnancy. Evidence regarding the use of medetomidine and dexmedetomidine in dogs and cats during pregnancy is not available. Local anaesthetics: Generally considered to be safe and non-teratogenic they are highly recommended. Herbal analgesic medications: Due to a lack of information, these should be avoided. Lactation Characteristics of a drug which would facilitate secretion into milk are high lipid solubility, low molecular weight and the non-ionized (charged) state. It is estimated that the neonate receives approximately 1% to 2% of the maternal dose of a drug. Where analgesia is essential and there are concerns for potential toxicity in the offspring, the milk should be pumped and discarded for 12 h before resuming suckling, and puppies and kittens should be bottle fed. Opioids: The lipid solubility of the opioid influences its appearance in the milk; pethidine (meperidine) > sufentanil > fentanyl > morphine > hydromorphone, therefore a more hydrophilic opioid, such as morphine, may appear in smaller amounts than a more lipid-soluble opioid such as pethidine. It is recommended that suckling occurs after peak levels of the opioid have waned. Pethidine (meperidine), butorphanol, nalbuphine are not recommended. Where opioids are selected for analgesia, mothers and offspring should be carefully observed and monitored for signs of opioid adverse effects. NSAIDs: Most NSAIDs are not lipid soluble, are highly protein bound to plasma proteins and may be present to a great degree in an ionised form in the plasma. It has been suggested that a single use of an NSAID is safe in nursing human mothers. Until studies are performed in lactating cats and dogs, NSAIDs should be administered with caution and as single doses only. Hemorrhage is a potential concern following the administration of non-cox selective, or COX-1 selective NSAIDs immediately after caesarian section, or even natural birth. In general, paracetamol is safe for use in dogs, but cannot be administered to cats. Local anaesthetics: Lidocaine and its metabolites have low lipid solubility; at therapeutic doses the concentrations in milk are small and unlikely to be a risk. Incision line infiltration is highly recommended. Ketamine: No reports on passage into breast milk were found, but it is expected to pass into breast milk. Herbal analgesic medications: Due to a a lack of information, these should be avoided. World Small Animal Veterinary Association. Adapted from Mathews K, et al. Guidelines for recognition, assessment and treatment of pain. Journal of Small Animal Practice 2014; 55: E10 E68 and produced by The British Small Animal Veterinary Association. See full text for further information. WSAVA would like to recognize the GPC sponsors 12 cliniciansbrief.com May 2015

15 GLOBAL EXCLUSIVE > SURGERY > PEER REVIEWED The Basic Surgery Kit Jan Janovec, MVDr, MRCVS VRCC Veterinary Referrals Laurent Findji, DMV, MS, MRCVS, DECVS Fitzpatrick Referrals Considering the virtually limitless range of surgical instruments, it can be difficult to assemble a cost-effective basic surgery kit. Some instruments may misleadingly appear multipurpose, but their misuse may damage them, leading to unnecessary replacement costs or, worse, intraoperative accidents putting the patient s safety at risk. Many instruments are available in different qualities and materials (eg, tungsten carbide instruments more expensive but much more resistant to wear and corrosion than stainless steel) and varied sizes to match the purpose of their use as well as the size of the surgeon s hand. Cutting Instruments Scalpel The scalpel is an indispensible item in a surgical kit designed to make sharp incisions. Scalpel incision is the least traumatic way of dissection, but provides no hemostasis. Scalpel handles come in various sizes, each accommodating a range of disposable blades (Figure 1). Entirely disposable scalpels are also available. Scissors Scissors are used for cutting, albeit with some crushing effect, and for blunt dissection. Fine scissors, such as Metzenbaum scissors (Figure 2), should be reserved for cutting and dissecting delicate tissues. Sturdier scissors, such as Mayo or suture scissors, are designed for use on denser tissues (eg, fascia) or inanimate objects (eg, sutures, drapes). All scissors can be either straight or curved, the latter intended for keeping the hand out of the surgeon s line of vision during use. Grasping Instruments Towel clamps Towel clamps are designed to secure drapes to the patient s skin. They are available in various sizes and with either penetrating or nonpenetrating tips. Towel clamps with penetrating tips can also be used for skin handling or temporary wound approximation during reconstructive procedures. Needle-holders Needle-holders are for manipulation of needles only. Their jaws are short and crosshatched to prevent any undesired movements of the needle during its passage through tissues. They are expensive and delicate instruments and therefore should never be misused (eg, for orthopedic wire twisting). Commonly used needle-holders are Mayo-Hegar and Olsen-Hegar (Figure 3). The latter combines needle-holders and scissors, minimizing instrument change but exposing to inadvertent cutting of the suture. Minimal Basic Surgery Kit n 1 instrument case n 1 scalpel handle n 1 pair Mayo scissors n 1 pair Metzenbaum scissors n 1 pair suture scissors n 1 pair Mayo-Hegar needle holder n 1 pair Brown-Adson tissue forceps n 1 pair DeBakey tissue forceps n 4 pairs mosquito hemostatic forceps (2 curved, 2 straight) n 4 pairs Crile hemostatic forceps (2 curved, 2 straight) n 8 pairs Backhaus towel clamps n 2 Senn-Miller retractors n Suction unit with tips (1 Frazier, 1 Poole) n Electrosurgery unit with unipolar and bipolar hand-pieces continues May 2015 Clinician s Brief 13

16 SURGERY A B A. No. 3 and No. 7 scalpel handles. 1 B. Nos. 10, 11, and 15 disposable scalpel blades (top to bottom). 3 Mayo-Hegar needle-holder. A A C B D 4 A, B. Mosquito hemostats with a detailed view of the jaws. C, D. Carmalt forceps with a detailed view of the jaws. B 2 A. Mayo, Metzenbaum, and suture scissors. B. Langenbeck and Senn-Miller hand-held retractors (top to bottom). Ratcheted Tissue Forceps These forceps are equipped with a ratchet that enables tissue manipulation without repeated grasping. They are also used for hemostasis, blunt dissection, and temporary hollow viscus occlusion. Their appropriate use can be determined by the design of their jaws, which can be straight or curved, smooth or serrated, or specifically shaped. Mosquito, Crile, and Kelly forceps are commonly used for occlusion of vascular pedicles. Carmalt forceps are suitable for spay procedures (Figure 4). Allis forceps and Babcock forceps have jaws specifically shaped for grasping tissues, and Doyen forceps have long smooth jaws designed for atraumatic 14 cliniciansbrief.com May 2015

17 temporary intestinal occlusion. Misuse of these forceps (eg, for grasping needles, orthopedic pins) can have serious consequences (eg, failure to hold occlusion of a large vascular pedicle). Thumb Forceps Thumb forceps, held in a chop-stick fashion in the nondominant hand, are designed for accurate tissue handling without direct contact between surgeon s fingers and tissue. They are also used to manipulate needles during suturing. Most commonly used thumb forceps are (listed from most to least traumatic): rattoothed forceps, Adson forceps, Brown-Adson forceps, and DeBakey forceps (Figure 5). Atraumatic forceps are used on delicate tissues such as hollow organs, whereas more traumatic forceps are reserved for dense tissue such as fascia, aponeuroses, etc. A basic surgical kit should contain at least a pair of toothed and a pair of nontraumatic thumb forceps. Retractors Retractors help improve exposure and protect retracted structures. Retractors can either be hand-held (by an assistant) or self-retaining. Their use is determined by the size and shape of their blade(s). Long blades are used for retraction of deep tissues. Sharp-blade retractors limit accidental slippage of the retractor and are usually used on strong tissues (eg, fascia, muscles, and subcutaneous tissue). Blunt retractors are useful for retracting delicate and fragile tissues (eg, viscera) or a larger amount of tissues. Commonly used hand-held retractors are Senn-Miller and Langenbeck retractors (Figure 2). Self-retaining retractors designed to maintain body cavities open (eg, Balfour or Gossett retractors for abdominal surgery) are useful, especially when a surgical assistant is not available. Other Equipment Suction Unit & Tips A suction unit (Figure 6) is an invaluable tool used for removing blood and other body fluids from the surgical field. Copious rinsing of the surgical field or body cavities is essential for surgical conditions (eg, septic peritonitis), and complete retrieval of lavage fluids, which is mandatory, can only be achieved through the use of a surgical suction unit. The device consists of a negative pressure generator, containers, tubing, and various tips, which can be either disposable or reusable. The configuration of the suction tip determines its use: Frazier tips are designed for pin-point suction, while Poole and Yankauer tips are designed not to be occluded during suction from body cavities. Electrocautery Electrocautery devices use electric current to produce heat to cut tissues and cauterize vessels. They consist of a generator and various accessories connected by cables (hand-piece, dispersive plate, and foot switch). Unipolar electrocautery can be used for A B C A B C A B 5 6 A. DeBakey thumb forceps. B. Rat-tooth thumb forceps. C. Brown-Adson thumb forceps with detailed view of the jaws. A. A suction unit. B. Yankauer, Poole, and Frazier suction tips (top to bottom). C. Electrosurgical unit. D. Unipolar and bipolar hand-piece. hemostasis as well as for cutting. Bipolar electrocautery can only be used for hemostasis, but it creates less collateral damage. Although relatively expensive, electrocautery is extremely worthwhile and almost mandatory to perform most soft-tissue surgeries with appropriate hemostasis and minimal complications (Figure 6). C D May 2015 Clinician s Brief 15

18 DEPARTMENT > CATEGORY > PEER REVIEWED The legacy of Neill Overman Neill P. Overman January 23, 1938 April 4, 2015 is fully centered in the veterinary profession, and his influence will long be felt by those who did not know him, as well as those who knew, respected, and esteemed him. While not himself a veterinarian, he championed the advancement of the profession as one of its own. Recognizing the need for authoritative, practical continuing education by those in practice, Neill took on providing for it himself. Compendium on Continuing Education for the Practicing Veterinarian, his first publication, quickly became a trusted everyday resource. At about the same time that it was launched, so was the Eastern States Veterinary Association Conference, now known as the NAVC Conference. Neill was enlisted as its exhibits manager, a role that he filled for many years, helping to build NAVC to what it is today. As media professionals, we learned much at Neill s side, not the least of which was to love this profession and those who serve in it. Neill made a mark that will endure for untold generations. Taking time to honor him is our privilege. continues 16 cliniciansbrief.com May 2015

19 OUR AUTHORS This month s issue proudly features the following speakers from recent NAVC Conferences: J. Brad Case, Autumn P. Davidson, Gregory F. Grauer, and Cheryl Lopate. J. BRAD CASE, DVM, MS, DACVS, is assistant professor and small animal surgeon at University of Florida. His primary research interest is minimally invasive soft tissue surgery, especially laparoscopy and thoracoscopy. A frequent speaker and laboratory instructor with the NAVC, Dr. Case is also a speaker for Florida Veterinary Medical Association. A graduate of University of California, Davis, he completed a rotating internship at Texas A&M and a master s in residency training at Colorado State University. procedures pro page 54 AUTUMN P. DAVIDSON, DVM, MS, DACVIM, is clinical professor of medicine and epidemiology at University of California, Davis. She specializes in small animal theriogenology and infectious disease and practices at Pet Care Veterinary Hospital. Dr. Davidson is a graduate of University of California, Davis, where she completed her small animal medicine residency. She completed her small animal medicine and surgery internship at Texas A&M University. comparative imagery page 25 W. ALEXANDER FOX-ALVAREZ, DVM, is master s student and small animal surgical resident at University of Florida, where he earned his DVM. His primary area of interest is exotic and zoo animal surgery, with a research emphasis on minimally invasive techniques. He completed a small animal emergency and zoo animal rotating internship at Valley Animal Hospital in Tucson. procedures pro page 54 GREGORY F. GRAUER, DVM, MS, DACVIM, is professor and Jarvis chair of medicine in the clinical sciences department at Kansas State University. His area of interest, research, and teaching is the small animal urinary system, a topic he lectures about at the NAVC Conference. He has served as professor and section chief of small animal medicine at Colorado State University and faculty member at University of Wisconsin Madison, where he completed his internship and residency and earned his master s. Dr. Grauer is a graduate of Iowa State University. ask the expert page 49 JAMES HOWARD, DVM, is small animal medicine and surgery rotating intern at University of Tennessee. His diverse interests include respiratory diseases and multi-modal treatment protocols for critical patients. Dr. Howard graduated from Ohio State University. ask the experts page 33 continues May 2015 Clinician s Brief 17

20 OUR AUTHORS CHERYL LOPATE, DVM, MS, DACT, is owner of Reproductive Revolutions in Aurora, Oregon, and veterinarian at Wilsonville Veterinary Clinic in Wilsonville, Oregon. She specializes in companion animal and equine reproduction. Dr. Lopate completed a residency in comparative theriogenology at Purdue University after receiving her MS in reproductive physiology and DVM from Ohio State University. diagnostic tree page 20 RON OFRI, DVM, PhD, DECVO, is associate professor of veterinary ophthalmology at his alma mater, Hebrew University of Jerusalem, where he was a member of the charter class. Winner of numerous Teacher of the Year awards, Dr. Ofri has written more than 60 reviewed papers and is an international speaker, contributing author to Veterinary Ophthalmology, and coauthor of Slatter s Fundamentals of Veterinary Ophthalmology. He received his doctorate from University of Florida, where he studied retinal function in glaucoma. procedures pro 28 SARAH SCHMIDT, DVM, DACVP (Clinical Pathology), performs diagnostic pathology for IDEXX reference laboratories in North Grafton, Massachusetts. Prior, she was a general small animal practitioner and lecturer at Tufts Cummings School of Veterinary Medicine. She received her DVM degree from University of Florida and completed her clinical pathology residency at Tufts University. top 5 page 22 M. KATHERINE TOLBERT, DVM, PhD, DACVIM, is assistant professor at University of Tennessee, where her laboratory focuses on using cell-based models to characterize pathogenic mechanisms of enteric infections and exploring novel therapies to prevent and/or ameliorate infectious enterocolitis in cats. Her varied clinical research includes studies of respiratory disease, acid-related disorders, and GI infections. A graduate of University of Georgia, where she completed a small animal internship, Dr. Tolbert completed a small animal internal medicine residency and a comparative biomedical sciences doctorate at North Carolina State University. ask the experts page 33 n cb 18 cliniciansbrief.com May 2015

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22 DIAGNOSTIC TREE > REPRODUCTION / DIAGNOSTICS > PEER REVIEWED Penile Discharge in Dogs PENILE OR PREPUTIAL DISCHARGE Author Insight To differentiate UTI from prostatic infection, compare culture and cytology of a cystocentesis or catheterobtained sample with a prostatic fluid wash or prostatic aspirate sample. INVESTIGATION Presenting signs Preputial or penile discharge (eg, bloody, purulent, mucoid) Excessive licking or signs of genital pain/discomfort Stranguria, hematuria, dysuria, pollakiuria Constipation, ribbon-like stool, tenesmus INVESTIGATION Clinical considerations Inability to extend penis from prepuce Lymphoid follicles or vesicular lesions on penis or prepuce Penile, urethral, or prostatic mass (smooth, irregular) Irregular mucosal surface on penis or prepuce Petechiae or ecchymoses on mucosal surfaces or skin Enlarged scrotum, scrotal contents Enlarged prostate on digital rectal examination Author Insight All bacteria that can cause pathology can also be normal flora. High numbers of a single organism along with signs of infection or inflammation suggest the organism is pathologic. Mixed populations indicate normal flora; antibiotics are not required. Mycoplasma spp is a common co-isolate when infection is present, but it may not indicate pathologic infection. 4 Common normal floras include Escherichia coli, Pseudomonas spp, Staphylococcus spp, Streptococcus spp, Pasteurella spp, Klebsiella spp, and Mycoplasma spp. Differentials Clear or mucoid discharge Hemorrhagic discharge Purulent discharge Persistent penile frenulum Hypospadias Traumatic penile adhesions Phimosis Herpesvirus infection 1,2 Neoplasia (penile, preputial) Hormonal imbalance with puberty, exogenous steroids, enodgenous estrogen (Sertoli cell tumor) UTI or incontinence Poor hygiene Calicivirus infection Trauma (penile, preputial) Foreign body Herpesvirus infection 1,2 Brucella canis infection Balanoposthitis or prostatitis from aerobic bacteria, Mycoplasma spp, Ureaplasma spp, fungi Benign prostatic hyperplasia Neoplasia of prostate, urethra, bladder, penis, or prepuce or squamous metaplasia of the prostate Exogenous steroids or endogenous estrogen (Sertoli cell tumor, estrogen creams or patches) 3 UTI or urolith Coagulopathy Poor hygiene Snake or insect bite Persistent penile frenulum Hypospadias Trauma, hair impaction Foreign body Phimosis B canis infection Balanoposthitis, prostatitis, orchitis, epididymitis from aerobic bacteria, Mycoplasma spp, Ureaplasma spp, fungi Neoplasia urethral, penile, preputial, prostatic UTI or urolith Poor hygiene Author Insight Some yellowish-white to slight light-greenish-tinged preputial discharge is normal. Intact and brachycephalic dogs tend to have increased normal discharge. The amount of normal discharge tends to increase with age, as self-grooming diminishes with aging. 20 cliniciansbrief.com May 2015

23 Cheryl Lopate, DVM, MS, DACT Reproductive Revolutions Aurora, Oregon DIAGNOSTICS General procedures CBC, serum chemistry panel Urinalysis and urine culture Coagulation panel, buccal mucosal bleeding time for platelet function Test for hemospermia B canis screening test; if positive for B canis, AGID For prostate/bladder disease Ultrasound of prostate, bladder, urethra Cytology of prostatic secretion, sediment or aspirates or urine sediment Cystocentesis for UA or urine culture Cytology or histopathology of prostatic wash, aspirate, or biopsy Culture of third fraction of ejaculate, prostatic wash fluid, or aspirate/biopsy Preputial mucosal cytology to look for evidence of hyperestrogenism (cornification) Abdominal radiographs Contrast urethrography For penile/preputial disease Extrusion of entire penis past bulbus glandis Cytology of penile or preputial surface lesions Preputial cytology to look for evidence of hyperestrogenism (cornification) Endoscopic examination of the prepuce Radiography to assess os penis Urethral catheterization to assess for partial obstruction from mass in urethra or at seminal colliculus How to Perform Prostatic Wash 1. Allow the patient to urinate 2. Sedate the patient 3. Empty the dog s bladder via catheter and flush with 5 10 ml of saline. Save sample for urine cytology and culture. 4. Pass a polypropylene or red rubber catheter over the pelvis rim. With a digit in the rectum, position the tip of the catheter just caudal to the prostate 5. Vigorously massage the prostate per rectum with the inserted digit 6. Occlude the urethral opening and inject 5 10 ml sterile saline 7. Advance the catheter forward a few centimeters while aspirating as much sample as possible 8. Perform cytology and culture on the recovered sample and compare to urine sample. TREATMENT Treatment of underlying condition Gentle cleansing with saline or a very dilute (weak tea-colored) povidone-iodine solution for balanoposthitis Probiotics for balanoposthitis or if patient is treated with long-term antibiotics to help maintain normal GI flora Antibiotics based on culture and susceptibility testing results for prostatitis or cystitis Foreign body removal Surgical removal of masses or correction of anatomic defects Treat benign prostatic hyperplasia with neutering, antiandrogens, or gonadotropin agonists Benign neglect for hormonal imbalance of peripubertal individuals Discourage licking Recurrent infections investigate prostate or urinary tract for primary source of infection Restrict exposure to exogenous hormones Contact state veterinarian if B canis confirmed Author Insight Infection may be secondary to inappropriate or prolonged antibiotic therapy and bacterial overgrowth of pathologic organisms. AGID = agar gel immunodiffusion, UA = urinalysis, UTI = urinary tract infection References 1. Genital disease in dogs caused by canine herpesvirus. Hill, H, Maré CJ. AM J Vet Res 35: ; Clinical considerations of canine herpesvirus infection. Anvik JO, Vet Med 86: , The genital Mycoplasma and Ureaplasma flora of healthy and diseased dogs. Doig PA, Ruhnke HL, Bosu WT. Can J Comp Med 45: , Canine mycoplasmas: Their ecologic niche and role in disease. Rosendal S. JAVMA 180: , May 2015 Clinician s Brief 21

24 TOP 5 > DIAGNOSTICS > PEER REVIEWED Top 5 Leukogram Patterns Sarah Schmidt, DVM, DACVP (Clinical Pathology)* Ashland, Massachusetts A CBC is often completed as part of the minimum database. When the CBC is performed with an in-house hematology analyzer, a blood smear evaluation should be pursued as well to verify automated results, including confirmation of white blood cell (WBC) differential and evaluation for atypical cells, such as mast cells, blasts, and nucleated red blood cells. Following confirmation of automated results, evaluation of the leukogram, which includes total WBC count, absolute values of individual leukocytes, and leukocyte morphology, should be performed to identify any pattern. When evaluating WBC differentials, absolute cell numbers (WBC count leukocyte %) should be interpreted as opposed to leukocyte percentage only. Top 5 Leukogram Patterns 1. Stress Leukogram 2. Inflammatory Leukogram 3. Persistent Lymphocytosis (of Mature Lymphocytes) 4. Neutropenia 5. Eosinophilia 1 Stress Leukogram A stress leukogram is characterized by neutrophilia, lymphopenia, eosinopenia, and potentially monocytosis. 1 It occurs primarily in dogs. The term stress denotes the presence of increased cortisol released from the adrenal gland secondary to severe disease (eg, diabetic ketoacidosis, renal failure), high body temperature, pain, dehydration, or hyperadrenocorticism. 1 n Neutrophilia occurs because of increased release of mature neutrophils from the bone marrow storage pool to circulating blood and decreased movement of neutrophils from circulating blood to tissue. n Lymphopenia results from retention of lymphocytes in lymphoid organs and lymphocyte lysis. n Eosinopenia is caused by decreased release of eosinophils from the bone marrow and increased lysis. n Lymphopenia is the hallmark of a stress leukogram. While the degree of neutrophilia may decrease over time, lymphopenia and often eosinopenia will persist as long as plasma concentrations of steroid hormones are increased. n Monocytosis is often found in dogs because of movement of monocytes from the marginating to circulating pool. Monocytosis can be variably found in feline stress leukograms. A stress leukogram may also be seen following administration of exogenous glucocorticoids. A single dose of glucocorticoids may result in a stress leukogram lasting for approximately 24 hours; glucocorticoids administered for longer than 10 days may result in a stress leukogram that persists for 2 3 days after the drug is discontinued. 2 The magnitude of the neutrophilia is usually up to twice the upper limit of the normal reference interval. * At the time of publication, Dr. Schmidt works with IDEXX. At the time of article creation, Dr. Schmidt was an independent contractor. 2 Inflammatory Leukogram An inflammatory leukogram may be characterized by neutrophilia, or in some instances neutropenia, with or without a left shift or toxic change. Inflammatory mediators result in the release of neutrophils from the bone marrow storage pool to the circulation, and an increased rate of bone marrow neutrophil production, with or 22 cliniciansbrief.com May 2015

25 without the presence of a left shift and toxic change. Following stimulation of the bone marrow by inflammatory mediators, it takes approximately 2 to 5 days for maturation and release of neutrophils. A left shift indicates that immature (nonsegmented) neutrophils have been released from the bone marrow into circulation prior to maturation to segmented cells. Toxic change includes Dohle bodies (pale blue irregularly shaped cytoplasmic inclusions), increased cytoplasmic basophilia, and foamy/vacuolated cytoplasm. Toxic change indicates accelerated production of neutrophils by the bone marrow (Figure 1). In general, as the left shift or degree of toxic change increases, so does the severity of the underlying inflammatory process. While neutrophils are emerging from the bone marrow, circulating neutrophils are migrating to the source of the inflammation. The presence of a neutrophilia vs neutropenia depends on the balance between neutrophil production and increased tissue demand. Inflammatory diseases include infectious causes (bacterial, fungal, viral, protozoal), immune-mediated diseases (immune-mediated hemolytic anemia, polyarthritis), and tissue necrosis. Many inflammatory diseases result in a neutrophilia that is 2 to 10 times the upper limit of the normal reference interval. Other diseases in which the infection is isolated, such as a walled-off abscess, may result in a marked neutrophilia because production and release from bone marrow is high but tissue consumption of circulating neutrophils is low as the cells cannot easily infiltrate the lesion. 1 After the source of the inflammation is removed (eg, infected uterus), neutrophilia may persist for 2 5 days because earlier stimulated neutrophil precursors will continue with maturation and the source of tissue consumption no longer exists. 3 Persistent Lymphocytosis (of Mature Lymphocytes) As lymphocytes may transiently increase following excitement or exercise secondary to epinephrine, a lymphocytosis should be verified by a repeat CBC. A review of the blood smear is indicated if the lymphocytosis is persistent, as differentials will be dependent on lymphocyte morphology (small, mature lymphocytes vs lymphoblasts) (Figures 2 and 3). Persistently increased numbers of small to intermediate lymphocytes with condensed (mature) chromatin can be the result of a neoplastic lymphocytosis or a nonneoplastic lymphocytosis. Chronic lymphocytic leukemia (CLL) is a type of neoplastic lymphocytosis in which lymphocytes appear small to intermediate in size and have condensed chromatin. The absolute lymphocyte count for CLL can be vary between 6000/µL and 8000/µL in dogs and cats, respectively, to greater than 150,000/µL. 3 Lymphocyte counts greater than 20,000 30,000/µL are generally more A toxic band neutrophil is found at 1 the top of the image above a toxic segmented neutrophil. Both cells have increased cytoplasmic basophilia and foamy cytoplasm. (Modified Wright s stain, 50 original magnification) The majority of the leukocytes are 2 small lymphocytes with condensed chromatin. A vacuolated monocyte is present at the top left of the image. Two broken cells are present at the right side of the image. (Modified Wright s stain, 50 original magnification) The leukocytes are blast cells, most 3 suggestive of lymphoblasts. The cells are approximately µm in diameter with immature chromatin and variably distinct nucleoli. (Modified Wright s stain, 50 original magnification) CLL = chronic lymphocytic leukemia, WBC = white blood cell continues May 2015 Clinician s Brief 23

26 TOP 5 worrisome for CLL than for nonneoplastic conditions, although some overlap may occur. Causes for nonneoplastic lymphocytosis include diseases that result in immune stimulation, including Ehrlichia canis infections in dogs, feline leukemia/feline immunodeficiency virus infection in cats, and Mycoplasma felis infection in cats. 2,3 Thymoma and hypoadrenocorticism are differentials for dogs and cats. Hyperthyroidism and immune-mediated hemolytic anemia are additional differentials for cats. Flow cytometry of a fresh blood sample (ideally within 2 days) can greatly aid in determining a neoplastic lymphocytosis from a nonneoplastic lymphocytosis. The presence of blast cells should be reviewed by a clinical pathologist. 4 Neutropenia Neutropenia can be caused by increased consumption of recently released and circulating mature segmented cells, decreased production, and immune-mediated destruction. Increased consumption can result from severe inflammatory disease, bacterial infections, or endotoxemia. Decreased production can result from insult to myeloid precursor cells from drugs or toxins or replacement of myeloid precursors by neoplastic cells. Immunemediated destruction is suspected when other causes of neutropenia have been ruled out and the patient responds to immunosuppressive drugs. The cause for neutropenia may be multifactorial as seen in parvovirus infections, in which the virus attacks rapidly dividing myeloid precursor cells and compromises gastrointestinal integrity, resulting in endotoxemia, as well as feline leukemia virus infections that can damage hematopoietic precursor cells and lead to secondary infections that consume circulating neutrophils. 4,5 5 Eosinophilia Increased bone marrow production of eosinophils is most commonly the result of parasite antigens or allergens. Parasites commonly associated with eosinophilia are those found within tissues including Dirofilaria immitis, Aelurostrongylus abstrusus, Toxocara spp, Toxascaris leonina, Ancylostoma caninum, A braziliense, A tubaeforme, and Uncinaria stenocephala. Blood cell parasites, including Mycoplasma spp, Babesia spp, and Cytauxzoon spp, do not typically result in an eosinophilia. Hypersensitivity reactions secondary to cutaneous allergens such as flea saliva are commonly associated with eosinophilia, whereas hypersensitivity reactions to inhaled allergens (atopic dermatitis) are generally not. 6 Eosinophilia has also been reported with generalized inflammation (including bacterial infections) of tissues rich in mast cells, including the lungs, intestinal tract, skin, and genitourinary tract. Reported eosinophil counts that have been associated with various diseases affecting these tissues range from ,000/µL with a median value of generally less than 7000/µL. 6 Hypoadrenocorticism (Addison s disease) is another consideration for eosinophilia and has been associated with eosinophil counts of µl. Idiopathic hypereosinophilic syndrome, which is characterized by eosinophil tissue infiltration, circulating granulocytes with mature morphologic features, and lack of anemia or thrombocytopenia is strongly considered with eosinophil counts greater than 20,000 µl. Conclusion Evaluation of the leukogram pattern can aid in formulating differential diagnoses. n cb References 1. Interpretation of leukocyte responses in disease. Weiser G. In Thrall MA (ed): Veterinary Hematology and Clinical Chemistry Ames: Blackwell, 2006, pp Interpretation of canine leukocyte responses. Valenciano AC, Decker LS, Cowell RL. In Weiss DJ, Wardrop KJ (eds): Schalm s Veterinary Hematology, 6th ed. Ames: Blackwell, 2010, pp Determining the significance of the persistent lymphocytosis. Avery AC, Avery PR. Vet Clin North Am Small Anim Pract 37: , Neutropenia in dogs and cats: Causes and consequences. Schnelle AN, Barger AM. Vet Clin North Am Small Anim Pract 42: , Neutropenia in dogs and cats: A retrospective study of 261 cases. Brown MR, Rogers KS. JAAHA 37: , Diseases associated with pronounced eosinophilia: A study of 105 dogs in Sweden. Lillihöök I, Gunnarsson L, Zakrisoon G, Tvedten H. J Small Anim Pract 41: , Suggested Reading Eosinophils and their disorders. Young KM, Meadows RL. In Weiss DJ, Wardrop KJ (eds): Schalm s Veterinary Hematology, 6th ed. Ames: Blackwell, 2010, pp Fundamentals of Veterinary Clinical Pathology, ed 2. Stockham SL, Scott MA Ames: Blackwell, 2008, pp General features of leukemia and lymphoma. Helfand SC, Kisseberth WC. In Weiss DJ, Wardrop KJ (eds): Schalm s Veterinary Hematology, 6th ed. Ames: Blackwell, 2010, pp Veterinary Hematology: A Diagnostic Guide and Color Atlas. Harvey JW St. Louis: Saunders Elsevier, 2012, pp CLL = chronic lymphocytic leukemia 24 cliniciansbrief.com May 2015

27 COMPARATIVE IMAGERY > THERIOGENOLOGY > PEER REVIEWED Determining Canine Estrus Stage via Vaginal Cytology Autumn P. Davidson, DVM, MS, DACVIM University Of California, Davis Performing vaginal cytology offers a rapid, inexpensive, and reliable in-clinic method to evaluate stages of the estrus cycle in the bitch. Veterinary discomfort with obtaining and interpreting vaginal cytology is common; submission to a commercial laboratory might result in diagnostic delays and increased client costs. Equipment required for vaginal cytology (cotton-tipped applicators, frosted microscope slides, commercial Romanowsky [Diff-Quik] stain, and light microscope) is already present in most small animal practices. Competence in vaginal cytology allows a clinician to: n Determine whether a bitch is actually in heat. n Aid in determining the correct time to begin performing more expensive serum progesterone and luteinizing hormone (LH) assays for precise ovulation timing. n Determine if it is too late in the estrus cycle to perform artificial insemination in dogs unable or unwilling to breed naturally. n Determine if a bitch is under the influence of estrogen (endogenous or exogenous). n Predict the correct day to perform an elective cesarean section (C-section). Proper Technique Proper technique is important so that cells obtained are representative of hormonal changes. The sample should be collected from the cranial vagina because cells from the clitoral fossa, vestibule, urethral papilla, or vestibulovaginal junction are not as indicative of the stage of the cycle and provide confusing results (A). A cotton-tipped applicator (moistened with water if needed) should be passed into the vulva in a dorsal direction and advanced horizontally above the clitoral fossa and urethral papilla into the vagina, which is at the level of the cranial thigh (B). After swabbing (by gently rubbing or rolling) the vaginal wall, the applicator is removed and rolled (not smeared) onto a glass slide (C). The slide should be labeled, including name and date (with a pencil). Routine Diff-Quik staining is performed after air-drying the slide. Scan the slide at low power first (10 ) and high power as necessary (40 ) to aid in particular cell identification. It is best to survey a large area of the slide for cell types. A B C C-section = cesarean section, LH = luteinizing hormone continues May 2015 Clinician s Brief 25

28 COMPARATIVE IMAGERY Questions Answered Through Vaginal Cytology n Is the bitch in heat? As estrogen rises during proestrus, maturation rate of the vaginal epithelial cells increases, as does the number of keratinized, cornified epithelial (ie, superficial) cells seen on a vaginal smear. Full cornification continues throughout estrus, which prepares the vagina for natural breeding. Proestrus and diestrus cytologies can be similar (parabasal and intermediate cells ± neutrophils). Rechecking in 48 hours can clarify the stage. n When should progesterone be tested for ovulation timing? Breeder clients should be advised to notify the clinic when they first notice vulvar swelling, vaginal discharge, or attraction to males in a bitch for which breeding is planned. Early proestrus should be documented by vaginal cytology (<50% cornified [superficial cells]). Vaginal cytology should be performed every 2 to 4 days until a significant progression in cornification is seen, usually above 70% superficial cells. At that point, serial hormonal assaying should begin. n Is it too late to breed? At the end of the fertile period, vaginal cytology undergoes the diestrual shift, which signifies the first day of diestrus. Breeding after the diestrual shift is rarely successful. n Is the bitch under the influence of estrogen (eg, ovarian remnant, unspayed, exposure to owner s hormone replacement medication)? The defining characteristic of estrogen influence is the presence of superficial cells in vaginal cytology, but this should be confirmed with additional tests. n How do I predict the right day for an elective C-section? If vaginal cytology is performed until the diestrual shift is observed, a retrospective analysis of the date of the LH surge (7 10 days previously), ovulation and ova maturation (approximately hours after the LH surge), and the fertile period (approximately 3 6 days after the LH surge) can be obtained. It is the least expensive way to perform ovulation timing, albeit retrospectiveiy, and can be useful if evaluation of gestational age becomes important, as parturition (C-section) should occur 56 to 58 days from the day of the diestrual shift. Vaginal Cytology Six types of cells typify vaginal cytology: parabasal cells (A), which look like small, O-shaped oat cereal pieces; small intermediate and large intermediate cells (B), which look like fried eggs; superficial ( cornified ) (C) cells, which look like corn flakes; neutrophils; and red blood cells. Non-cornified Cornified A B C Parabasal Intermediate Superficial For further suggested reading, see page 32. C-section = cesarean section, LH = luteinizing hormone 26 cliniciansbrief.com May 2015

29 Remember the Estrus Cycle The 4 phases of the estrus cycle are: 1. Anestrus (not in heat): Parabasal cells predominate; the cellularity is low (A). 2. Proestrus (early estrogen influence): From early to late proestrus, a gradual shift from parabasal and intermediate cells (small then larger) and finally superficial cells occurs (B). Typically, red blood cells are present in large numbers (C). 3. Estrus (receptive, fertile): Superficial cells predominate and their nuclei become pyknotic or absent/anuclear (D, E). 4. Diestrus (the luteal phase): Onset of diestrus is marked by a precipitous decline in the number of superficial cells and reappearance of intermediate and parabasal cells within 1 to 2 days. Neutrophils are commonly observed (F), and large numbers of bacteria are also often present (G). n cb A B C D E F G

30 PROCEDURES PRO > OPHTHALMOLOGY / DIAGNOSTICS > PEER REVIEWED Ophthalmic Examination Made Simple Ron Ofri, DVM, PhD, DECVO Hebrew University of Jerusalem Rehovot, Israel What You Will Need n Room that can be darkened n Transilluminator n Magnifying loupe n Schirmer tear test strips n Fluorescein stain strips n Tonometer n Topical anesthesia n Tropicamide solution n Ophthalmoscope n Fine forceps n Swabs An ophthalmic examination should not be a daunting experience. Interpretation of examination findings may be challenging; however, the examination follows a logical, anatomical order. Furthermore, it does not require expensive equipment. In fact, the most important items required are non-ophthalmic (see What You Will Need). STEP-BY-STEP n OPHTHALMIC EXAMINATION STEP 1: GROSS INSPECTION Mild blepharospasm in the left eye of a 1 cat diagnosed with feline herpesvirus 1 associated dendritic ulcers. Signs of mild pain are best observed from a distance, without touching the facial area. Observe the patient as it walks into the room. An unfamiliar environment, like the examination room, may highlight visual deficits that can later be evaluated in more detail. After completing the history and physical examination, begin the ocular assessment by carefully observing the patient from a distance. At this point, avoid touching the patient s facial area as this may cause distortion of the palpebral fissure. While observing the patient, consider: n Are both eyes open normally? Is there evidence of pain (Figure 1) or photophobia? Is the animal blinking normally? n Are the eyes of normal size and position? Is there evidence of exophthalmos or buphthalmos? Are the pupils of equal size? n Is the eyelid conformation normal? Is there evidence of entropion or ectropion (usually of the lower lid)? Is the third eyelid elevated? n Is there ocular discharge? What is its nature? 28 cliniciansbrief.com May 2015

31 STEP 2: ASSESS VISION Vision is most commonly tested by evaluating the menace response. This involves making a sudden, threatening gesture, which should elicit a blink response. The menace response involves cerebral cortical integration and interpretation and, therefore, is not a reflex. The menace response should be evaluated in one eye, while the other eye is covered (Figure 2). Avoid touching the patient s eyelashes/hair or causing wind movement; this may lead to a false-positive response. Consider making the menace gesture from behind a glass partition. Author Insight Medications (sedatives, opioid analgesics) can alter mental status, and the menace response may be missing in a visual animal. Reasons for a false negative include facial nerve paralysis (ruled out by testing the blinking reflex), young age (usually <10 12 weeks), and patient s mental status. The menace response test 2 administered by making a threatening gesture with the hand. The untested eye is covered, and care is taken not to touch the facial hair, to prevent a false-positive response. STEP 3: EVALUATE PUPILS After the light has been dimmed, pupil dilation should be evaluated. In the dim light, stand far enough away from the patient to visualize both pupils simultaneously, using the tapetal reflection. The tapetal reflection also serves to highlight (by means of retroillumination) any ocular opacities, particularly in the lens or vitreous humor. Next, use a bright light to evaluate the pupillary light reflex (PLR). Unlike the menace response, the PLR is a subcortical reflex. Its afferent arm depends on the integrity of the retina, optic nerve, optic chiasm, and proximal optic tracts up to the pretectal nuclei. Therefore, it does not test vision, and a normal PLR may be found in a cortically blind animal. The PLR is usually present (although it may be diminished or slow) in animals suffering from outer retinal degeneration, cataracts, and other causes of subcortical blindness. Nevertheless, the PLR is an important test as it helps localize lesions cause vision loss. If one of the pupils does not react to light, or if it cannot be visualized (eg, cases of severe corneal edema or hyphema), the consensual PLR should be checked (Figure 3). Alternatively, check the dazzle reflex; this is also a subcortical reflex, which is manifested as a bilateral, partial blink in response to a very bright light. Severe hyphema following head trauma 3 in a dog. As the pupil cannot be seen, checking the consensual PLR or dazzle reflex has great prognostic value. Author Insight A common cause of a false-negative PLR is a weak source of stimulating light. Use a fully charged focal transilluminator to elicit the reflex. PLR = pupillary light reflex continues May 2015 Clinician s Brief 29

32 PROCEDURES PRO STEP 4: EXAMINE ANTERIOR EYE STRUCTURES Continue the examination in a dark room using magnification and a focal light source. The anterior eye structures are examined in anatomical order. STEP 4A EYELIDS & EYELASHES Evaluate the size of the palpebral fissure; look for a narrowed or enlarged fissure. Carefully examine the skin for discharge and for signs of dermatologic disorders (eg, dermatitis, alopecia, scaling, swelling, crusting, and ulceration). Pay particular attention to the eyelid margin; normally, the entire margin should be in close contact with the globe (A). Lack of contact may be caused by ectropion (drooping lid). If the margin, or parts of it, cannot be seen, the lid may be inverted (entropion). Eyelash abnormalities may be better visualized if the lid is slightly retracted. Dark lashes can then be highlighted against the background of the white conjunctiva. STEP 4B THIRD EYELID & CONJUNCTIVA At rest, the third eyelid should be mostly retracted and hardly visible. The inner aspect of the third eyelid margin may be examined after application of topical anesthetic and eversion of the lid with fine forceps. Look for foreign bodies or hyperplasia of lymphatic follicles. Similarly, examine the conjunctiva lining the inner aspect of the eyelids and globe for moistness, as well as any change in color, congestion, edema, prominent vessels, masses, thickening, discharge, or subconjunctival hemorrhage (B). STEP 4C CORNEA & SCLERA The normal cornea should be smooth and transparent. Any deviation from these characteristics represents pathological changes. Look for loss of transparency (C) caused by: n Edema a bluish haze of the stroma with an orange peel outline n Pigmentation deposition of melanin in the epithelium or superficial stroma, usually caused by chronic irritation n Vascularization individual blood vessels that appear branching if the vascularization is superficial or chronic, and/or brush-bristle -like if deep or acute n Cellular infiltration white-to-yellow haze in the stroma with indistinct borders and in the presence of other signs of active inflammation n Lipid or mineral deposition glistening white speckles in the stroma n Fibrosis a white, feathery opacity of the stroma, which presents with well-defined borders and no other signs of inflammation. Look for surface irregularities, which may be caused by ulceration, perforation and iris prolapse, granulation tissue, feline corneal sequestration, keratoconus, or foreign bodies. Evaluate the corneal diameter. An enlarged diameter may indicate glaucoma, while a reduced diameter will indicate a phthisical or microphthalmic eye. In unilateral cases, one can easily compare the corneal diameter of the presenting eye to that of the normal eye. If uncertain, or in bilateral cases, the corneal diameter should be measured using the markings on a Schirmer tear test strip. The corneal diameter is breed-dependent, but is mm in most dogs, and mm in most cats. Alternatively, use an ultrasound machine to measure the axial length of the globe, which should be about 21 mm in most dogs and cats. A The eyelids of the right eye are in correct anatomical position, firmly in contact with the globe, and the eyelid margin of the entire lower lid can be visualized. B The outer surface of the third eyelid can be inspected by pressing on the globe (through the upper lid), thus causing protrusion of the third eyelid. The palpebral conjunctiva of the lower eyelid is also inspected at the same time by everting the lower eyelid. C Corneal edema and superficial vascularization in a dog with leishmaniasis. Blepharitis is also present. 30 cliniciansbrief.com May 2015

33 STEP 4D ANTERIOR CHAMBER Assess the depth of the anterior chamber (best visualized from the side), as it may be increased or decreased in various intraocular diseases. Normally, the aqueous humor should be clear. Look for any opacities or masses, including: n Blood n Fibrin amorphic white to yellow strands or clots in the anterior chamber (D) n Hypopyon inflammatory cells in the anterior chamber n Aqueous flare microscopic inflammatory material in the anterior chamber, which causes scattering of a well-focused light slit n Luxated lens a clear or opaque sphere in the anterior chamber n Persistent pupillary membranes fine strands of iris with a base in the iris collarette, and a distal tip that may be free floating, or touching the lens capsule, corneal endothelium, or a distant part of the iris n Uveal cysts single or multiple, free-floating or fixed fluid-filled balloons that have well-defined borders and can be transilluminated n Vitreous strands fine, gray-to-white wisps that can be seen entering the anterior chamber at the pupillary margin D Hyphema and fibrin in the anterior chamber cause loss of aqueous humor transparency. STEP 4E IRIS & PUPIL Look for alterations in pupil shape, which may be caused by: n Anterior or posterior synechiae adhesion of the iris to the cornea or the anterior lens capusle, respectively, will result in an irregularly shaped pupil, and decreased or absent iris motility n Iris atrophy loss of iris tissue, especially near the pupil margin, resulting in holes or very thin iris, which can be retroilluminated n Hypoplasia or coloboma congenital absence of iris tissue, leading to iris bowing, or formation of holes or notches in the iris (E) Changes in pupil color may indicate cataract, hemorrhage, or retinal detachment. The pupil may be miotic in uveitis, mydriatic in glaucoma and various retinal diseases, and abnormally dilated or constricted in various nervous system diseases. Examine the surface of the iris for any masses or changes in color. These may be caused by inflammation, hemorrhage, pigmentary changes, atrophy or neoplasia. Fluttering of the iris may indicate lens luxation. STEP 4F LENS A comprehensive lens examination requires dilation of the pupil. The lens may be examined with direct illumination and visualization, or by retroillumination using tapetal reflection. The two main pathologies are opacities, which would indicate cataract or luxation (F). Anterior lens luxation can be diagnosed rather easily, as the anterior chamber is mostly filled with a clear or opaque sphere, usually causing corneal edema and severe pain. Posterior lens luxation should be suspected when the anterior chamber is deeper than normal and the iris is fluttering, as it no longer rests on the lens. The lens may sometimes be seen resting horizontally in the bottom of the vitreal cavity, and the optic nerve head and retinal vessels may be seen without the aid of an ophthalmoscope. E The pupil is abnormally shaped as a result of iris coloboma in the nasal half of the pupil (6 to 12 o clock). The red reflection through the pupil indicates a subalbinotic fundus, which is a normal variation. F A nuclear cataract visible with direct illumination in the eye of a dog. Author Insight Elderly dogs with nuclear sclerosis are frequently presented for cataracts. Dilate the pupil and use retroillumination to reach a correct diagnosis. continues May 2015 Clinician s Brief 31

34 STEP 5: OPHTHALMOSCOPY Ophthalmoscopy should be conducted in a dark room, following pupil dilation. Carefully inspect the entire fundus, evaluating changes in the tapetum, nontapetum, blood vessels, and optic disc. Additional Tests n Schirmer tear testing is used to evaluate tear production and diagnose keratoconjunctivitis sicca. It should be conducted early in the examination, as any ocular manipulation may induce reflex tearing, and prior to the topical administration of any diagnostic or therapeutic eye drops. n Fluorescein staining is used to diagnose corneal ulcers. Superficial corneal disease may be diagnosed using Rose Bengal, which stains devitalized epithelium. n Samples for bacteriology, mycology, and cytology may be taken as indicated. Bacteriology and mycology samples should be taken before any drops are put in the eye, as solutions frequently contain preservatives. n Nasolacrimal patency is evaluated by passage of fluorescein from the eye to the nose, by cannulating the nasolacrimal system, and by dacryocystorhinography. n Ultrasonography is frequently used in ophthalmology. Main indications are for imaging the retrobulbar area and the posterior segment when they cannot be visualized (eg, because of hyphema or cataracts). CT and MRI techniques may be used in certain cases. n Additional tests, including gonioscopy (evaluation of the iridocorneal angle as part of a glaucoma diagnosis) and electroretinography (recording electrical responses of the retina to flashes of light, to determine retinal function) may be available in referral centers. n cb 5 Monocular indirect ophthalmoscopy is used to examine the fundus. Author Insight Perform an ophthalmoscopic examination of all patients, not just ophthalmic cases. This will help practitioners gain the required proficiency and familiarity with normal fundus variations. Suggested Reading Diagnostic Techniques. Maggs DJ. In Maggs DJ, Miller PE, Ofri R. Slatter s Fundamentals of Veterinary Ophthalmology, 5th ed St. Louis: Elsevier, 2013, pp Examination of the Eye and Adnexa. Barnett KC, Heinrich C, Sansom J. In Canine Ophthalmology. An Atlas & Text London: WB Saunders, 2002, pp 1 8. Examination of the Eye and its Adnexa. Stades FC, Wyman M, Boevé MH, Neumann W, Spiess BM. In Ophthalmology for the Veterinary Practitioner, 2nd ed Hannover: Schlutersche-Verlagsgesellschaft, 2007, pp Eye Examination and Diagnostics. Gelatt KN. In Essentials of Veterinary Ophthalmology, 3rd ed Ames: Wiley-Blackwell, The Eye Examination and Diagnostic Procedures. Featherstone HJ, Heinrich CL. In Gelatt KN. (ed) Veterinary Ophthalmology, 5th ed Ames: Wiley-Blackwell, 2013, pp The Ophthalmic Examination and Anamnesis. Martin CL. In Ophthalmic Diseases in Veterinary Medicine London: Manson Publishing, continued from page 21 Suggested Reading Ovulation timing: Concepts and controversies. Goodman M. Vet Clin North Am Small Anim Pract. 31: , Practicing theriogenology. Davidson AP. In Nelson RW, Couto CG (eds). Small Animal Internal Medicine, 5th ed St. Louis: Elsevier, 2014, pp cliniciansbrief.com May 2015

35 ASK THE EXPERTS > ONCOLOGY / DIAGNOSTICS > PEER REVIEWED Feline Tracheal Tumors: Uncommon or Overlooked? James Howard, DVM M. Katherine Tolbert, DVM, PhD, DACVIM University of Tennessee You have asked What do I need to consider when presented with a feline patient in respiratory distress to prevent a delayed or missed diagnosis of tracheal neoplasia? The experts say Facing a dyspneic feline patient can be intimidating for veterinarians and frightening for owners. There are many causes of feline respiratory distress, but one that receives little attention is tracheal neoplasia. Feline tracheal tumors are infrequently reported. 1 As such, clinical suspicion is typically low, and there is a paucity of recommended diagnostic and treatment plans for feline tracheal tumors. The scarcity of reported or confirmed feline tracheal tumors is mirrored in human literature, where 2% of respiratory tract tumors are reported to originate from the trachea. 2 No predisposing causes are known for tracheal neoplasia. 3 One hypothetical factor responsible for limiting neoplastic invasion may be the unique anatomic morphology of the trachea, which includes a patent rigid lumen with dynamic airflow and kinociliary respiratory epithelium. Unrecognized immunologic defenses may also provide antineoplastic protection. In a case series exploring feline upper airway tumors, laryngeal tumors were 3 times more common than tracheal tumors. 4 This, too, is reflected in the human literature, with a large retrospective study reporting that development of laryngeal tumors is 40 times more likely than tracheal tumors. 5 It is not understood why this prevalence disparity exists in spite of similar anatomic topography. Epidemiology Cats with tracheal tumors are typically middle-aged patients (median age, 9.5 years; range, 2 13 years), and there is no known sex predilection. 6 Interestingly, dogs with tracheal tumors show a bimodal age distribution, with presenting signs noted before 2 and after 6 years of age. 6 This pattern results from the variance in tumor types of different age groups. Younger canine patients may be diagnosed with benign osteochondroma; older patients are at risk for adenocarcinoma and chondrosarcoma, among others. 4 Domestic short-haired cats are overrepresented in reports of tracheal tumors, but this may be the result of a disproportionate population bias. 7 An overrepresentation of Siamese cats with tracheal lymphoma has been reported; however, no other breed predispositions were noted. 6,7 Although supportive therapies rarely result in resolution of clinical signs, the tumor location, concurrent comorbidities, anesthetic risks, financial constraints, and owner expectations may limit aggressive treatment. continues May 2015 Clinician s Brief 33

36 ASK THE EXPERTS Thoracic radiographs performed on a cat with mixed respiratory 1 signs. Moderate bronchial and mild unstructured interstitial pulmonary patterns consistent with nondescript chronic airway disease and age-related changes can be observed. 2 Cervical radiographs performed on the same cat as in Figure 1. A large cervical tracheal mass (arrow) occluding approximately 90% of the trachea at C3 C5 can be observed. Clinical Signs There are no pathognomonic signs that signal the presence of feline tracheal tumors. The most common presenting complaints include dyspnea, stridor, wheezing, dysphonia, and coughing. 6,7 These nonspecific signs present a challenge to veterinarians as they mimic other diseases. The insidious nature of tracheal tumors may also present a diagnostic and therapeutic challenge. Cats with tracheal tumors often receive supportive treatment for general respiratory illness, which results in delayed intervention and progression of clinical disease. Moreover, 40% to 50% of the tracheal lumen can be occluded before clinical manifestations of the disease are recognized. 8 Diagnostics A thorough physical examination, including tracheal palpation, auscultation, and a laryngeal examination, are paramount to early detection of upper respiratory tumors in cats with nonspecific respiratory illness. Radiographs remain the most widely available screening modality for identification of tracheal neoplasia. 7,9,10 Air provides an excellent natural contrast medium for diagnosis of tracheal masses. Cats with tracheal tumors may have concurrent lung pathology. Thus, the presence of lower respiratory disease should not preclude evaluation for tracheal tumors if clinical suspicion exists. Failure to pursue additional imaging, including cervical and thoracic radiographs, may lead to a misdiagnosis or delay in therapy (Figures 1 and 2). Studies have shown no significant difference in tumor predilection for the cervical trachea vs the intrathoracic trachea. Esophagrams provide an additional inexpensive diagnostic test. This modality aids in the identification of tracheal tumors through exclusion of artifacts, including esophageal superimposition and extraluminal compression from surrounding structures. 11 Tracheoscopy and computed tomography provide information for surgical planning and assessment of peritracheal invasion. 11,12 Treatment Treatment options should be individualized for each patient and considerate of the owners expectations. Given the generally low metastatic rate, aggressive surgical intervention is recommended when the mass is deemed resectable (with the exception of primary lymphoid tumors). 2,3,13 Resection and anastomosis are possible for tumors located in both the cervical and thoracic trachea. Historically, surgical planning has allowed for removal of 50% of the trachea without secondary stenosis. 8 However, a more recent study suggests that although tracheal diameter remains unaffected, negative changes to the luminal diameter of lobar bronchi occur with 30% tracheal resection and anastomosis procedures. 14 Endoscopic debulking using a wire snare is also described and may afford prolonged survival without the need for concurrent medical management. Moreover, it may provide immediate clinical relief. 9 Debulking is not without risk as tracheal tumors may be highly vascular and invasive. Therefore, associated complications can include intraluminal hemorrhage and cervical or mediastinal emphysema if a full-thickness hole in the tracheal wall is made. Clients should be informed that debulking procedures are palliative, and recrudescence of disease should be anticipated. Chemotherapy and radiation can be considered but require a definitive diagnosis. 34 cliniciansbrief.com May 2015

37 These treatment options are typically reserved for tumors of lymphoid origin, where they are considered to be the treatment of choice. Similar to endoscopic debulking, chemotherapy and radiation are considered palliative. Tracheal stenting is a palliative treatment that can be offered to patients when surgery is not an option. 15 Progression of disease should be anticipated in these cases. Therefore, stents should not to be considered a first-line therapy. Stent placement has been described in a small population of cats with benign and neoplastic causes of tracheal narrowing. 16 No complications followed these procedures, but welldocumented risks in humans include stent dislodgement and stricture formation. 15 Supportive Care Advanced disease often dictates the choice of supportive care for cats with tracheal tumors. Although supportive therapies rarely result in resolution of clinical signs, the tumor location, concurrent comorbidities, anesthetic risks, financial constraints, and owner expectations may limit aggressive treatment. Supportive care options include antiinflammatory drugs, antibiotics for secondary bacterial infections, and bronchodilators. Routine veterinary evaluations and client education to recognize worsening clinical signs cannot be overemphasized. Progressive tumor growth puts cats at high risk for acute respiratory distress. A thorough client discussion is a necessity to ensure patients are closely monitored for progressive disease. Prognosis The limited number of reported cases makes prognostication difficult. Survival may be influenced by treatment selection; however, the overall prognosis for cats with tracheal tumors is guarded. Jakubiak et al demonstrated an overall median survival time of cats with malignant laryngeal and tracheal tumors of 15.5 days ( days). 7 Reported survival times for surgical resection and endoscopic debulking of tracheal tumors ranged from 3 35 months and 1 35 months respectively. 9,10,17 In a case series, chemotherapy and radiation treatment in 2 cats with lymphoma provided remission and long-term resolution of clinical signs for 17 and 19 months, respectively. 18 Survival times for supportive care are difficult to assess because of challenges associated with consistent patient follow-up and limited published data. Conclusion Cats with tracheal tumors are presented with nonspecific clinical signs and are likely under-recognized. Erroneous clinical assessment and recognition may lead to delayed treatment and decreased survival rates. 5 Prompt therapeutic intervention requires appropriate clinical suspicion and diagnostics. Widely available imaging modalities, including cervical, thoracic radiographs, and contrast esophagrams, aid in the diagnosis of tracheal neoplasia. Multiple treatment options exist, including surgical resection, interventional debulking, chemotherapy and radiation, and supportive care. Appropriate patient selection, diagnosis, treatment choice, and owner education may result in a better prognosis than previously reported. n cb References 1. Obstructive lesions and traumatic injuries of the canine and feline tracheas. Roach W, Krahwinkel DJ, Jr. Contin Educ Vet 31:E6, Primary tracheal tumors: review of 37 cases. Ahn Y, Chang H, Lim YS, et al. J Thorac Oncol 4: , Respiratory tract. In Morris J, Dobson JM (eds): Small Animal Oncology Malden: Blackwell Science, 2001, p Tracheal and laryngeal tumors in the dog and cat: Literature review and 13 additional patients. Carlisle CH, Biery DN, Thrall DE. Vet Radiol 32: , Clinical aspects and treatment of primary tracheal malignancies. Honings J, Gaissert HA, van der Heijden HF, et al. Acta Otolaryngol 130: , Primary tracheal tumors in dogs and cats. Brown MR, Rogers KS. Compend Cont Educ Pract 25: , Laryngeal, laryngotracheal, and tracheal masses in cats: 27 cases ( ). Jakubiak MJ, Siedlecki CT, Zenger E, et al. JAAHA 41: , Diseases of the trachea and bronchi. Nelson AW. In Slatter DH (ed): Textbook of Small Animal Surgery, 3rd ed Philadelphia: WB Saunders, 1985, pp Bronchoscopic debulking of tracheal carcinoma in 3 cats using a wire snare. Queen EV, Vaughan MA, Johnson LR. JVIM 24: , Tracheal adenocarcinoma in 2 domestic shorthaired cats. Evers P, Sukhiani HR, Sumnersmith G, et al. J Small Anim Pract 35: , Computed tomography of a cat with primary intratracheal lymphosarcoma before and after systemic chemotherapy. Dugas B, Hoover J, Pechman R. JAAHA 47:E131-E137, Computed tomography correlation of airway disease with bronchoscopy Part II: tracheal neoplasms. Jamjoom L, Obusez EC, Kirsch J, et al. Curr Probl Diagn Radiol 43: , Tumors of the respiratory system. Withrow SJ. In Withrow SJ, Vail DM, Page RL (eds): Small Animal Clinical Oncology, 5th ed St. Louis: Saunders, 2007, pp Progressive tracheal resection and anastomosis alters position of lobar bronchi but not tracheal diameter. Souza C, Reinero C. Veterinary Cancer Society/Veterinary Society of Surgical Oncology Mid-Year Meeting, March Treatment of tracheal tumors. Gaissert HA, Honings J, Gokhale M. Semin Thorac Cardiovasc Surg 21:290-5, Intraluminal tracheal stenting for treatment of tracheal narrowing in three cats. Culp WT, Weisse C, Cole SG, Solomon JA. Vet Surg 36:107-13, Diagnosis and treatment of tracheal basal cell carcinoma in a Maine coon and long-term outcome. Green ML, Smith J, Fineman L, et al. JAAHA 48: , Primary intratracheal lymphosarcoma in four cats. Brown MR, Rogers KS, Mansell KJ, et al. JAAHA 39: , May 2015 Clinician s Brief 35

38 Capsules Inside Look for these respected commentators in this issue: Jason Bleedorn Allyson Gosling Takuo Ishida Francisco Laredo Ellen M. Lindell Esteban Pujol Cecilia Robat Elke Rudloff John J. Schaefer Christopher Snyder Heather Troyer Julie Walker Bruce Williams Ewan Wolff Insulin options...36 Rocky Mountain spotted fever Diagnosing parasites Light therapy Refrigerated plasma Carbimazole reaction Inhibiting fibrinolysis Managing biliary atresia Tear film stabilization Effects of baicalin...41 HSA diagnosis...41 Periodontal disease Gallbladder rupture Trypanosoma cruzi Feline hippocampal necrosis Canine compulsive disorder Multimodal rehabilitation...45 Research Note: Making Insulin Inroads Canine diabetes mellitus is characterized by hyperglycemia caused by an absolute or relative deficiency in the pancreatic β-cell hormone insulin. The production of purified beef and pork insulin is diminishing with the introduction of recombinant techniques for the production of human insulin. The manufacture of recombinant insulin is problematic, as production methods are based on prokaryotic expression systems that lack the intracellular machinery and enzymes required for correct folding and processing of proinsulin to insulin. The gene product, preproinsulin, undergoes substantial post-translational Takometer at English Wikipedia modification in pancreatic β-cells before becoming biologically active. A more efficient method would be to synthesize recombinant insulin that does not require post-translational modification to exert biological activity. Illustration of insulin molecules courtesy of In this study, 3 recombinant canine single-chain insulin (SCI) analogs were developed. All were capable of binding to insulin receptors and stimulating glucose uptake in cells without post-translational processing. Recombinant canine SCI analogs could be easily produced in bacteria to offer a potential treatment option for diabetic dogs. Source Recombinant canine single chain insulin analogues: Insulin receptor binding capacity and ability to stimulate glucose uptake. Adams JP, Holder AL, Catchpole B. VET J 202: , Production of purified beef and pork insulin is diminishing with recombinant techniques for production of human insulin. 36 cliniciansbrief.com May 2015

39 CAPSULES Wait a Tick: R rickettsii Attachment Time This study evaluated the onehealthinitiative.com minimum feeding period required by Amblyomma aureolatum to transmit Rickettsia rickettsii, causative agent of Rocky Mountain spotted fever (RMSF). A aureolatum ticks are the main vector of RMSF in the metropolitan area of São Paulo, Brazil. Guinea pigs were infested with fed or unfed adult A aureolatum ticks or unfed nymphs, all inoculated with R rickettsii. Results showed unfed nymphs and unfed adult ticks needed to be attached >10 hours to transmit disease, whereas adult ticks that had fed on rabbits just prior to attachment on the guinea pigs needed >10 minutes for transmission. A previous study on guinea pigs demonstrated a process called reactivation in which R rickettsii in fasting ticks loses pathogenicity and virulence, but allowing infected fasting ticks to feed for >48 hours induces R rickettsii to revert to a virulent state. This reactivation may be responsible for the different time requirements for disease transmission between fed and unfed ticks. Minimum attachment times as low as 2 hours have been noted for Dermacentor andersoni ticks transmitting Rickettsia rickettsii. The elevated infection and fatality rates for humans diagnosed with RMSF in São Paulo are likely the result of ticks feeding on domestic dogs in the rainforest, then making contact with humans. Tickremoval procedures in RMSF-endemic areas may have implications for RMSF transmission, as the typical expectation that tick-borne bacteria require tick attachment >2 hours may discourage humans from immediately removing ticks. Commentary The question of the minimum tick-attachment time needed for transmission of different pathogens is critical in evaluating infection risk. A 36-hour minimum attachment time is commonly referenced regarding Borrelia burgdorferi transmission by Ixodes scapularis; however, minimum attachment times as low as 2 hours have been noted for Dermacentor andersoni ticks transmitting R rickettsii. The species of tick and host, life stage of the tick, previous feeding history, sex of the tick, attachment site, and other factors could potentially affect this estimate. Fever, seroconversion, and lesion development were used as indicators of successful transmission in this study. The males previous feeding history, unfed since molting vs partially fed, had a significant impact on minimum attachment time, with a minimum of >10 hours noted in the former case (similar to nymphal transmission) and as little as 10 minutes attachment required in the latter case. This is significant in understanding tickborne disease transmission and recommending prevention techniques. John J. Schaefer, DVM, MS, PhD, DACVM Source Feeding period required by Amblyomma aureolatum ticks for transmission of Rickettsia rickettsii to vertebrate hosts. Saraiva DG, Soares HS, Soares JF, Labruna MB. EMERG INFECT DIS 20: , Research Note: Fecal Findings & Parasite Diagnosis Parasitic diseases comprise some of the most important zoonoses, especially in developing countries where onehealthinitiative.com sanitary conditions are not ideal. Toxocara spp and Ancylostoma spp are 2 such parasites that infect dogs and can also infect humans. In humans, these parasites are known to cause visceral larva migrans and cutaneous larva migrans. This study evaluated different techniques for diagnosing parasites in fecal samples. The study analyzed 285 fecal samples collected in Brazil from public areas and private backyards. Samples were analyzed using 3 techniques: Willis-Mollay flotation technique; spontaneous sedimentation (Hoffman, Pons, and Janer); and modified centrifugal flotation. More than half (56.49%) were positive for eggs and/or oocysts of intestinal parasites; 44.21% detected with the Willis technique, 31.57% by the Hoffman technique, and 45.14% via centrifugal flotation. The centrifugal flotation and Willis techniques showed good concordance. The authors concluded that the centrifugal flotation method showed higher sensitivity for detecting Ancylostoma spp and Toxocara spp and could be used with the Willis technique for routine diagnostic samples. Source Evaluation of different parasitological techniques for diagnosing intestinal parasites in dogs. de Santana BB, da Silva TLB, Ramos RAN, et al. OPEN J VET MED 5:19 24, continues May 2015 Clinician s Brief 37

40 CAPSULES Laser-Aided Healing Far-infrared (FIR) radiation comprises non-visible electromagnetic waves with wavelengths of µm. Infrared radiation transfers energy to surrounding tissues and can be perceived as heat through skin thermoreceptors. In this study, 18 rats were divided into 3 equal groups: 1) nerve injury without FIR biostimulation; 2) nerve injury with FIR biostimulation; and 3) noninjured controls. Rats in groups 1 and 2 had the sciatic nerve surgically transected, then sutured to itself. In control rats, the nerve was approached but not transected. Rats were irradiated for 30 minutes 5 times per week for 2 weeks after the second postoperative day. Nerve function was assessed by dipping the feet in ink and assessing gait at weekly intervals following surgery. The rats were then euthanized, the gastrocnemius muscles weighed, and the sciatic nerves dissected and histologically compared. Wound-healing at the site of sutured skin was found to occur faster and hair regrowth to be denser in treated rats. In addition, the untreated nerve injury group experienced significantly slower nerve recovery than the FIR-treated group. Gastrocnemius muscle evaluation showed reduced atrophy in the FIRtreated group. Histologically, transverse and longitudinal sections of the sciatic nerve were compared between groups; results showed superior nerve regeneration in the FIR-treated group compared with the untreated nerve injury group. FIR radiation therapy accelerated and improved regeneration of injured peripheral nerves in the rats; however, the exact mechanism for improvement needs to be elucidated. evidence is compelling for using various forms of light therapy Commentary Light therapy, including low-level laser therapy or cold laser, is an up-and-coming form of treatment. Clinical studies, however, are lacking. It is not clear why light of certain wavelengths may work better in different clinical settings, such as the FIR radiation of this study. Future clinical studies must include cats and dogs to be relevant to our practice, but for now, evidence is compelling for using various forms of light therapy in wound management and states of acute or chronic inflammation. Heather Troyer, DVM, DABVP, CVA Source Far-infrared therapy promotes nerve repair following end-to-end neurorrhaphy in rat models of sciatic nerve injury. Chen T-Y, Yang Y-C, Sha Y-N, et al. EVID BASED COMPLEMENT ALTERNAT MED 2015: , 2015, doi: /2015/ Quicker Time to Transfusion? Transfusion of fresh frozen plasma (FFP) is used to treat various coagulopathies. FFP is usually stored at -20 C; at this temperature, FFP maintains the activities of its clotting factors for up to 1 year. However, because FFP is frozen, it must be thawed before it is transfused, and the time delay could negatively impact the recipient. The purpose of this prospective study was to determine how long it takes to thaw FFP and how plasma refrigeration affects the activity of coagulation factors (V, VII, VIII, IX, X, and fibrinogen), clotting times (prothrombin time [PT] and activated partial thromboplastin time [aptt]), and FFP sterility. Mean thawing time was 34.7 ± 1.38 minutes. Refrigeration for 2 weeks significantly decreased clotting factor activity as well as prolongation in PT and aptt times, but all times remained within reference intervals. Sterility was not found to be affected. Refrigerated plasma, which does not have the thawing time delay associated with FFP, could be clinically effective in treating coagulopathies. Critical coagulopathic patients could receive plasma sooner, possibly improving their prognosis. Commentary Anyone who has had a dying-in-front-of-your-eyes anticoagulant rodenticide toxicity case will find this article useful. The study authors at Tufts determined that plasma can be refrigerated for 2 weeks and still contain viable coagulation factors. In contrast to FFP, frozen plasma and stored plasma would not be expected to contain adequate concentrations of labile factors V and VIII. Although this is not an issue when transfusing cases with anticoagulant rodenticide intoxication, it is an issue when transfusing bleeding type A hemophiliacs or when transfusing cases with massive hemorrhage. Coagulation factors V and VIII in refrigerated plasma had acceptable activity after 14 days, which means refrigerated plasma may benefit patients with those deficiencies. What we do not know is how long it takes to warm the refrigerated plasma to the same degree as the frozen plasma and if these results would hold for FFP that is warmed and stored in the refrigerator. Elke Rudloff, DVM, DACVECC Source An ex vivo evaluation of efficacy of refrigerated canine plasma. Grochowsky AR, Rozanski EA, de Laforcade AM, et al. J VET EMERG CRIT CARE 24: , cliniciansbrief.com May 2015

41 CAPSULES Carbimazole-Associated Vasculitis Feline hyperthyroidism can be treated medically, surgically, or with radioactive iodine. In this case study, a 9-year-old spayed cat presented to a primary care veterinarian. Emaciated and tachycardic, it had a large palpable goiter on the right side of its neck. It was aggressive, and blood sampling was not possible. The cat was treated with 15 mg of carbimazole once daily for presumptive hyperthyroidism with a plan to evaluate suitability for radioactive iodine treatment. On day 72, the cat presented with acute onset of left pelvic-limb lameness. On day 77, necrosis of the tail tip was reported and carbimazole was discontinued. By day 83, the lameness had progressed and the left digits II to IV were firm, cold, and discolored with deep pain absent. There was no sensation in the distal part of the tail. Although ultrasonography of the kidneys on day 70 was unremarkable, repeat examination revealed multiple renal infarcts. Mid-femoral amputation and tail amputation were performed. Histological examination of the tissue revealed the vascular lumens partially to fully occluded by mature fibrin thrombi; vasculitis was present. The cat recovered and was eventually treated with radioactive iodine. Commentary Previously, carbimazole for hyperthyroidism in cats has been reported as well-tolerated with limited side effects. Carbimazole or methimazole have been administered to hyperthyroid cats for 2 weeks before attempting other therapy to assess for renal insufficiency. A recent spot-on formulation of carbimazole has made this pro-drug even more appealing. In this case report, the authors describe the first occurrence of an immune complex deposition-mediated condition in a cat with digital and tail necrosis following carbimazole administration. Although this is compelling and vasculitis is evident on histopathology, hypersensitivity reactions to medications with immune complex deposition are neither common nor unique to carbimazole. Although the authors reference a similar condition in humans, there is no way of confirming a link between the two conditions without diagnostic testing in recently affected animals. Dermatologic signs and lameness are strong reasons to temporarily discontinue any drug regimen. Further work is needed to discover whether humans provide a reasonable model for immune complex hypersensitivity in cats experiencing carbimazole side effects. Ewan Wolff, DVM, PhD Source Carbimazole-associated hypersensitivity vasculitis in a cat. Bowlt K, Cattin I, Stewart J. J SMALL ANIM PRACT 55: Reducing Postoperative Hemorrhage Hyperfibrinolysis is a risk factor for bleeding. Antifibrinolytic drugs onehealthinitiative.com have been used in veterinary medicine to reduce postoperative hemorrhage in greyhounds, a breed at greater risk for postoperative bleeding complications. In humans, tranexamic acid (TEA) and ε-aminocaproic acid (EACA) inhibit fibrinolysis. This study sought to determine the minimum plasma concentrations of TEA and EACA needed to completely inhibit fibrinolysis in canine blood after induction of in vitro hyperfibrinolysis. The concentration of EACA and TEA needed to inhibit fibrinolysis was µg/ml and µg/ml, respectively. This study confirmed that dogs are hyperfibrinolytic compared to humans. Commentary The use of antifibrinolytic agents (TEA and EACA) has increased in veterinary patients for treatment of observed or anticipated postoperative hemorrhage. Although evidence has supported the notion that these drugs may reduce postoperative complications in dogs, ideal therapeutic blood concentrations and doses have not been established. This study demonstrates that higher concentrations of TEA or EACA are necessary to inhibit in vitro fibrinolysis in canine plasma as compared with human plasma. This work opens the door for further pharmacokinetic studies, which will bring veterinarians closer to establishing antifibrinolytic treatment protocols for dogs. Once dose ranges have been established, our profession will be bettersuited to assess therapeutic efficacy. Although antifibrinolytic treatment already shows promise in reducing postoperative hemorrhage in greyhounds, additional benefits (and possibly additional complications) may be observed when higher doses are used in dogs. Julie Walker, DVM, DACVECC Source Evaluation of tranexamic acid and ɛ-aminocaproic acid concentrations required to inhibit fibrinolysis in plasma of dogs and humans. Fletcher DJ, Blackstock KJ, Epstein K, Brainard BM. AM J VET RES 75: , continues May 2015 Clinician s Brief 39

42 CAPSULES Straightforward Diagnosis, Challenging Treatment Extrahepatic biliary atresia is a common cause of cholestasis in children but is rare in animals. It can involve any portion of the biliary tree, including the hepatic, cystic, or common bile duct. The cause of the malformation is unknown, but early surgical intervention is critical. If left untreated, cholestasis, recurrent cholangitis, portal hypertension, and hepatic cirrhosis can develop. Imaging of the biliary tree by ultrasound or direct contrast cholangiogram may help identify this condition. This case report details the clinical, imaging, and surgical features of a 4-week-old pug with extrahepatic biliary atresia. The puppy presented with lethargy and poor weight gain despite a good appetite. CBC and serum chemistry panel analysis revealed neutrophilic leukocytosis and elevations in bilirubin, alkaline phosphatase, alanine aminotransferase, and glutamate dehydrogenase. A biliary drainage problem was suspected based on the presence of acholic feces, elevated ammonia, and dilation of the gallbladder and bile duct on ultrasonography. There was no ultrasonographic evidence of a portosystemic shunt, and the major duodenal papilla could not be identified. Exploratory laparotomy revealed absence of the major duodenal papilla that allows entrance of the common bile duct into the intestines. A cholecystoduodenostomy was performed. Feces color was normal the day after surgery. Postoperative ultrasounds over 6 months showed that the stoma remained functional, maintaining a small gallbladder. At 15 months postoperatively, the dog s ammonia level and clinical function were normal, although bile acid concentrations remained quite elevated. Commentary This report describes successful surgical management of biliary atresia in a dog. Surgical intervention is required to establish a portal for drainage of bile from the liver into the intestines. Establishing the diagnosis is straightforward; however, the perioperative management and surgical rerouting of any portion of the biliary system is technically challenging, particularly in such a young, small patient. The short- and longterm outcome after cholecystoduodenostomy was good in this individual patient, which suggests this may be a viable salvage option in animals. Jason Bleedorn, DVM, DACVS The short- and long-term outcome after cholecystoduodenostomy was good. Source Extrahepatic biliary atresia in a 4-week-old pug. Thiel C, Steinbach S, Schmidt M, et al. VET SURG 44:35 40, Tear Film Stabilization The tear film consists of several layers: a mucin layer covering the ocular surface; an aqueous layer above that; and a lipid layer that covers the tear film surface. Mucin is important because it helps create a smooth refractive surface, decreases shear force between the corneal epithelium and aqueous layer, inhibits microbe adhesion, and prevents drying. Diquafosol is a P2Y 2 purinergic receptor agonist that stimulates aqueous tear and mucin secretion from conjunctival epithelial and goblet cells respectively. In this study, Western blotting and immunohistochemical analysis demonstrated that P2Y 2 receptors were present in canine conjunctivae at the level of the conjunctival epithelium and goblet cell surfaces. Following administration of 3% diquafosol to 6 laboratory dogs, there was an increase in goblet cell mucin secretion; however, this required at least 180 minutes. Diquafosol may have some use in dogs to treat corneal epithelial disorders. Commentary Poorly responsive cases of canine keratoconjunctivitis sicca represent a frustrating subset of patients presenting to the veterinary practitioner. This creates a niche market for the development of novel topical products to improve and stabilize the tear film. The results of the pilot study, which used normal dogs in an experimental setting, may support the ongoing investigation of the use of 3% diquafosol ophthalmic solution in dogs diagnosed with clinical tear film abnormalities or corneal epithelium disorders. Few new products of this type are re-evaluated in the form of peer-reviewed, masked, prospective clinical studies; this charges the general practitioner with making an anecdotal judgment call of cost vs benefit. The reality is that many of the pharmaceutical tear-stabilizing compounds available fail to result in a significant impact when prescribed to dogs with clinical disease when subjectively compared to products labeled for ocular lubrication alone. The cost of any new product thus must be carefully weighed against the true expectation for improvement in patient comfort and clinical signs. Allyson Gosling, DVM Source Conjunctival expression of the P2Y 2 receptor and the effects of 3% diquafosol ophthalmic solution in dogs. Terakado K, Yogo T, Kohara Y, et al. VET J 202:48 52, cliniciansbrief.com May 2015

43 Georgi on My Mind Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the synovial membranes and proliferation that leads to bone destruction and joint malformation. Biologic agents (eg, tumor necrosis factor inhibitors, interleukin [IL]-1 antagonists, NSAIDs) are clinically effective in RA patients but have toxic side effects. Nuclear factor (NF)-kB is highly activated in the pathogenesis of RA and may enhance recruitment of inflammatory cells and production of proinflammatory mediators. NF-kB also controls the expression of gene products that influence inflammation, immunity, cell proliferation, and apoptosis. Baicalin is a flavonoid found in the dry root of the medicinal plant Scutellaria baicalensis Georgi. It is used in Asia to treat brain, hepatic, and inflammatory diseases. Evidence shows that baicalin has antiinflammatory, antioxidant, antiapoptotic, and immune regulation properties. It may have a role in anti-inflammation and immune regulation. This study investigated the effect of baicalin in a collageninduced arthritis (CIA) model of human RA in rats. Rats with confirmed CIA were divided into groups; each received daily intraperitoneal injections of 50, 100, or 200 mg/kg baicalin, 1 mg/kg methotrexate, or physiological saline for 30 days. Significant suppression of collagen-induced joint inflammation injury was noted in a dose-dependent manner in rats receiving baicalin. This improvement was assessed by observing decreased redness and swelling of the ankle and decreased secretion of key cytokines in pathologic synovia. Commentary Medicinal plants used in herbal medicine are controversial because of a lack of substantial evidence in the literature of their efficacy. Studies such as this one help support our understanding of a molecular pathway for efficacy, which is important in understanding ancient therapies and creating buy in from skeptical practitioners. Further studies are needed to evaluate the clinical effectiveness of compounds such as baicalin in animals, especially to compare the effectiveness of the whole herb vs its molecular constituent and when using alternate routes of administration. Heather Troyer, DVM, DABVP, CVA Early Diagnosis of Hemangiosarcoma Splenic hemangiosarcomas (HSAs) are common vascular tumors in dogs. As prognosis for these tumors is poor, differentiation from other benign splenic masses would be helpful. It is hypothesized that vascular endothelial growth factor (VEGF) might play a role in growth of these tumors. VEGF is an endothelial cell-specific mitogen that regulates angiogenesis and is stimulated by hypoxia, inflammatory cytokines, growth factors, hormones, and oncogenic mutations. It has been proposed to be a diagnostic marker of malignancy. This study investigated whether serum VEGF could differentiate splenic HSAs from nonmalignant splenic hematomas using a commercial enzymelinked immunosorbent assay (ELISA). Serum VEGF levels were significantly higher in dogs with splenic masses compared to healthy dogs but did not differ significantly between dogs with HSAs and those with hematomas. This serum ELISA measured VEGF 164 isoform, which may not be the dominant angiogenic factor in HSAs and hematomas. Further studies are necessary to investigate possible roles of other angiogenic factors, including other VEGF isoforms. VEGF has potential clinical utility as a diagnostic marker for dogs with splenic lesions; however, it may not be useful for distinguishing between different types. Commentary In the quest to find early markers of neoplasia for diagnosis and/or therapeutic targets, VEGF has been widely studied in patients with cancer, including HSA. Results are controversial, and this test is not helpful in distinguishing neoplasia from benign conditions. Surgical excision and histopathology remain the gold standard for diagnosis and treatment of canine splenic tumors. Early diagnosis may be achievable by regular screening of geriatric patients with bloodwork and imaging; however, the benefit of early diagnosis is unknown in patients with HSA. Our therapeutic arsenal is limited, and the cost of regular screening is high. Cecilia Robat, DVM, DACVIM (Oncology) Source Serum vascular endothelial growth factor in dogs with haemangiosarcoma and haematoma. Frenz M, Kaup F-J, Neumann S. RES VET SCI 97: , Source Inhibitory effect of baicalin on collagen-induced arthritis in rats through the nuclear factor-kb pathway. Wang H-Z, Wang H-H, Huang S-S, et al. J PHARMA- COL EXP THER 350: , continues May 2015 Clinician s Brief 41

44 CAPSULES Battling Periodontal Pathogens One of many contributing factors to periodontal disease severity is oral microflora. In this in vitro study, the antimicrobial kill kinetics of a 0.125% v/v medium-chain triglyceride (ML:8) emulsion were compared to chlorhexidine digluconate (0.12% v/v) and a xylitol-containing dental formulation against resistant biofilm forms of 10 canine and feline periodontal pathogens. The ML:8 emulsion showed significant activity against the biofilm forms of the 10 pathogens. The anti-biofilm efficacy was significantly better than xylitol and comparable to chlorhexidine digluconate. At 5 minutes, the ML:8 and chlorhexidine digluconate solutions had >70% kill rates, which were maintained throughout the 24-hour testing period. The test compound also showed a significantly lower toxicity profile compared to chlorhexidine digluconate. There is potential for this ML:8 emulsion formulation to be used long-term as a water additive, although clinical trials will be required to establish in vivo efficacy. Commentary Balancing client compliance with patient acceptance is a constant challenge when managing periodontal home care in dogs and cats. Tooth brushing remains the gold standard in prevention and management of oral disease. When something more effective becomes available, it will change the standards of human and veterinary oral hygiene. Topical products with active ingredients such as medium-chain triglycerides may prove a safe alternative to products on the market provided they can contact bacteria in all the right locations in the mouth. Products targeting periodontal disease management need appropriate contact time with biofilm and subgingival penetration, both of which can be challenging in veterinary patients. The profession will watch closely for the clinical application and evaluations of products with this active ingredient. If this product proves clinically effective, consider it one more tool in the toolbox for periodontal home care rather than a complete solution to all our periodontal disease problems. Christopher Snyder, DVM, DAVDC Source Antimicrobial efficacy of an innovative emulsion of medium chain triglycerides against canine and feline periodontopathogens. Laverty G, Gilmore BF, Jones DS, et al. J SMALL ANIM PRACT 56: , Gallbladder Rupture A 6-year-old spayed albino ferret (Mustela putorius) presented with a 2-day history of lethargy and anorexia. There was marked cranial abdominal pain. Significant neutrophilic leukocytosis and hypoalbuminemia were noted on blood work. Liver enzymes were within normal limits. IV fluids, 5 mg/kg marbofloxacin PO q12h, 20 mg/kg metronidazole IV q12h, 4 mg/kg ranitidine IV q8h, and 0.1 mg/ kg morphine SC q6h were initiated. Abdominal ultrasound revealed bile duct inflammation, hyperechogenicity of abdominal fat and peritoneum, peritoneal effusion, and thickening and hyperechogenicity of the biliary tree. Gas bubbles were observed in the gallbladder. Fine-needle aspirate of peritoneal fluid produced yellow-to-green turbid liquid, with cytology indicative of bile peritonitis. Cholecystectomy is recommended for gallbladder rupture in mammals. Surgical technique in ferrets is similar to that in other mammals. Several gallbladder perforations were seen in this ferret. The gallbladder was removed and submitted for culture and histopathology and liver biopsy. There was pure growth of Pseudomonas aeruginosa. Histopathologic findings included severe lymphocytic and granulomatous cholecystitis with cystic glandular hyperplasia of the gallbladder mucosa and marked lymphocytic cholangiohepatitis. The ferret showed clinical improvement and was eating on its own the day after surgery. Meloxicam (0.2 mg/kg PO daily) was given for 1 week, and antibiotics were continued for 4 weeks. Commentary This well-written, excellently referenced article reminds me of the frequency of biliary disease in the ferret compared to other species. Over the years, I have encountered obstruction, choleliths, bacterial infection, coccidiosis, mucosal hyperplasia (very common), and neoplasia (usually metastatic, and most often malignant lymphoma). As a pathologist, I want to draw attention to the histologic finding of a lymphocytic cholangiohepatitis in this case a common finding in ferret liver biopsies. Although in this case it was associated with gallbladder disease, in ferrets (especially older ferrets), it is most often seen in association with inflammatory bowel disease. When I see it, I think bowel inflammation first, gallbladder second. Bruce Williams, DVM, DACVP Source Gallbladder rupture associated with cholecystitis in a domestic ferret (Mustela putorius). Huynh M, Guillaumot P, Hernandez J, Ragetly G. J SMALL ANIM PRACT 55: , cliniciansbrief.com May 2015

45 CAPSULES The Kissing (Bug) Disease onehealthinitiative.com Trypanosoma cruzi is a protozoan parasite known to infect humans, wildlife, and dogs. Infection occurs when hematophagous triatomines (kissing bugs) bite hosts and bugs feces enter bite sites or mucous membranes. In humans, this causes Chagas disease. Symptoms of T cruzi infection in humans and dogs include acute myocarditis, chronic heart disease, and sudden death; infection can also be asymptomatic. Study authors examined the seroprevalence of T cruzi in dogs from 7 Texas shelters. There are enzootic cycles involving infected wildlife reservoirs and domestic dogs across the southern United States; dogs in Texas are at high risk. A total of 205 blood samples were taken, and T Identifying FHN cruzi exposure was determined using the Chagas STAT-PAK, a rapid immunochromatographic test. Of those, 18 dogs tested positive, which makes the overall seroprevalence 8.8%. For individual shelters, prevalence ranged 6.7% 13.8%. Because of shelter dogs widespread exposure to T cruzi, these dogs could act as sentinels for assessing transmission risk; however, the importance of dogs as a reservoir host has not been studied in the United States. Further research is needed to evaluate the association between exposure of shelter dogs to T cruzi and the risk for Chagas disease in humans. Commentary This study sought to detect the presence of anti-t cruzi antibodies in a population of shelter dogs from Texas. Blood samples were also examined for parasite DNA by 2 PCR methods. No significant differences in seropositivity were noted with regard to location, sex, age, breed, or adoption history. Shelter dogs are a useful population to examine the occurrence of T cruzi infection as an indication of potential risk to humans and owned dogs. Local exposure was likely in these cases as seropositivity was not biased by location or age of the animal, and some of the shelters were in regions where kissing bug vectors are well-established. John J. Schaefer, DVM, MS, PhD, DACVM Source Shelter dogs as sentinels for Trypanosoma cruzi transmission across Texas, USA. Tenney TD, Curtis-Robles R, Snowden KF, Hamer SA. EMERG INFECT DIS 20: , A 7-year-old cat was presented for a 3-day history of behavioral changes (excessive vocalization, facial territorial marking, inappropriate urination) followed by salivation and focal seizures. At examination, the cat was agitated and pyrexic. It was also hypersalivating and exhibited anisocoria. Treatment with cooling, IV fluids, and anticon-vulsants was initiated, but the cat continued to deteriorate. MRI findings were compatible with hippocampal necrosis. Over the next day, the cat began to show improvement; however, it then experienced an episode of vomiting and aspiration of ingesta followed by cyanosis and cardiorespiratory arrest. Initial resuscitation was successful, but the owner declined continued care, and the cat died. Necropsy was grossly unremarkable except for pallor of the hepatic tissues. Histologic changes in the brain showed subacute degenerative encephalopathy involving the hippocampus. The cause of this disease in cats remains unknown. Commentary The hippocampus is an area of the brain thought to be involved in processing sensory information and forming memories. Feline hippocampal necrosis (FHN) is infrequently reported and carries a poor prognosis. Until MRI abnormalities were defined in 2008, most FHN diagnoses were made at postmortem examination of brain tissue from cats that died or were euthanized. In 2011, Pakozdy and others 1 reported antemortem diagnosis via MRI and survival in a small number of cats with FHN. The case presented in this report had normalization of neurological examination findings preceding death because of an acute aspiration event. Perhaps now, with better antemortem diagnostic criteria, we are more likely to identify less severe cases and advance knowledge of this condition. Julie Walker, DVM, DACVECC Source Hippocampal necrosis in a cat from Australia. Adagra C, Piripi SA. CASE REPORTS IN VETERINARY MEDICINE 2014: , 2014, doi: /2014/ Complex partial cluster seizures in cats with orofacial involvement. Pakozdy A, Gruber A, Kneissl S, et al. J Feline Med Surg 13: , continues May 2015 Clinician s Brief 43

46 CAPSULES Canine Compulsions Canine compulsive disorder (CCD) is characterized by behaviors such as licking, flank-sucking, tail-chasing, and light-chasing that occur repetitively and without clear purpose. Environmental factors may play a role. For example, owners may unintentionally reinforce tail-chasing by laughing at or scolding the dog. Compulsive licking or circling might be brought on by boredom or confinement. An understanding of these contributing and exacerbating environmental factors may assist in the development of improved therapies. The diagnosis of compulsive disorder is made when a behavior is performed out of context and interferes with the patient s ability to live a normal life. This 3-part study used functional analysis to evaluate the role of antecedents and reinforcers in CCD. Study 1 was an exploratory phase in which owners (n = 99) completed an online survey about their dogs stereotypic behaviors, including triggers and consequences. Statistical analysis did not reveal consistent trends. Study 2 was a prospective case study of 5 dogs from Study 1. These dogs exhibited light-chasing, circling, or licking. Analysis showed that light-chasing in 2 dogs was independent of social consequences whereas circling and licking in 3 dogs was reinforced by owner attention. Study 3 showed that manipulating reinforcers in 3 dogs reduced these unwanted behaviors. The authors concluded that functional analysis methodology is useful in individual CCD cases and that unwanted compulsive behaviors can be decreased by manipulation of environmental/owner variables. The ability to identify specific reinforcers in individual owner-dog pairs allows for tailored therapy. Commentary As this article suggests, many factors can contribute to the development and maintenance of repetitive behaviors. The authors remind us that it is important to identify controllable reinforcers and that behavioral and environmental modification are critical to treatment. Stereotypic behavior can have many causes and may reflect inadequate enrichment, inadvertent owner reinforcement, or attention-seeking. The diagnosis of compulsive disorder is made when the behavior is performed out of context and interferes with the animal s ability to live a normal life. In moderately severe clinical cases, the behavior cannot be interrupted. Therefore, initially, it may not be possible to manipulate reinforcers. Underlying medical and behavioral conditions, whether comorbid or causative, need to be addressed for long-term control and patient welfare. Ellen M. Lindell, VMD, DACVB Source The role of environmental and owner-provided consequences in canine stereotypy and compulsive behavior. Hall NJ, Protopopova A, Wynne CDL. J VET BEHAV 10:24 35, cliniciansbrief.com May 2015

47 Physical Rehabilitation & Multimodal Treatment This report describes a 3.5-year-old, 25.5-kg dog that developed severe progressive weakness and bilateral plantigrade stance of the pelvic limbs following ovariohysterectomy. Clinical signs indicated a distal sciatic nerve injury, likely from compressive neuropathy and nerve stretch from surgical positioning. There were also ulcerations on the dorsa of the rear paws and enlarged popliteal lymph nodes. Positioning may have caused ischemia and mechanical deformation of the nerve at and proximal and distal to the compression site. Weekly to bimonthly physical rehabilitation was initiated along with home rehabilitation using support boots, carts, and orthotics. Low-level laser therapy (cold laser) was used to accelerate wound collagen synthesis and promote granulation, and on the distal sciatic nerve and the distal left pelvic limb to enhance nerve regeneration, preserve muscle tissue, and reduce inflammation. Neuromuscular electrostimulation was applied to the caudal thigh muscles and tibial muscles to stimulate sensory nerves, exert trophic effects on the denervated muscle, and promote motor axonal regeneration. Ultrasound was applied to the cranial tibialis and gastrocnemius muscles to increase regenerating nerve fibers and myelination. The dog was This case demonstrated the potential utility of physical rehabilitation and custom orthotics for return to function and improved quality of life. aggressively treated and evaluated over 15 months, by which time it could support its hocks 2 3 cm above the ground without orthotics. Postural deficits were still noted, but superficial pain perception was present and the ulcerations healed. Although it was not clear which modality afforded the most improvement, this case demonstrated the potential utility of physical rehabilitation and custom orthotics for return to function and improved quality of life. Commentary Multimodal drug and non-pharmaceutical therapeutic strategies have long been known to work synergistically to improve outcomes, reduce drug doses and subsequent side effects, and provide a more comprehensive plan for convalescence. However, it is difficult to design a controlled study to determine which treatment works best because a multimodal approach involves many variables. The greatest challenge for a pain practitioner or physical rehabilitator is to artfully combine the components of a treatment plan to individualize the treatment. In this case, physical rehabilitation, drug therapy, orthotics, and at-home manipulation all had individual benefits, including lymphatic and microcardiovascular support at the cellular level of the trauma, support of nerve and motor regeneration, development of strength, and reduction of pain and inflammation. As more reports like this are generated, differences in treatment strategies can be compared so that we can further understand what constitutes the best therapeutic approach. Heather Troyer, DVM, DABVP, CVA Source Use of physical therapy in a dog with bilateral severe plantigrade stance. Ree J, Hayashi K, Woelz J, Kim SY. JAAHA 51:31 35, n cb May 2015 Clinician s Brief 45

48 SYMPOSIUM CAPSULES Western Veterinary Conference n February 2015 n Las Vegas, NV The Western Veterinary Conference (WVC) provides continuing education to veterinary professionals by engaging recognized authorities to deliver valuable information at its annual conference and through its special programs. Additional WVC Capsules are available online at cliniciansbrief.com/2015-wvc-capsules Save the Date WVC Annual Conference March 6-10, 2016, in Las Vegas, NV Chronic proliferative otitis, nonsurgical treatment Perpetuating factors of chronic otitis externa primarily consist of proliferative changes and failure of epithelial migration. Left untreated, these factors can create a downward spiral of infection and inflammation and cause discomfort, treatment failures, and relapses. Proliferative changes narrow the ear canal lumen and create folds in which microorganisms can multiply. They must be managed as a distinct clinical problem in order for otitis externa to fully resolve. The cornerstone of treatment is maintaining a clean ear canal, which requires serial ear flushes under general anesthesia or sedation. Topical and/or systemic glucocorticoids and antimicrobials are used until stenosis subsides and cytology yields normal levels of flora and absence of inflammatory cells. This is often costly and time-consuming and involves multiple follow-up examinations and extensive home care; managing client expectations is paramount. Ear flushes are conducted under anesthesia using soft red rubber feeding tubes (typically 5- or 8-Fr) and an otoscope with a surgical otoscope head or a video otoscope. Water or saline warmed to body temperature is commonly used. Once the tip is placed, the flushing solution is gently infused, then aspirated along with any loosened debris. Brushes intended for cleaning endoscopic equipment work well but must be used with extreme care near the tympanum. Hard-to-treat patients may receive indwelling treatment tubes fashioned from 5-Fr feeding tubes and sutured in place. Care must be taken to protect the airway when flushing ears if no endotracheal tube is in place. Griffin CE Ebola in companion animals: What do we know? Ebola is a highly infectious but moderately contagious disease found primarily in West Africa. The Ebola virus is transmitted via direct contact with the blood or body fluids of a sick individual or through contact with contaminated objects (eg, needles); it is not spread through air or water, nor carried by insects, although related viruses can infect mosquitos. Infected humans generally develop symptoms within 2 21 days, and the disease is often fatal, especially in countries with developing medical systems. The companion animal role in the disease cycle has not been elucidated but appears limited. The Pteropodidae family (Old World fruit bat) of fruit bat is thought to be a natural host, but other infected animals including chimpanzees, gorillas, monkeys, forest antelope, and porcupines can spread the Ebola virus through blood, secretions, organs, or body fluids. The bushmeat trade may also play a role. To date, exposed dogs have not been reported to exhibit Ebola signs, but it is important for veterinarians to keep apprised of developing knowledge. Chatfield J 46 cliniciansbrief.com May 2015

49 Inter-cat aggression: Helping cats to get along It is important to understand social behavior when managing inter-cat aggression or introducing a new cat into an established cat household. Although they usually engage in solitary hunting behavior, cats are social and may form long-term pair bonds, live in family groups, or live in larger groups with a relatively stable long-term membership. They demonstrate individual recognition and have preferred associates of either gender with which they often groom. Male cats can spend time with a particular group or migrate between groups. There are dominance hierarchies within groups; submission and fear are signaled with ears, tail, and head down and body crouched. A fearfully aggressive cat will have an arched back with ears back and tail arched. Because new cats are not readily accepted, their introduction is best done if the new animal is separated with rotation throughout the house to introduce the scent. Kittens and juvenile cats are more easily introduced than adults and can learn social skills from residents. Exposure through glass or screen is ideal, and rewards for good behavior are useful. If dominance, fear aggression, or play aggression escalates, systemic desensitization and counter-conditioning can be used. Medications may aid treatment. Aggressive cats can receive fluoxetine ( mg/kg q24h), paroxetine (0.5 mg/kg q48h), or clomipramine (0.5 mg/kg q24h). Buspirone ( mg/cat q12 24h) can help increase confidence in fearful cats. Curtis TM Thromboembolic therapies: Any progress? In dogs and cats, therapeutic agents for thromboembolic processes are indicated for a variety of conditions (eg, disseminated intravascular coagulation, pulmonary thromboembolism). These thromboembolic agents are classified broadly as either thrombolytic or anticoagulant. Thrombolytic agents those that directly lyse a blood clot via stimulation of the endogenous thrombus removal system include urokinase, streptokinase, and recombinant tissue plasminogen activator (rt-pa). Release of t-pa by endothelial cells should initiate clot degradation. The t-pa binds to fibrin in the clot and turns plasminogen to plasmin, which digests the fibrin. This is a nonspecific process, however, and leads to pathologic and physiologic fibrin degradation. Therefore, hemorrhage is the most likely side effect associated with thrombolytic agents. Anticoagulant agents (eg, aspirin, ticlopidine, clopidogrel) interfere with clot formation via COX-1 and platelet aggregation inhibition. They are useful agents for prophylaxis of thromboembolic disease in predisposed patients. Studies show that clopidogrel appears superior to aspirin at preventing thromboembolism recurrence in affected cats. Unfractionated heparin, low-molecular-weight heparin, and warfarin are anticoagulant agents that help limit primary thrombus expansion and new thrombi formation downstream from a disintegrating thrombus. This allows endogenous thrombolytic mechanisms to dissolve the existing clot. As with thrombolytic agents, the major adverse effect with anticoagulant agents is hemorrhage. Heparin and warfarin overdose can be corrected with protamine and vitamin K, respectively. Maxwell LK How can I examine him if I can t get too close? Sedating and treating dogs and cats Fear and anxiety are common causes of patient aggression in practice. Some fearful patients respond well to various levels of physical restraint; however, other options such as oral or injectable sedatives are occasionally necessary. At the first sign of fear or anxiety in a patient, it is important to stop and evaluate the situation and the patient. If the patient is mildly fearful and/or anxious, a slow approach, avoiding eye contact and calming the patient with head covers or pheromone sprays may be an option. Alternatively, the owner may wish to postpone a scheduled procedure in the interest of desensitizing the patient to the components of veterinary visits. This can be accomplished by exposing the patient to all aspects of the visit (eg, car ride, travel crate, practice setting, personnel) and providing positive associations through high-value rewards. Because some procedures cannot be postponed and some owners do not opt to delay visits, sedation may be necessary for a quality physical examination and to obtain diagnostic samples. Pheromones and oral sedatives may prove useful for mildly fearful patients. For more fractious animals, intramuscular injections of an opioid combined with dexmedetomidine and benzodiazepine typically provide good sedation. Landsberg GM continues

50 SYMPOSIUM CAPSULES There really are good tumors Soft-tissue sarcomas (STSs) are commonly seen on middle to distal extremities. Cytology helps surgical planning as, if STS is present, 3-cm margins and a fascial plane below these tumors are recommended. With incomplete surgical excision, options are adjuvant therapy, additional surgery, full-course radiation, or intralesional chemotherapy. Hepatocellular carcinoma is the most common primary liver tumor in older dogs. Signs include anorexia, weight loss, and vomiting. Blood work usually reveals elevated liver enzymes. Abdominal ultrasound can determine location and extent of disease but not degree of malignancy. Primary lung tumors usually present with a cough, possible dyspnea, lethargy, anorexia, and weight loss. Radiographs reveal a focal soft-tissue density in a single lung lobe. Multiple densities are likely indicative of metastases from another primary neoplasia. Lung lobectomy is the most effective treatment. Anal gland anal sac adenocarcinomas present with tenesmus and hypercalcemia. Rectal examination plays an important part in diagnosing subclinical patients. Staging with thoracic radiographs and abdominal ultrasound are crucial before surgery. Intestinal sarcomas present with nonspecific GI signs. Surgery which may be curative for sarcomas caught early and immunohistochemistry are recommended. Plasma cell tumors include multiple myelomas and extramedullary plasmacytomas. The latter are found in the oral cavity, colon, and skin; patients exhibit normal globulin levels. Thymomas are often slow-growing. Presurgical chemotherapy can reduce tumor size. Feline small cell lymphomas present with weight loss, anorexia, vomiting, and diarrhea. Blood work is often unremarkable; abdominal ultrasound may reveal intestinal wall thickening. Full-thickness biopsies are best for diagnosis. Chemotherapy is often successful. Wright ZM Looks hormonal, but it s not Cushing s or hypothyroid Many causes of alopecia can look like those caused by Cushing s disease or hypothyroidism, but are not. This presentation examined what these other causes might be. Allergic, parasitic, and infectious causes must be ruled out in pruritic patients with alopecia before non-endocrine or endocrine (alopecia X, hormone-replacement therapy, hyperestrogenism) diagnoses are considered. The exact cause of alopecia X is unknown; castration, melatonin, lignans, mitotane, and trilostane are treatment options. Alopecia can also occur when a patient has contact with a human undergoing hormone-replacement therapy via topical formulations. Comedones and nipple/vulvar enlargement may be noted. Eliminating exposure is curative. Hyperestrogenism is caused by Sertoli cell or, less commonly, a testicular interstitial tumor and by cystic ovaries or an ovarian tumor. Signs include bilaterally symmetric alopecia of the perineal, inguinal, or flank regions, often with enlarged nipples, vulva, or prostate. Linear preputial dermatosis in males is highly suggestive of hyperestrogenism. Castration or spaying is indicated. Canine flank alopecia, which is triggered by daylight changes, causes variable alopecia, hyperpigmentation, fine scaling, or secondary folliculitis. Pattern alopecia causes hair loss on or around the pinnae, lips, ventrum, or caudal thighs. Both alopecia X and hyperestrogenism may respond to melatonin. Color dilution alopecia occurs when macromelanosomes in dilute color hairs cause hair-shaft fractures. Alopecia in dilute areas and secondary folliculitis are common. Alopecia areata and pseudopelade are autoimmune conditions that cause hair-bulb destruction. Hair loss in pseudopelade is typically permanent. Focal alopecia can occur after different types of injections (eg, rabies vaccination). Anagen and telogen effluvium occur when a stressful event disrupts normal hair growth and resolves with time if the inciting event is removed. Rosenberg AS n cb 48 cliniciansbrief.com May 2015

51 ASK THE EXPERT > NEPHROLOGY / DIAGNOSTICS > PEER REVIEWED Laboratory Evaluation in Dogs & Cats with Chronic Kidney Disease Gregory F. Grauer,* DVM, MS, DACVIM Kansas State University You have asked What do I need to know about laboratory measurement and reporting when diagnosing and treating chronic kidney disease? The expert says Chronic kidney disease (CKD) is a major cause of morbidity and mortality in dogs and cats. The prevalence of CKD has been estimated to be 0.5% to 1.0% in dogs and 1% to 3% in cats 1,2 and increases with age, especially in cats. As many as 30% to 50% of cats 15 years of age or older have CKD. 3-5 Nephron damage associated with CKD is usually irreversible and often progressive. Progressive loss of renal function in dogs tends to be common, linear, and relatively rapid compared with cats. Cats may have stable renal function for months to years and be relatively unaffected by CKD or may have slowly progressive disease over several years; stable cats may also experience an abrupt, unpredictable decline in renal function. Soft tissue mineralization, systemic hypertension, intraglomerular hypertension, and proteinuria have been associated with progression of CKD (Figure 1). Although it is not usually possible to improve renal function in CKD, it is logical to assume that early diagnosis can improve clinical outcomes. There is firm evidence for dietary treatment and increasing evidence that anti-proteinuric treatments can slow the progressive nature of CKD. Early CKD Diagnosis Serum Creatinine Concentration Early nonazotemic CKD (International Renal Interest Society [IRIS] Stage 1) (Table 1, page 51) can be diagnosed in dogs and cats with abnormal renal palpation or renal imaging findings, persistent renal proteinuria, or urine concentrating deficits. CKD is usually diagnosed based on persistent azotemia superimposed on an inability to form hypersthenuric urine. (Some cats with CKD retain the ability to concentrate urine.) Serum creatinine concentrations are used as a marker of glomerular filtration rate (GFR). Creatinine is produced from the nonenzymatic degradation of creatine and creatine phosphate in skeletal muscle; therefore, serum creatinine concentrations reflect muscle mass as well as GFR. CKD = chronic kidney disease, GFR = glomerular filtration rate, IRIS = International Renal Interest Society Progressive loss of renal function in dogs tends to be common, linear, and relatively rapid compared with cats. * Dr. Grauer has research projects funded by IDEXX and has been paid by IDEXX to attend meetings as a key opinion leader in his field. continues May 2015 Clinician s Brief 49

52 ASK THE EXPERT Interpretation of serum creatinine concentrations can be influenced by analysis method (Jaffe s reaction vs enzymatic; benchtop vs reference laboratory) as well as variations in reference intervals that can lead to false-positive or false-negative determinations of azotemia. 6,7 Although reference ranges need to be individualized, many veterinary nephrologists suggest that renal azotemia begins with serum creatinine concentrations lower than most reference ranges (ie, 1.4 and 1.6 mg/dl in dogs and cats, respectively). 8 The sensitivity of serum creatinine concentrations for the early diagnosis of azotemia or CKD is improved if a lower reference range is employed. Serum creatinine concentrations must be interpreted in light of the patient s muscle mass, urine-specific gravity, and physical examination findings to rule out pre- and postrenal causes of azotemia. Dogs have large variations in muscle mass that will tend to increase the breadth of reference ranges. 9 Despite these issues, longitudinal, consistent assessment of serum creatinine concentrations is an excellent tool to assess renal function and diagnose early CKD. Serum symmetric dimethylarginine (SDMA) is derived from intranuclear methylation of L-arginine by proteinarginine methyltransferases and is released into the circulation after proteolysis. SDMA is eliminated primarily by renal clearance and represents a potential biomarker for diagnosing and monitoring CKD. 10,11 In 2 recent longitudinal studies, SDMA concentrations increased above normal approximately 17 months prior to serum creatinine concentration increasing above reference range (serum creatinine concentration >1.8 mg/dl in a dog study and >2.1 mg/dl in a cat study). 10,12 Interestingly, a serum creatinine concentration of >1.6 mg/dl occurred in the feline study, at nearly the same time the SDMA was increased above normal. 10 Urine Protein/Creatinine Ratio (UP/C) Proteinuria in dogs and cats with CKD 1 Potential Mechanisms for CKD Progression Systemic hypertension Loss of nephrons Afferent arteriole dilation Activation of renin angiotensin aldosterone system Efferent arteriole constriction Elevated intraglomerular pressure Proteinuria Glomerular capillary tuft depicting afferent arteriole dilation and efferent arteriole constriction Image courtesy of Mal Hoover Rooks, CMI, of Kansas State University Progressive glomerular and tubulointerstitial damage CKD = chronic kidney disease, IRIS = International Renal Interest Society, SDMA = symmetric dimethylarginine, UP/C = Urine protein/creatinine ratio 50 cliniciansbrief.com May 2015

53 - Table 1. Serum Creatinine Concentrations & IRIS CKD Stages Serum creatinine concentrations (mg/dl) Stage 1 (Nonazotemic CKD) Stage 2 (Mild renal azotemia) Stage 3 (Moderate renal azotemia) Stage 4 (Severe renal azotemia) Cats < >5.0 Dogs < >5.0 can occur because of glomerular and/or tubular lesions. Glomerular proteinuria can be caused by loss of integrity of or damage to the capillary wall (eg, immune complex disease and X-linked hereditary nephropathy). It is also likely that increases in glomerular capillary pressure increase the amount of filtered plasma protein. Intraglomerular hypertension may result from loss of nephrons (afferent glomerular arteriole dilation and efferent arteriole constriction) and from systemic hypertension being transmitted into glomerular capillaries. Structural glomerular disease and CKD are often accompanied by systemic hypertension that can exacerbate intraglomerular hypertension and glomerular proteinuria. Tubular proteinuria occurs when reabsorption of protein from glomerular filtrate is compromised. Tubular proteinuria is typically of lesser magnitude than glomerular proteinuria. Reduced tubular reabsorption of protein can occur with tubulointerstitial injury and decreased numbers of functioning tubules. Whether caused by capillary wall lesions, tubular lesions, or intraglomerular hypertension, excessive protein in the glomerular filtrate may contribute to additional glomerular and tubulointerstitial lesions, and lead to loss of more nephrons. Proteinuric renal disease and systemic hypertension often coexist, and it can be difficult to separate effects of high systemic and intraglomerular pressures and proteinuria. Table 2. IRIS Classification of Renal Proteinuria Urine protein/creatinine ratio Diagnosing renal proteinuria in cats and dogs with CKD is a multistep process. Albumin is the major urine protein in dogs and cats, but specificity of dipstick screening for albuminuria is poor (especially in cats). Traditional dipstick-positive proteinuria should be confirmed with a more specific follow-up test (eg, sulfosalicylic acid turbidimetric test, UP/C [Table 2], or species specific albuminuria assays). The second step Classification <0.2 Nonproteinuric (cats); (dogs) Borderline proteinuric >0.4 (cats); >0.5 (dogs) Proteinuric Best Practice: Measuring Blood Pressure in assessment of proteinuria is to determine its origin (physiologic or benign proteinuria and pre- and postrenal proteinuria need to be ruled out). Renal proteinuria is persistent and associated with a benign or inactive urine sediment (hyaline casts may be observed in the urine sediment in cases of renal proteinuria). Persistent proteinuria is defined as at least 2 positive tests at 2-week intervals. Subsequently, via Blood pressure should be measured in a quiet area before examining the patient, typically in the presence of the owner after a 5- to 10-minute acclimation period. The ACVIM panel on hypertension suggests discarding the first measurement, then obtaining a minimum of 3 (preferably 5 7) consecutive measurements with less than 10 20% variability in systolic blood pressure. 16 The animal s disposition, body position, heart rate, cuff size, and measurement site, as well as all measured values, should be recorded. Many clinicians suggest that hypertension be documented on more than 1 occasion before accepting the diagnosis of hypertension (unless ocular lesions compatible with systemic hypertension already exist). continues May 2015 Clinician s Brief 51

54 ASK THE EXPERT serial monitoring of the UP/C, it should be determined if the proteinuria is stable, increasing, or decreasing. The current recommendation is to treat persistent proteinuria of renal origin with a renal diet (reduced dietary protein, phosphorus, and sodium, supplemented with N-3 fatty acids and alkalizing agents) and an angiotensinconverting enzyme (ACE) inhibitor. Borderline proteinuria warrants increased monitoring via the UP/C ratio. Note that borderline and even normal levels of proteinuria in cats have been associated with poor outcomes. For example, in cats with naturally occurring CKD, relatively mild proteinuria (UP/C ) increased the risk for death or euthanasia 2.9-fold compared with cats with UP/Cs < In a study of nonazotemic cats older than 9 years with CKD, 95 cats (median age 13) were followed for 12 months or until death or azotemia developed. Azotemia was defined as a serum creatinine concentration >2.0 mg/dl; 29/95 (30.5%) cats developed azotemia. Proteinuria at presentation (median UP/C of 0.19 vs 0.14) was significantly associated with development of azotemia in these geriatric cats. 14 Finally, when 112 client-owned cats with stable CKD were compared with 101 client-owned cats with progressive CKD, median UP/Cs in the progressive group were higher than the stable group (0.27 vs 0.14). 15 A 0.1 increase in UP/C was associated with a Table 3. IRIS Classification of Systolic Blood Pressure for Dogs & Cats Systolic blood pressure (mm Hg) Risk for target organ damage <150 Minimal AP Low AP Moderate AP2 >180 High AP3 24% increase in risk of CKD progression. 15 It should be noted that overlap of UP/C values was present in these studies, and therefore clinical relevance in individual cats may be difficult to determine. Nonetheless, proteinuria is an important risk factor for the development of azotemia in cats and the progression of CKD in dogs and cats and should be monitored closely. Management of CKD Systolic Blood Pressure IRIS blood pressure substaging for dogs and cats with CKD is based on risk of target organ (ocular, neurologic, cardiac, and renal) damage (Table 3). Not long ago, indirect systolic blood pressure measurements > mm Hg were considered the threshold for hypertension. Despite inherent difficulties with indirect blood pressure measurement in dogs and cats, it may be appropriate to consider systolic hypertension to be present at lower pressures (>160 mm Hg). Arterial pressure (AP) category In a recent study, 45 dogs with naturally occurring CKD were divided into 3 groups based on initial systolic blood pressure and were followed for up to 2 years. The groups were defined as: high ( mm Hg), n = 14; intermediate ( mm Hg), n = 15; and low ( mm Hg), n = 16. The initial high-systolic blood pressure group had increased risk of uremic crisis and death compared with the low-pressure group (median survival <200 days vs >400 days, respectively). 17 In cats with a remnant kidney-wrap model of CKD, systolic hypertension (mean pressure of 168 mm Hg) was associated with reduced GFR (1.34 vs 3.55 ml/min/ kg), increased UP/C (1.2 vs 0.1), and increased glomerulosclerosis. 18 Similarly, in dogs with the remnant kidneywrap model of CKD, systolic hypertension (>160 mm Hg) was associated with reduced GFR, increased UP/Cs, and increased mesangial matrix accumulation, tubular lesions, fibrosis, and cellular infiltrates. 19 Cats with progressive CKD had higher systolic blood pressures Table 4. IRIS Treatment Recommendations for Serum Phosphorus in Dogs & Cats with CKD IRIS CKD stage Target serum phosphorus (mg/dl) Management options Renal diet or normal diet with enteric binder Renal diet +/- enteric binder Renal diet with enteric binder Renal diet with enteric binder 52 cliniciansbrief.com May 2015

55 than did cats with stable CKD (155 mm Hg vs 147 mm Hg). 15 Finally, in 69 cats with naturally occurring CKD, high time-averaged systolic blood pressure (159 mm Hg vs 136 mm Hg) was correlated with glomerulosclerosis and hyperplastic arteriolosclerosis. 20 Serum Phosphorus Concentrations Similar to serum creatinine reference ranges, serum phosphorus reference ranges vary among laboratories. This variability is caused in part by higher serum phosphorus concentrations observed in healthy, growing puppies and kittens. Soft tissue mineralization of the kidney causes irreversible nephron damage and is associated with CKD progression in dogs and cats. Cats with stable CKD had lower serum phosphorus concentrations than did those cats with progressive CKD (4.4 vs 5.1 mg/ dl). 15 Serum phosphorus concentration is a predictor of CKD progression in cats, with a 41% increase in the risk of progression for every 1.0 mg/dl increase in serum phosphorus concentration. 15 In 80 client-owned cats with CKD, serum phosphorus concentrations correlated with renal interstitial fibrosis. 20 In dogs with CKD, a serum calcium times phosphorus product >70 mg/dl was a poor prognostic indicator. 21 These findings have prompted closer scrutiny of therapeutic targets for serum phosphorus in dogs and cats with CKD 8 (Table 4). Summary Closer monitoring of serum creatinine and UP/C may facilitate early diagnosis of CKD in dogs and cats. Longitudinal assessment of these parameters provides better data than one-time evaluations. No laboratory test is perfect; trending laboratory data using the same test methodology tends to improve diagnostic sensitivity. Once CKD has been diagnosed, standard of care renoprotective treatment includes a renal diet, potentially in combination with one or more enteric phosphate binders for hyperphosphatemia, ACE inhibitors, or calcium channel blockers for proteinuria and hypertension. Tighter control of hyperphosphatemia, renal proteinuria, and systolic hypertension may improve treatment outcome. n cb References 1. Health status and population characteristics of dog and cats examined at private veterinary practices in the United State. Lund EM, Armstrong JP, Kirk CA, et al. JAVMA 214: , Linking treatment to staging in chronic kidney disease. Brown SA. In August JR (ed): Consultations in Feline Internal Medicine St. Louis: Elsevier Saunders, 2010, pp Medical management of feline chronic renal failure. Polzin DJ, Osborne CA, Adams LG, Lulich JP. In Kirk RW and Bonagura JD (eds): Kirk s Current Veterinary Therapy XI Philadelphia: Saunders, 1992, pp Clinical progression of early chronic renal failure and implications for management. Ross SJ, Polzin DJ, Osborne CA. In August JR (ed): Consultations in Feline Internal Medicine St Louis: Elsevier Saunders, 2005, pp Feline renal failure: Questions, answers, questions. Lulich JP, Osborne CA, O Brien TD, et al. Compend Cont Educ Pract Vet 14: , Plasma creatinine in dogs: intra- and inter-laboratory variation in 10 European veterinary laboratories. Ulleberg T, Robben J, Nordahl KM, et al. Acta Vet Scand 53:25, Lack of utility of laboratory normal ranges for serum creatinine concentration for the diagnosis of feline chronic renal insufficiency. Boozer L, Cartier L, Sheldon S, et al. JVIM 16:354, (abstract) IRIS Staging of CKD. International Renal Interest Society (2013); com/guidelines/staging.shtml; accessed Mar Assessments of factors that affect glomerular filtration rate and indirect markers of renal function in dogs and cats. Miyagawa Y, Takemura N, Hirose H. J Vet Med Sci 79: , Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in cats with chronic kidney disease. Hall JA, Yerramilli M, Obare E, et al. JVIM 28: , Relationship between serum symmetric dimethylarginine concentration and glomerular filtration rate in cats. Braff J, Obare E, Yerramilli M, et al. JVIM 28: , Symmetric dimethylarginine increases earlier than serum creatinine in dogs with chronic kidney disease. Yeramilli M, Yeramilli M, Obare E, et al. JVIM 28: (abstract), Survival of cats with naturally occurring chronic renal failure is related to severity of proteinuria. Syme HM, Markwell PJ, Pfeiffer D, Elliott J. JVIM 20: , Evaluation of predictors of the development of azotemia in cats. Jepson RE, Brodbelt D, Vallance C, et al. JVIM 23: , Clinicopathologic variables predicting progression of azotemia in cats with chronic kidney disease. Chakrabarti S, Syme HM. Elliott J. JVIM 26: , Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats. Brown S, Atkins C, Bagley R, et al. JVIM 21: , Association between initial systolic blood pressure and risk of developing a uremic crisis or dying in dogs with chronic renal failure. Jacob F, Polzin DJ, Osborne CA, et al. JAVMA 222: , Evaluation of a technique of inducing hypertensive renal insufficiency in cats. Mathur S, Brown CA, Dietrich UM, et al. Am J Vet Res 65: , Effects of hypertension on renal function and morphology in Page/remnant kidney dogs. Finco DR, Lloyd DE. JVIM 17: (abstract), Histomorphometry of feline chronic kidney disease and correlation with markers of renal dysfunction. Chakrabartis, Syme HM, Brown CA, Elliott J. Vet Pathol 50: , Prognostic role of the product of serum calcium and phosphorus concentrations in dogs with chronic kidney disease: 31 cases ( ). Lippi I, Guidi G, Marchetti V, et al. JAVMA 245: , ACE = angiotensin-converting enzyme, CKD = chronic kidney disease, GFR = glomerular filtration rate, IRIS = International Renal Interest Society, UP/C = Urine protein/creatinine ratio May 2015 Clinician s Brief 53

56 PROCEDURES PRO > SURGERY > PEER REVIEWED Open & Laparoscopic-Assisted Incisional Gastropexy W. Alexander Fox-Alvarez, DVM J. Brad Case, DVM, MS, DACVS University of Florida Gastric dilatation volvulus (GDV) is a life-threatening medical and surgical emergency. The acute medical crisis is brought on by massive gastric distension, which compresses critical vasculature, causing gastric ischemia, impaired venous return, and poor cardiac output. This leads to hypovolemic shock, myocardial ischemia, cardiac arrhythmia, electrolyte imbalance, visceral necrosis, and other detrimental effects. Large- and giant-breed dogs, underweight dogs, and dogs with a large thoracic depth:width ratio are at greater risk for developing GDV. This risk increases with age. One study found large and giant purebred dogs to have a lifelong risk for developing GDV of 24% and 21.6%, respectively. 1 What Is a Gastropexy? Gastropexy is a surgical procedure that creates a permanent adhesion between the pyloric antrum and the right abdominal wall, preventing gastric volvulus. When used to treat patients with GDV, recurrence rates drop to less than 5% compared with more than 50% if no gastropexy is performed. 2 In a recent GDV = gastric dilatation volvulus, PDS = polydioxanone suture study, at-risk dogs treated with prophylactic incisional gastropexy had no episodes of GDV after a mean follow-up time of 2 years results that are the same as or better than those for other reported techniques. 3 Several gastropexy techniques have been described, including incisional, belt-loop, circumcostal, tube, incorporating, gastrocolopexy, endoscopically assisted, laparoscopic-assisted, and laparoscopic gastropexy. 4 The minimally invasive procedures employ an incisional gastropexy in their technique. The authors prefer the incisional gastropexy technique because it is relatively safe, effective, and technically simple to perform. 3 Prophylactic gastropexy can be performed alone or at the same time as sterilization in at-risk breeds. This article serves as a reference for performing incisional gastropexy using both open and laparoscopic-assisted 5 techniques. Patient Positioning For both open and laparoscopic-assisted incisional gastropexy, the patient should be positioned in dorsal recumbency and the abdomen prepared using standard aseptic technique. What You Will Need For Open Incisional Gastropexy n Standard surgical pack n 2-0 polydioxanone suture (PDS) or other monofilament absorbable suture of choice E F For Laparoscopic-Assisted Incisional Gastropexy n Standard surgical pack n 2-0 PDS or other monofilament absorbable suture of choice n #11 blade n Video laparoscopy tower (A) with camera (B), insufflation tubing (C), light cable (D), and video capture device n 10-mm laparoscopic Babcock forceps (E) n 5-mm laparoscope 0 (F) n 5-mm trocar (G) and 10-mm trocar (H) B C D A G H 54 cliniciansbrief.com May 2015

57 STEP-BY-STEP n OPEN INCISIONAL GASTROPEXY STEP 1 After standard abdominal draping, make a ventral midline abdominal incision extending from the xyphoid to 2 3 cm caudal to the umbilicus. Remove the falciform fat using electrosurgical dissection or ligation and en-bloc removal if necessary (not shown). STEP 2 Place two towel clamps in the abdominal musculature of the right body wall, and have an assistant elevate them to further improve visualization of the right cranial abdomen. Then bring the pyloric antrum to the intended gastropexy site in the transversus abdominis muscle (A). Using 2-0 PDS on a taper needle, place a simple A interrupted suture first through the cranial-most aspect of the proposed antral incision site and then through the corresponding cranial point of the planned transversus incision, roughly 1 to 2 cm caudal to the 13th rib (B). Do not remove the needle from this suture, and leave tags long enough to tie. Using a second reel of suture, B repeat this step for the caudal aspect of the proposed gastropexy site. The needles will remain on these suture lines, as they will be used to suture the gastropexy in a continuous pattern after incisions are made. Author Insight Inadvertent incision into the diaphragm can occur if the gastropexy incision in the transversus abdominis is made too cranially or too dorsally. Pay special attention to muscle fiber direction in determining the appropriate location for the gastropexy incision. Diaphragm muscle fibers run obliquely and should be identified and avoided. PDS = polydioxanone suture continues May 2015 Clinician s Brief 55

58 PROCEDURES PRO STEP 3 Use the left hand to pinch the stomach at the intended gastropexy site so the submucosa can be felt slipping out of grasp (A) (Debakey forceps show the location of the submucosa and mucosa after the slip). With the stomach and body wall sutured in position, use a scalpel to make a 4- to 5-cm longitudinal incision in the seromuscular layer of the pyloric antrum between the two stay sutures (B). Incise only the seromuscular layer of the stomach without entering the gastric lumen. Then make a mirror incision into the transversus abdominis between the stay sutures (C). Author Insight Pinching the stomach wall allows the surgeon to feel the mucosal layer slip out of the grip from the seromuscular layer and helps isolate the cut to the seromuscular layers, preventing accidental incision into the gastric lumen. A B C STEP 4 Using the previously placed stay sutures as anchor points for the continuous suture pattern, appose the abdominal and gastric incisions (A). Suture the more dorsal and lateral incision first with the cranial stay suture strand. Finish this suture line, and tie it to the tag of the caudal stay suture. Finally, suture the more ventral and medial incisions in apposition using the caudal suture line (B). To complete the gastropexy, tie the suture to the tag of the cranial suture knot. Close the abdomen (routinely). A B 56 cliniciansbrief.com May 2015

59 STEP-BY-STEP n LAPAROSCOPIC-ASSISTED GASTROPEXY STEP 1 Using the modified Hasson technique, place a 5-mm cannula 1 to 2 cm caudal to the umbilicus on the midline as follows. Using a #11 blade, make an incision through the skin no longer than the inner diameter of the cannula (A). Continue the incision through the subcutaneous tissue into the linea alba. Place stay sutures in the linea to provide outward traction on the body wall while placing the port (B). Place a trocar cannula assembly or threaded screw-in cannula through the incision and into the abdomen (C). Once the cannula is in place, attach CO 2 insufflation tubing and pressurize the peritoneal cavity to a maximum 10 to 12 mm Hg. Insert the laparoscope into the cannula and observe the peritoneum briefly to ensure that no iatrogenic trauma or hemorrhage has occurred. A C Author Insight To avoid the cranial epigastric vasculature when making the next incision, use the laparoscope light to trans-illuminate the proposed site for the second port (D). B D STEP 2 Make the port incision just lateral to the right margin of the rectus abdominis muscle and 1 to 2 cm caudal to the 13th rib (A). Place the 10-mm cannula in a similar fashion under laparoscopic visualization. Once both ports are in place, reduce insufflation to 8 mm Hg (B). A B PDS = polydioxanone suture continues May 2015 Clinician s Brief 57

60 PROCEDURES PRO STEP 3 Place laparoscopic Babcock forceps into the cranial port, and grasp the pyloric antrum midway between the greater and lesser curvatures (A). Once the pylorus is firmly grasped, deflate the abdomen. Remove the Babcock forceps and cannula at the same time, exteriorizing the pyloric antrum (B). Extend the incision in the abdominal wall musculature to a length of 4 5 cm in a direction parallel to the last rib (not shown). Using 2-0 PDS on a taper needle, place a simple interrupted suture through the cranial-most extent of the proposed gastropexy site and then through the corresponding cranial point of the incision into the transversus abdominis. Do not remove the needle from this suture. Repeat the same step for the caudal extent of the proposed gastropexy site using a new reel of suture, roughly 4 cm caudal to the first suture. The needles will remain on these stay sutures, as they will be used to suture the gastropexy in a continuous pattern after the incision into the antrum is made. After stay sutures are placed, release the Babcock forceps from the antrum. A B STEP 4 Make a 4-cm incision in the seromuscular layer of the pyloric antrum (A). Starting from the previously placed stay sutures, suture the seromuscular incision to the edges of the incision in the transversus abdominis (B) as described with the open technique until both edges are sutured and there is 360 contact between them (C). Close the external and internal abdominal oblique muscles over the gastropexy site using 2-0 PDS (D). A B C D 58 cliniciansbrief.com May 2015

61 STEP 5 Before routine closure of the subumbilical laparoscope port, observe the gastropexy site laparoscopically to ensure that no malposition of the antrum resulted from the procedure. If no problems are identified, remove the port and close the body wall, subcutaneous tissue, and skin routinely. n cb References 1. Incidence of and breed-related risk factors for gastric dilatationvolvulus in dogs. Glickman LT, Glickman NW, Schellenberg DB, et al. JAVMA 216:40 45, A prospective study of survival and recurrence following the acute gastric dilatation-volvulus syndrome in 136 dogs. Glickman LT, Lantz GC, Schellenberg DB, Glickman NW. JAAHA 34: , Efficacy of incisional gastropexy for prevention of GDV in dogs. Benitez ME, Schmiedt CW, Radlinksy MG, Cornell KK. JAAHA 49: , Gastropexy (stomach). Cornell K. In Tobias KM, Johnston SA (eds): Veterinary Surgery: Small Animal, Vol 2 St. Louis: Elsevier/ Saunders, 2012, pp A rapid and strong laparoscopic-assisted gastropexy in dogs. Rawlings CA, Foutz TL, Mahaffey MB, et al. Am J Vet Res 62: , PDS = polydioxanone suture Practice Hotline The latest in products and services Cats, Cutting, & Classical Research published in the Journal of Feline Medicine and Surgery suggests that music classical in particular benefits cats undergoing surgery. In the study, 12 female cats undergoing neutering were fitted with headphones and exposed to 2 minutes of silence (as a control), followed randomly by 2 minutes each of Barber s Adagio for Strings (Opus 11), Natalie Imbruglia s Torn, and AC/ DC s Thunderstruck. The cats were in a more relaxed state (lower values for respiratory rate and pupil diameter) under the influence of classical music, with pop music producing intermediate values, and heavy metal producing the highest values. To read the article, go to bit.ly/1p0f7tj. Press release 3/2015 Generic Medications Get OK to Launch Putney, which focuses on developing and selling generic prescription medications for companion animals, recently launched a new generic prescription medicine and plans to roll out another next month. In April, the company released its enrofloxacin antibacterial injectable solution for managing bacterial pathogens in dogs. The company has also received FDA Center for Veterinary Medicine approval for its tiletamine zolazepam injectable. Commercial launch is planned for June Go to putneyvet.com for more information. Press releases 4/2015 It s Elementary: Therapy Dog that Visits Schoolchildren Is Books & Barks Winner In the second annual Books & Barks contest held by pet insurance agency Pets Best, the winner was Ellie Rose, a 5-year-old Bernese mountain dog that regularly visits Peterson Elementary students in Naperville, Illinois. Pets Best awarded $1,000 to the school, where students lined the halls and applauded as Ellie Rose did a celebratory lap. Pets Best also awarded $500 to a pet therapy organization selected by Ellie Rose s owner and handler; she chose Bernese Friends Worldwide Rescue, which focuses on rehoming Bernese mountain dogs in need. To read more about the contest created to recognize the inspirational work of therapy dogs in classrooms and libraries, visit petsbest.com/blog/books-andbarks-contest. Press release 4/2015 May 2015 Clinician s Brief 59

62 Quiz Corner Quiz Corner is offered by the publisher for entertainment purposes only and does not apply toward CE credit. Questions are provided by editorial staff and are not subject to peer review. Quiz Yourself on this issue s features TOP 5 page A single exogenous dose of glucocorticoids can result in a stress leukogram that persists for approximately 24 hours. A. True B. False COMPARATIVE IMAGERY page When interpreting vaginal cytology, the presence of both basal and intermediate cells is indicative of which stage of the estrus cycle in dogs? A. Anestrus B. Proestrus C. Estrus D. Diestrus E. Either (B) or (D) DIAGNOSTIC TREE page When investigating the cause of penile or preputial discharge, isolation of Mycoplasma spp on culture is always indicative of pathologic infection. A. True B. False ASK THE EXPERTS page A pathognomonic clinical sign of feline tracheal tumors would be: A. Dyspnea B. Cough C. Dysphonia D. There are no pathognomonic clinical signs for feline tracheal tumors. PROCEDURES PRO page Assessing the pupillary light reflex in a patient is an effective and inexpensive method for testing vision. A. True B. False ASK THE EXPERT page Standard of care renoprotective treatment for CKD includes which of the following: A. Renoprotective diet B. Enteric phosphate binders C. ACE-inhibitor and/or calcium channel blocker D. Any/all of above as clinically indicated PROCEDURES PRO page When gastropexy is used to treat GDV patients, recurrence rates drop from >50% to less than %. Answer key: 1: True 2: E 3: False 4: D 5: False 6: D 7: 5 Polling Place Go to cliniciansbrief.com to weigh in. We asked... Who reads the cytology slides in your practice? You answered... A. The technician(s)... 31% B. The veterinarian on the case... 35% C. 1 or 2 of our vets with interest in cytology... 10% D. We send our cytology slides out to a lab... 24% This month s question... What kind of diet do you recommend for your patients going on a hypoallergenic diet trial? A. Any commercial diet with a novel protein and carbohydrate B. A therapeutic diet with a novel protein and carbohydrate C. A therapeutic diet with hydrolyzed soy protein D. A home-cooked diet 60 cliniciansbrief.com May 2015

63 PRACTICAL SOLUTIONS TO EVERYDAY CHALLENGES. Subscribe to Veterinary Team Brief for FREE to receive: The only publication to combine medical and professional skills in one resource Essential tips for team-based medicine, including clinical strategies, client communication, and practice protocols Brief, concise formats for the entire veterinary team SUBSCRIBE FOR FREE AT VETERINARYTEAMBRIEF.COM/SUBSCRIBE OR CALL From the publisher of Clinician s Brief