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ReferralFor Contact Fall CE informationdetails and Partners In Care Veterinary Referral News from Angell Animal Medical Center Summer 2016 π Volume 10:2 π angell.org π facebook.com/AngellReferringVeterinarians

TO ECHO OR NOT TO : THE ECHO? INCIDENTALLY A PRIMER ON PROXIMAL NEWEST ANESTHETIC DETECTED HEART OSTEOARTHRITIS: CANINE GI NEOPLASIA ABDUCTING ULNA INDUCTION AGENT MURMURS IN MYTHS AND TRUTHS AND

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ANESTHESIA CARDIOLOGY

Alfaxalone: To Echo or Not to Echo? The Newest Anesthetic Incidentally Detected Induction Agent Heart Murmurs in Dogs ππStephanie Krein, DVM, DACVAA and Cats angell.org/anesthesia ππRebecca Malakoff, DVM, DACVIM (Cardiology) [email protected] 617-541-5048 MSPCA-Angell West angell.org/cardiology [email protected] 617-541-5038

ince the introduction of anesthesia hundreds of years ago, the eterinarians commonly auscult heart murmurs during agents used to provide , induction, and maintenance of routine exams for presenting for non-cardiac anesthesia have become profoundly safer. Although the drugs we reasons (for example, annual vaccine appointments. use today are much safer, there still exists no perfect anesthetic Although it would be wonderful if every such could Sagent. Since came onto the market, it has been the most widely haveV a full cardiac workup, not every client may have the resources used and arguably one of the safest anesthetic induction agents used in or inclination to follow up with an echocardiogram or visit to a both human and . Alfaxalone, brand name Alfaxan, cardiologist, requiring general practitioners to be able to provide is the newest anesthetic induction agent to enter the United States market information to enable their clients to make the best diagnostic after approval by the FDA in 2014. Although it is new in this country, it decisions and plans for their pets. In 2015, a group of board- has been available and used widely throughout the world since 2001. certified cardiologists brought together as the “Working Group of Alfaxalone is a neurosteroid that enhances the actions of GABAA, the the ACVIM Specialty of Cardiology on Incidentally Detected Heart most important inhibitory neurotransmitter in the body, to produce Murmurs” published a reference article in JAVMA providing muscle relaxation and anesthesia. Alfaxalone comes as a clear, colorless, current information by species and age group to help non-irritating, aqueous formulation and is marketed for intravenous use in this endeavor.1 This summary will highlight some of the key only, although it can be used off label and administered intramuscularly points made by the authors, although it is worth noting that the full (IM) as part of a sedation protocol. Alfaxalone is a class IV controlled article provides even more information that is well worth reading. substance and needs to be kept in a lock box, and a log sheet must be created to record the amounts used each time.

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1. ANESTHESIA

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1,6,7 FIGURE 1 cats. Although overall satisfactory recoveries Cats: Alfaxalone use in cats is associated with are noted, things such as tremors, twitching, a smooth induction of anesthesia, minimal ANESTHESIA 4 4Alfaxalone, brand name Alfaxan, is the paddling, and face rubbing can occur. Longer cardiorespiratory depression, and a satisfactory newest anesthetic induction agent to enter the United States market after approval by recovery times are noted with alfaxalone than recovery, although events such as tremors the FDA in 2014. with propofol (may not be true for constant rate and twitching can be noted. Since cats can infusions). Alfaxalone recoveries are more be difficult to handle, often requiring satisfactory than those seen with and intramuscular sedation, alfaxalone could fill a /. much-needed void in providing an option that has overall minimal cardiovascular effects. Dogs: Induction has been shown to be smooth Cardiovascular disease often goes undiagnosed in dogs, although events such as myoclonus in cats, especially those that are difficult to and tremors can be seen, especially in handle, and the drugs used to sedate cats IM inappropriately premedicated dogs. Recovery currently have many unwanted cardiovascular has also been proven to be overall satisfactory side effects. The use of an opioid, a sedative with the use of alfaxalone, although events (midazolam or dexmedetomidine), and such as head shaking, excitation, and sensitivity alfaxalone frequently provides a rapid and to noise have been seen.8 satisfactory sedation of these cats, as well as a smooth recovery. It is my clinical opinion that EFFECTS ON OTHER BODY SYSTEMS alfaxalone causes less hypotension after CARDIOVASCULAR EFFECTS OF ALFAXALONE Intracranial pressure: Although not thoroughly induction than does propofol in cats. Alfaxalone studied at this point, it is thought that can also be used as a constant rate infusion for Cats: There are several different studies alfaxalone is safe for use in patients with maintenance of anesthesia in cats. For these evaluating the effects of alfaxalone on heart rate, intracranial disease.1,9 reasons, alfaxalone may indeed become widely systemic vascular resistance, contractility, and used in feline anesthesia. cardiac output, and these studies do not all agree Intraocular pressure and tear production: in their findings. The overall picture of Alfaxalone has been shown to increase Other species: Although beyond the scope of alfaxalone in cats is that it may decrease, intraocular pressure to the same degree as this article, alfaxalone has been used and although usually not to a clinically significant propofol (clinical significance unknown) studied in many other species, including alpacas, value, heart rate, decrease systemic vascular and to decrease tear production to a greater ruminants, rabbits, ferrets, fish, and reptiles. resistance, and mildly decrease contractility and degree than propofol.10,11 cardiac output.1,2 When compared to propofol, it is thought that alfaxalone is similar in its effects, Hepatic and renal: Alfaxalone does not appear to For more information about Angell’s Anesthesia although it may maintain systemic vascular have any unwanted effects on either the hepatic Service, please call 617-541-5048 or email [email protected]. resistance better than propofol, thereby leading or the renal system.1 to higher blood pressures. CLINICAL USE OF ALFAXALONE Dogs: Alfaxalone has been shown to cause an REFERENCES Dogs: Alfaxalone use in dogs is associated with increase in heart rate and a decrease in 1 Warne LN, Beths T, Whittem T, Carter JE, Bauquier a smooth induction of anesthesia, minimal systemic vascular resistance (although mild SH. A review of the pharmacology and clinical cardiorespiratory depression (although a and still within normal physiologic range) application of alfaxalone in cats. Vet J. 2015 decrease in systemic vascular resistance and after induction.3 It is thought to be a useful Feb;203(2):141–8. blood pressure can be seen), and a satisfactory induction agent in both healthy and 2 Ribas T, Bublot I, Junot S, Beaufrère H, Rannou recovery. In dogs in which an increase in heart hemodynamically unstable dogs.4 In dogs with B, Gagnière P, et al. Effects of intramuscular rate is desired, such as those with degenerative advanced heart failure, etomidate still remains sedation with alfaxalone and butorphanol on valvular disease, alfaxalone may be a more the drug with minimal effects on the echocardiographic measurements in healthy appropriate agent than propofol. Although cats. J Feline Med Surg. SAGE Publications; 2015 cardiovascular system.3 solely labeled for intravenous administration, Jun;17(6):530–6. alfaxalone can be given IM as part of the RESPIRATORY EFFECTS OF ALFAXALONE 3 Rodríguez JM, Muñoz-Rascón P, Navarrete-Calvo premedication in difficult-to-handle dogs. Cats: A recent study has shown that alfaxalone R, Gómez-Villamandos RJ, Domínguez Pérez JM, Alfaxalone does not provide analgesia, and Fernández Sarmiento JA, et al. Comparison of the maintains respiratory rate and end tidal CO2 at adequate premedication and pain control must cardiopulmonary parameters after induction of normal levels as compared to the decrease seen be used in order to provide smooth inductions anaesthesia with alphaxalone or etomidate in dogs. 5 with propofol. and recoveries with this drug. In addition to its Veterinary Anaesthesia and Analgesia. Blackwell use both IV and IM, the author of this article Publishing Ltd; 2012 Jul;39(4):357–65. Dogs: Respiratory rate has been shown to be has used intranasal administration to deliver 4 Psatha E, Alibhai HI, Jimenez Lozano A, Armitage decreased from baseline after induction with alfaxalone in a Doberman with severe Von Chan E, Brodbelt DC. Clinical efficacy and alfaxalone, but apnea is less commonly noted Willebrand’s disease. This technique has not cardiorespiratory effects of alfaxalone, or diazepam/ 3 than with propofol. been described in the literature. Alfaxalone fentanyl for induction of anaesthesia in dogs that can be used in both healthy dogs and in those are a poor anaesthetic risk. Veterinary Anaesthesia INDUCTION AND RECOVERY QUALITY less stable to provide sufficient induction into and Analgesia. Blackwell Publishing Ltd; 2011 Jan WITH ALFAXALONE 1;38(1):24–36. anesthesia.4 Alfaxalone can also be used as a Cats: Induction and recovery from alfaxalone constant rate infusion to maintain anesthesia anesthesia has been shown to be satisfactory in throughout various procedures. (CONTINUED ON PAGE 10)

2. Partners In Care π Summer 2016 π Volume 10:2 CARDIOLOGY

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The group described characteristics that aid in FIGURE 1 determining whether a murmur is pathological CARDIOLOGY (resulting from a cardiovascular lesion) as 44Dr. Malakoff performs an echocardiogram on a feline patient opposed to nonpathological (associated with a structurally normal heart). A nonpathological murmur may be termed functional if there is a physiological cause, such as anemia, or innocent if no obvious physiological cause is identified. The authors modified a “6-S” rubric used in human cardiology to indicate features more likely to be associated with a nonpathological murmur: murmurs that are:

1. Soft (generally grade 1 or 2/6) 2. Systolic 3. Small (localized to left heart base or to one location with no radiation) 4. Single (no other abnormal heart sounds, such as clicks, gallops, or arrhythmias) 5. Short (predominantly heard in early or mid systole) and 6. Sensitive (absent or much softer at rest than with excitement or exercise)

It is important to note that this rubric may be cardiovascular testing (echocardiography), greater availability. If the thoracic radiographic more useful in dogs, as with cats, it is often not second opinion auscultation by a cardiologist, findings are normal, clinically important heart possible to classify systolic murmur grades 1 to or reexamination and reauscultation after a disease is uncommon (absence of cardiomegaly 3/6 as pathological or nonpathological. period of two to four weeks. Any murmurs may suggest a nonpathological murmur or louder than a grade 3/6 or continuous in mild/early degenerative mitral valve disease). Nonpathological murmurs are commonly duration warrant further investigation. If there is cardiomegaly or other cardiovascular ausculted in puppies, but pathological Murmur intensity and location is less helpful abnormalities, echocardiography is more murmurs are heard as well, typically resulting for predicting specific diagnoses and prognoses strongly recommended. For large-breed dogs from congenital heart disease. The most for cats than dogs. For example, cats with a (>20 kg), fewer conclusions may be reached common congenital heart defects diagnosed small, clinically insignificant ventricular confidently based solely on physical exam in dogs in the United States are pulmonic septal defect may have a loud (grade 5/6) findings. Large-breed dogs with a left apical stenosis, subaortic stenosis, patent ductus systolic murmur. systolic murmur may have dilated arteriosus, and ventricular septal defect, with cardiomyopathy or degenerative mitral valve some breed predispositions to particular For both puppies and kittens with heart disease, and degenerative valve disease can disorders. Further investigation of an murmurs warranting further investigation, 2-D progress more rapidly in dogs of this size incidentally ausculted murmur in a young and Doppler echocardiography by a cardiologist compared to small-breed dogs. Therefore, for is warranted if the murmur is continuous, are recommended as providing the best this size group of dogs, echocardiography diastolic, prolonged such that it obscures the diagnostic and prognostic information. ECG should be recommended as the initial second or both heart sounds, or accompanied and thoracic radiographs may provide useful diagnostic test of choice. Other findings to by transient abnormal heart sounds (such as a ancillary information but cannot provide a prompt recommendation for echocardiography split-second heart sound). Murmurs ausculted definitive diagnosis of the cause of the murmur. in adult and geriatric dogs share some in locations other than the left heart base (such Assessment of cardiac size on thoracic similarities as with juveniles: diastolic or as radiating to the carotid region, over the right radiographs in cats can have limited accuracy, continuous murmurs, murmur location other hemithorax, or best heard at the left apical especially as concentric ventricular hypertrophy than left apical, murmur accompanied by region over the mitral valve) or that are loud is not radiographically apparent. arrhythmia, or murmur that is recent in onset (grade 3/6 or louder), with PMI over the left and coexists with vague systemic signs (to rule For adult and geriatric dogs with an incidental heart base, warrant further testing. out possible infective endocarditis). heart murmur, consider signalment aids in Young cats (<6 months) may have determining the most likely etiology of Systolic heart murmurs are fairly common in nonpathological murmurs or pathological pathological murmurs. The majority of small- healthy adult and geriatric cats. The most murmurs, and as previously emphasized, the breed (<20 kg) dogs with a systolic murmur common form of heart disease causing a specific characteristics that separate these two over the left apex have degenerative mitral pathological murmur in cats is hypertrophic categories fail to reliably do so in most cats with valve disease. Although echocardiography cardiomyopathy, and the most common cause grade 1 to 3/6 systolic murmurs. If such a provides more precise and accurate information of a nonpathological murmur is dynamic right murmur is ausculted, the author suggests regarding the cause of the murmur and is ideal ventricular outflow tract obstruction. Because three different possible approaches: further in these cases, thoracic radiographs are often performed first because of lower cost and (CONTINUED ON PAGE 10)

Partners In Care π Summer 2016 π Volume 10:2 3. O 4. about this disease that may be useful to review. review. to useful be may that disease this about facts (OA key some or DJD) and osteoarthritis of features clinical about have may clients myths of the some are Below experiences. own their from extrapolated directly usually is view their and disease of this understanding alimited have clients Oftentimes, evaluated. patient every nearly in present is osteoarthritis Service, Medicine Pain Center’s Medical Animal Angell In progression. and diagnosis, of pathophysiology, details the about much too don’t we yet think see, veterinarians that bone and cartilage overgrowth (osteophytes), (osteophytes), overgrowth cartilage and bone alterations, bone subchondral degeneration, meniscal with joints synovial of the failure functional and structural in result that of disorders of arange outcome pathological and clinical of OA “the is definition One cats. and dogs in true less is This disease. of the hallmark a is loss cartilage humans, namely species, some In joint. of amoveable tissues all in abnormalities by characterized is that a disease OA but OA, by is affected is cartilage course, Of OF CARTILAGE ADISEASE IS OSTEOARTHRITIS MYTH: dogs. adult five one in than more and of age 55 years over of people percent 80 over in OA present is that are Estimates people. and cats, dogs, aged in prevalent very is OA course, Of injury. acute OA an not have and already puppies their that learn to surprised quite usually are Clients of age. months six are they before puppies in interactions social with problems or even intolerance, exercise of lameness, signs recognize may clients patients, For these dysplasia. or elbow coxofemoral in as asymmetry, joint congenital to due are patients of OA young in examples common most The obesity). (i.e., joints normal on forces abnormal by or joints abnormal forceson normal by caused be OA can maturity. skeletal reach they before OA even significant have will patients Sadly, of our some AGING OF ADISEASE IS OSTEOARTHRITIS MYTH: PAIN MEDICINE the most common chronic disease disease chronic common most the (DJD)) probably is disease joint degenerative with synonymously (OA used –here steoarthritis 1 617-541-5140 [email protected] angell.org/painmedicine π and Truths Myths onA Primer Osteoarthritis: π Lisa Moses, VMD, DACVIM, CVMA DACVIM, VMD, Moses, Lisa

tissues instigates pain and pain disability.tissues instigates joint the to damage the repair to attempts overexuberant body’s the patients, many In tissues. of joint repair and breakdown between equilibrium dynamic of the unbalancing an species. other than bone of subchondral sclerosis or develop osteophytes form to tendency of a less have which of cats, true particularly is This on radiographs. visible damage structural significant without OA have pain can species of any patients Conversely, cats. and dogs of true also is this self-reporting, without infer can we as best As mobility. or decreased pain any reporting without damage) structural (i.e., of OA evidence radiographic have people Many DISABILITY AND PAIN WITH CORRELATED MYTH: RADIOGRAPHIC OSTEOARTHRITIS IS response.” inflammatory asynovial and cartilage, of articular loss and disability from OA are not directly linked linked OA directly not from are disability and Pain underdiagnosed. seriously be to appears FIGURES 1&2 FIGURES 3 This may be one reason why feline OA why feline one reason be may This 2 OA is a reflection of of OA areflection is Care In Partners EROSIVE-TYPE ARTHRITIS AND RHEUMATOID TO CONTRAST IN CONDITION, MYTH: OSTEOARTHRITIS IS A NONINFLAMMATORY increases in endogenous mechanisms mechanisms analgesic endogenous in increases of because occurs reduction pain further increased, be can activity and reduced is pain Once pain. chronic experiencing for patients relieving pain directly is reduction Weight cytokines. production pro-inflammatory of the via state pain inflammatory an to contributes directly and active biologically is fat that understand not may Clients gain. weight atrophy, further and muscle pain, to due exercise of decreased cycle avicious to leading degeneration, joint initiate may weight Excess compliance. weight-reduction in tool powerful a be can loss of weight benefits pain-relieving direct the and pathogenesis about Education understand. rarely clients that pain joint and of weight interaction acomplex is force. There of loading asimple from far is effect its but pain, and of ajoint degeneration to leading factor significant and acommon is weight Excessive JOINT THE ON FORCE DECREASED OF BECAUSE PAIN JOINT REDUCES REDUCTION WEIGHT MYTH: time. over of pain signs clinical variable to relate may inflammation of levels that idea the to leading wanes, and waxes naturally course disease The mediators. chemical via tissues affected to damage permanent for the consequences important has also but central) and peripheral (both of pain pathogenesis the role in alarge play does Inflammation OA not. is while disease, asystemic is arthritis, IMPA or rheumatoid like arthritis, mediated immune Primary disease. of the phases at different intensity in varies that process degenerative inflammatory anonpurulent involve does pathogenesis noninflammatory. In fact, osteoarthritis termed was osteoarthritis years, For many individual pain cognition. pain individual and system, nervous the in processing pain alteration, biochemical change, of structural interaction acomplex as of OA pain origin the Fox describes factors. of multiple relationship dynamic intricate, an to due is generation pain because severity radiographic to 2016 π Summer 1 π Volume 10:2

PAIN MEDICINE ANGELL AT NASHOBA: LOW COST CARE PAIN MEDICINE FOR QUALIFIED LOW INCOME CLIENTS

Angell Animal Medical Center and Nashoba Valley Technical associated with activity and muscle pain isn’t seen, then clients are likely High School have partnered to create Angell at Nashoba, a mass. When significant weight reductions wasting their money and may be doing one-doctor clinic dedicated to providing quality veterinary occur in OA patients, there is also an harm if patients have GI or other care to low income pet owners and training more technicians eventual reduction in hyperalgesia and adverse effects from these agents. within Northern Massachusetts. For the pets of owners that altered pain thresholds. In the Pain financially qualify, Angell at Nashoba provides discounted: Medicine Service at Angell, weight reduction is the most effective method For more information about Angell’s Pain Spay/neuter services Medicine Service, please call 617-541-5140 used to reduce pharmacological or email [email protected]. dependence on . Vaccinations

MYTH: DISEASE-MODIFYING REFERENCES AND SUGGESTED Basic veterinary care OSTEOARTHRITIS DRUGS (DMOADS) READINGS REDUCE OA SEVERITY AND Open weekdays from 7:45am-4:00pm throughout the year, RESULTING PAIN 1 Fox, SM. Chapter 2: Pathophysiology of Osteoarthritic Pain in Chronic Pain in Small the clinic does not provide overnight care, specialty service Like the rest of the story about OA, Animal Medicine. Manson Publishing, care, nor 24/7 emergency service as Angell’s Boston and the truth about DMOADs is complex. London, 2010. Waltham facilities do, but will refer cases as appropriate to When the pathogenesis of OA was 2 Hunter DJ and Hellio Le Graverand- surrounding specialty veterinary referral hospitals. being uncovered years ago, cartilage Gastineau M. How Close Are We to Having To contact the Angell at Nashoba clinic, please call degeneration was thought to be the Structure-Modifying Drugs Available? Med 978-577-5992. The clinic is located at: 100 Littleton Road, dominant process in pain generation and Clin N Am 93: 223-234, 2009. Westford, Massachusetts. disability. Pharmacological substances 3 Lascelles, BDX. Feline Degenerative Joint that impact cartilage degeneration were Disease. Veterinary 39; 2-13, 2010 originally called chondroprotective THE STAFF AT ANGELL AT NASHOBA Sofat N, Ejindu V, Kiely, P. What Makes agents. This label was changed to LAURENCE SAWYER, DVM DMOADs because they were thought to Osteoarthritis Painful? The evidence for local Dr. Sawyer has been in small impact the course of the degeneration and central pain processing. Rheumatology 50: 2157-2165, 2011. animal private practice since and to have clinical benefit. Since that 2001. She has also volunteered terminology change, the FDA and its Vandeweerd JM, et al. Systematic Review of regularly at Tufts at Tech European counterpart have defined Efficacy of Nutraceuticals to Alleviate Clinical Community Veterinary Clinic DMOADs as agents that modify Signs of Osteoarthritis. J Vet Intern Med 26: 448-456, 2012. since its inception in 2012. OA structure by slowing joint-space She enjoys clinical medicine narrowing (which is much more and surgery, teaching, and common in people) and provide pain community service and is excited to be part of the Angell and disability symptom reduction. team that has established a community veterinary clinic at Currently, no DMOAD exists that Nashoba Valley. meets this criterion. Some of these agents do slow structural progression but do not improve function or pain in LISA QUINONES, CVT patients. Some of these agents improve Lisa has been working as a pain in certain patients but do not slow veterinary technician since progression of structural changes. 2007, starting her career in a Because pain and dysfunction are not fast-paced emergency and directly or solely related to structural critical care practice. In 2010, progression, delaying structural changes she moved to Boston and joined doesn’t always show clinical benefit. The MSPCA-Angell’s surgery team, bottom line is that some of these agents working as an anesthesia tech are beneficial for individual patients, and becoming the department’s supervisor in 2013. Lisa but there is no evidence suggesting enjoys volunteer work, painting, yoga, gardening, reading, long-term benefit or prophylaxis from and being outdoors with her two dogs. DMOADs in most patients. For most Additionally, Department of Elementary and Secondary patients, these agents do not actually Education (DESE) licensed high school animal science modify the disease course at all. For teachers will be part of the program. Their main focus will patients in the Pain Medicine Service, be the education of the high school students in the necessary we advise a one- to two-month trial theoretical and clinical elements for acquiring a veterinary of so-called DMOADs and then a assisting license. Students and staff will also work alongside reevaluation of their benefits. It has been the staff at Angell at Nashoba. suggested that some joint supplements may have anti-inflammatory effects in For more information, please visit: www.angell.org/nashoba. particular individuals using an unknown Follow the clinic on Facebook: www.facebook.com/AngellAtNashoba. mechanism. Our clinical experience using these agents would support that idea. If clear reduction in disability or

Partners In Care π Summer 2016 π Volume 10:2 5. PATHOLOGY

Canine GI Neoplasia PATHOLOGY ππPamela Mouser, DVM, MS, DACVP Anatomic Pathologist, Angell Animal Medical Center angell.org/lab [email protected] 617-541-5014

he most enjoyable cases from a Angell submissions were further tabulated by to be arising from rectal papillary adenomas. diagnostic pathologist’s perspective section of the GI tract affected, and it is Rectal plasma cell tumors (plasmacytomas) are those that have beautiful, interesting to note that some tumor types were the next most-common rectal tumor type picturesque lesions. I am often partial predominated in certain areas (see Table 1). For and tended to have a high recurrence rate (five of Ttoward nice gross lesions, and gastrointestinal example, eight of the 13 gastric were seven tumors). neoplasia can certainly provide some great epithelial proliferations ranging from photo opportunities. In this article, I will adenomatous hyperplasia to gastric GROSS LESION APPEARANCE summarize just over six years of surgical biopsy adenocarcinoma. Interestingly, there were no The three major types of gastrointestinal data for canine gastrointestinal neoplasia (mid- lymphoma diagnoses in the stomach, although malignancy are illustrated in Figure 1, using 2009 through late 2015), including samples this may represent case bias since a cytological small intestinal lesions as examples. taken from the stomach to the rectum; illustrate diagnosis of lymphoma may preclude surgical Adenocarcinomas arise from the inner aspect of the gross appearance of common neoplastic biopsy. One-third of the neoplastic processes in the GI wall (tunica mucosa), are often lesions; and compare findings to published data. the small intestine were diagnosed as carcinoma circumferential in the small and large intestine, and another third as lymphoma. This is in and induce a desmoplastic response. These ANGELL DATA SUMMARY contrast to the ileocecocolic junction, cecum, tumors are therefore firm, frequently cause Of the 108 canine gastrointestinal (GI) and colon, where adenocarcinoma and stricture of the intestinal lumen, and may cause neoplasms in our database from the past six lymphoma were only diagnosed once each out of annular constriction of the wall referred to as a years, the most common diagnoses in 17 neoplastic submissions. Gastrointestinal “napkin-ring” lesion. Lymphoma is also often descending order were adenoma or stromal tumors (GISTs) appeared to favor the circumferential, but tends to be more expansile adenomatous hyperplasia (32, 26 of which cecum, although some of the unclassified than carcinoma, causing effacement of all layers were rectal papillary adenoma submissions), sarcomas occurring at other sites may have been with a homogenous tan color. Intestinal adenocarcinoma (21), and lymphoma (13). If all recategorized as GISTs if immunohistochemical sarcomas range from pale tan to almost white, sarcomas were considered together as a group, phenotyping had been performed. Over half of are firm to fibrous, and have a more eccentric they would weigh in at a total of 24 cases. the rectal masses were papillary adenomas, and distribution compared to the other two lesions. three cases classified as carcinoma were noted Of course, regardless of how characteristic a

44Table 1: Canine gastrointestinal neoplasia diagnosed via biopsy between mid-2009 and late 2015, separated by submission site.

SMALL ILEOCECOCOLIC STOMACH INTESTINE JUNCTION CECUM COLON RECTUM TOTAL

Adenocarcinoma 3 11 1 6* 21 Lymphoma 11 1 1 13 Sarcoma† 1 4 1 2 1 1 10 GIST 1 2 6 1 10 Leiomyosarcoma 2 1 1 4 Adenoma/polyp 5 1 26 32 Plasma cell tumor 1 7 8 Leiomyoma 2 1 2 5 Mast cell tumor 1 1 1 3 Neuroendocrine carcinoma 1 (insulinoma) 1 2 TOTAL 13 33 1 10 6 45 108

* Three cases of rectal carcinoma were in situ carcinomas arising within rectal papillary adenomas. † Masses classified as sarcomas included lesions without IHC for further distinction, KIT-negative sarcomas that did not have morphology typical of leiomyosarcoma, and one extraskeletal invading the small intestine.

6. Partners In Care π Summer 2016 π Volume 10:2 Care In Partners overall median survival time was 77 days. 77 was time survival median overall the and remission, achieved of dogs percent 50 over just chemotherapy; multiagent with treated dogs in outcome apoor reported phenotype most common. most phenotype T-cell with cells, lymphoid of large composed typically is dogs in lymphoma Alimentary number. sample low relatively of our afactor simply is or workups, case during imaging diagnostic of use consistent our through sarcomas of small/incidental detection more frequent reflects bias, of selection aform represents set data our in of sarcomas proportion greater the whether uncertain am I characterized. further not were that sarcomas additional several GISTs, and with of carcinomas number equal an show submissions biopsy our rectum, the to cecum the from neoplasms of our all group a as dogs, in of GI lymphoma incidence the underestimate may set data biopsy our Thus, possible. when patients these in avoided is surgery that Isuspect data, survival this Given cats, and dogs in neoplasia of alimentary review a recent In REPORTS PUBLISHED TO DATA COMPARISON diagnosis! for final essential is grossly, histopathology appears mass carcinomas diagnosed in the rectum. the in diagnosed carcinomas of proportion greatest the with dogs, in malignancy intestinal large common most the is carcinoma that suggests also article review The “sarcomas.” as together tumors mesenchymal all lump not do we if set data our by corroborated is which dogs, in GI malignancies common most the are lymphoma and adenocarcinoma supportive care. supportive or both, chemotherapy, surgery, with treated were that lymphoma gastrointestinal with dogs 30 in of 13 days) survival (median time survival short a remarkably reported study 4 PATHOLOGY FIGURE 1 FIGURE 4 created epithelium. by neoplastic glands cystic large or of foci either representing mass, the of wall the in spaces cystic shows section cut the of inspection Close lumen. intestinal the of narrowing causing mass in carcinoma intestinal an of photograph gross The AdemonstratesImage a firm circumferential 2016 π Summer 1 the author indicates that that indicates author the 3 A prospective study also also study Aprospective 2 One retrospective retrospective One

π Volume 10:2 1 If we we If 4

Angell biopsy service: biopsy Angell biopsygastrointestinal submissions to the of canine years six from on data based made be can points take-home following The SUMMARY tumors. stromal gastrointestinal as now classified are and immunohistochemistry via for (CD117) KIT positive – are tumors associated their – and cells These of Cajal. cells interstitial the from arise actually origin smooth-muscle as classified previously of tumors 50 percent) over well (often proportion asignificant that suggest and masses intestinal sarcomatous of evaluation careful amore prompted have immunohistochemistry in advances However, recent leiomyosarcomas. as diagnosed were tumors of GI mesenchymal majority the Historically, biopsy. surgical precludes likely diagnosis of this confirmation cytological smooth-muscle counterparts. smooth-muscle their than more commonly GISTs metastasize that evidence is there endeavor, as academic an just more than be may types sarcoma intestinal widely used for canine mast cell tumors. cell mast for canine used widely now those as such agents, chemotherapeutic specific with provide for treatment options also may receptor, kinase atyrosine KIT, • • • narrowed with this mass. this with narrowed is also lumen intestinal the that Note lymphoma. is intestinal wall, intestinal the of effacement layer and expansion full-thickness causing mass, 4 • • • 4 the canine GI tract. canine the in diagnosed malignancies common most of GISTs) number the anotable were (with sarcoma and lymphoma, Adenocarcinoma, GISTs occurring in the cecum. the in GISTs occurring of proportion greatest the with intestine, large the in lymphoma and carcinoma than frequently more diagnosed was Sarcoma intestine. small the in frequency equal with diagnosed were lymphoma and carcinoma while stomach, the in predominated tumors Epithelial This B: smooth,Image homogenous tan 5,6 The distinction between between distinction The

7 Positivity for for Positivity

relative to the intestinal lumen. intestinal the to relative distribution eccentric the to contributes likely which muscularis), (tunica GI wall the of layers outer the from arise typically lesions Both tumor. stromal agastrointestinal of image inset the to this Compare leiomyosarcoma. is a appearance afibrous with 4 Service, please call 617-541-5014 please Service, Angell’s about Pathology information more For • 7 6 5 4 3 2 1 REFERENCES: [email protected] 4 • The irregular, eccentric intestinal mass mass intestinal irregular, eccentric The C: Image sarcoma is firm and eccentric. and firm is sarcoma tan; homogeneously but circumferential also is lymphoma firm; and annular be to tends Grossly, adenocarcinoma characteristics. Vet Pathol 2013;50:779-788. Pathol Vet characteristics. microscopic, immunohistochemical, and molecular on based sarcomas gastrointestinal nonlymphogenic, Kiupel Classification M. ofcanine nonangiogenic, E, V, Gregory-Bryson Yuzbasiyan-Gurkan S, Hayes Am Vet Med Assoc 2007;230:1329-1333. Assoc Med Vet Am J (1990-2003). in cases 42 dogs: leiomyosarcomas from tumors stromal gastrointestinal of and immunohistochemical differentiation Clinical KA. Skorupski SJ, Mehler KN, Russell Vet Surg 2007;36:302-313. histologic, and immunohistochemical evaluation. in 72 clinical, dogs: muscle tumors smooth of small cecal and intestinal Reclassification J. Van Haar Kirpensteijn Gaag ter G, der I, Maas CPHJ, 2009;23:317-322. Med Intern JVet in dogs. lymphoma gastrointestinal of treatment for chemotherapy combination of al. Efficacy et KE, Collister AS, Moore Rassnick KM, 2007;43:313-321. Assoc Anim Hosp JAm lymphoma. gastrointestinal (1997-2004) canine cases 30 of of outcomes Clinical M. Kiupel PH, Kass Frank Reimer SB, JD, Vet Pathol 2004;41:141-146. lymphoma. in canine gastrointestinal lymphocytes of Characterization H. and Steinberg KA Coyle Clin Vet and Small cats. Anim 2012;42:693-706. dogs geriatric in neoplasia Alimentary MD. Willard . or email or

7.

PATHOLOGY SURGERY

Proximal Abducting Ulna Osteotomy SURGERY ππNick Trout, MA, VET MB, DACVS, ECVS

angell.org/surgery [email protected] 617-541-5048

erhaps it reflects breed popularity reduce pain and improve elbow function? This FIGURES 4 & 5 (golden retrievers, Labradors, Bernese is, in broad terms, the general premise behind mountain dogs, rottweilers), but at PAUL, the proximal abducting ulna osteotomy 44Lateral (Figure 4) and AP (Figure 5) postoperative Angell, the dominant subtypes of (Kyon Veterinary Surgical Products). radiographs of Pendo’s radius/ulna. Note the Pcanine elbow dysplasia are fragmented medial significant degenerative joint disease in the elbow. coronoid process (FMCP) and osteochondritis Pendo, a five-year-old neutered male golden dissecans (OCD). FMCP is a separation of the retriever had been medically managed for DJD medial aspect of the coronoid process from the secondary to left elbow dysplasia for many years. ulna, whereas OCD is caused by failure of More recently, his function had been declining normal endochondral ossification on the despite excellent weight management, exercise medial aspect of the humerus. The long-term limitations, joint supplements, and meloxicam. effect of these developmental imperfections is Pendo appeared to be a good candidate for a degenerative joint disease (DJD), leading to PAUL procedure. Following radiographic wear and erosion of cartilage on the medial preoperative planning, the affected elbow was aspect of the elbow joint. When visualized scoped to ensure cartilage damage was limited arthroscopically (Figure 1), the delineation to the medial compartment and, in Pendo’s between destroyed cartilage medially and case, to remove a loose coronoid fragment. The healthy white pristine cartilage in the lateral caudal approach to the proximal ulna is simple, compartment is striking. with minimal soft tissue dissection, allowing an ulna osteotomy with an oscillating saw to create FIGURE 1 a small caudal step of two to three millimeters in the proximal ulna, lowering the coronoid. 44Arthroscopic image of an elbow joint This is secured using a titanium six-hole, PAUL Postoperative radiographs confirmed documenting delineation between eroded cartilage plate (Kyon) applied to the lateral aspect of the appropriate implant position (Figure 4 and in the medial compartment and more normal cartilage in the lateral compartment. ulna, spanning the osteotomy gap (Figure 2 and Figure 5), and the leg was placed in a soft Figure 3). padded bandage for one to two weeks. Exercise restriction is important for the next six to FIGURES 2 & 3 eight weeks, but physical therapy, including hydrotherapy, can begin at week four. 44Lateral view (Figure 2) and a caudomedial- craniolateral oblique view (Figure 3) of a bone model The ulna is often slow to heal, and the majority to demonstrate ulna osteotomy and PAUL plate of dogs will take at least three to six months to application (images courtesy of Kyon, www.kyon.ch). see maximal clinical improvement. In Pendo’s case, his lameness was better than before surgery in just a few weeks. Nine months later, he was going for 45-minute leash walks twice daily, playing off leash, and only limping the day after higher levels of activity, things that he was been unable to do for years.

I am assured that a large multicenter study of PAUL cases and their outcomes is in the works. For now we are forced to rely upon smaller case Biomechanical studies have suggested that dogs numbers. One study (R. Whitelock, PAUL load about 65 percent on the medial aspect of Clinical Experience Symposium Presentation, the elbow joint and 35 percent on the lateral 2014) involving 32 cases, asked owners whose aspect. What if it were possible to make a subtle dogs had undergone PAUL, “How is your dog change in limb alignment that would unload now compared to pre-surgery?” None said the medial compartment, make better use of “worse,” one said “same,” and 31 out of 32 said that healthy lateral cartilage, and in doing so, “better.” Seventy-two percent noted some degree

8. Partners In Care π Summer 2016 π Volume 10:2 ANGELL WELCOMES NEW STAFF DENTIST AND RADIOLOGIST

Angell Animal Medical Center is extremely pleased to announce that of lameness during certain activities, but 97 percent Jessica Riehl, DVM, DAVDC has joined our Dentistry Service, and Ruth reported meaningful improvement. Van Hatten, DVM, DACVR has joined our Diagnostic Imaging Service in Boston. Pendo may be my poster dog for PAUL, and I am always wary of anecdotes as proof of success; however, PAUL JESSICA RIEHL, DVM, DAVDC does appear to have a place as a viable treatment Dr. Riehl joined Angell in 2016 after practicing alternative in carefully selected cases where clinicians at a veterinary specialty hospital in Seattle, and owners are frustrated by the challenges of medical Washington. She grew up in Connecticut and management for chronic elbow dysplasia. obtained her Bachelor’s Degree in Zoology at Connecticut College. Dr. Riehl graduated from University of Wisconsin-Madison School of For more information about Angell’s Surgery Service, please in 2010. She then went on call 617-541-5048 or email [email protected]. to complete a small animal rotating internship in West Islip, NY followed by a residency in Dentistry and Oral Surgery at the University of Wisconsin-Madison. Dr. Riehl became a Diplomate of the American Veterinary Dental College in 2014 and currently serves on the Credentials Committee for the AVDC. She is excited to return to New England. Outside of work Dr. Riehl enjoys cooking, outdoors, and spending time with her husband, son, and pets (Fern and Kota). EDUCATION ππUniversity of Wisconsin-Madison School of Veterinary Medicine, DVM, 2010 ππConnecticut College, BA, 2004 SPECIALTY TRAINING ππVeterinary Medical Center of Long Island, Small Animal Internship 2010-2011 ππUniversity of Wisconsin-Madison School of Veterinary Medicine, Residency in Dentistry and Oral Surgery, 2011-2014 CERTIFICATION ππDiplomate, American Veterinary Dental College, 2014

RUTH VAN HATTEN, DVM, DACVR Dr. Ruth Van Hatten attended Boston University, where she received her Bachelor’s degree in Biology with a minor in Anthropology. She earned her DVM degree at Tufts University in 2010. Upon graduation, she completed a small animal rotating internship at Angell Animal Medical Center in Boston and a residency in diagnostic imaging at Cornell University. After finishing her residency, she stayed on as faculty in the diagnostic imaging service at Cornell University Hospital for Animals. Dr. Van Hatten has a special interest in abdominal imaging, specifically ultrasound and CT. Dr. Van Hatten grew up in upstate NY, but considers Boston her home. In her free time, she enjoys watching Boston sports, traveling, and hiking, with some shopping mixed in! EDUCATION ππTufts University School of Veterinary Medicine, DVM, 2010 ππBoston University, BA, 2001 SPECIALTY TRAINING ππCornell University, Residency in Diagnostic Imaging, 2011-2014 ππAngell Animal Medical Center, Small Animal Rotating Internship, 2010-2011 CERTIFICATION ππDiplomate, American College of Veterinary Radiology, 2014

Partners In Care π Summer 2016 π Volume 10:2 9. ANESTHESIA CARDIOLOGY

Continued from page 2 Continued from page 3

5 Campagna I, Schwarz A, Keller S, Bettschart- there is so much overlap in how these murmurs murmur becomes of more paramount Wolfensberger R, Mosing M. Comparison of the sound, it is generally impossible to differentiate importance as well. effects of propofol or alfaxalone for anaesthesia pathological and nonpathological murmurs in induction and maintenance on respiration in cats based on auscultation alone. Additional cats. Veterinary Anaesthesia and Analgesia. 2015 findings that would strengthen the For more information, about Angell’s Cardiology Sep;42(5):484–92. Service, please call 617-541-5038 or email recommendation for echocardiography in an 6 Mathis A, Pinelas R, Brodbelt DC, Alibhai HI. [email protected]. Dr. Malakoff works full adult include presence of a gallop sound, time at our Waltham location. Comparison of quality of recovery from anaesthesia arrhythmia, a murmur that is diastolic or in cats induced with propofol or alfaxalone. continuous, a murmur that is loud (grade 3/6 or Veterinary Anaesthesia and Analgesia. Blackwell louder), or increased strength of the apex beat. Publishing Ltd; 2012 May 1;39(3):282–90. REFERENCES Thoracic radiography is less useful for 1 Cote E, Edwards NJ, Ettinger SJ et al. Management 7 Gieseg M, Hon H, Bridges J, Walsh V. A comparison determining whether significant cardiac disease of incidentally detected heart murmurs in dogs and of anaesthetic recoveries in cats following induction is present, as concentric hypertrophy (such as with either alfaxalone or ketamine and diazepam. N cats. J Am Vet Med Assoc 2015;246(10): 1076-1088. with hypertrophic cardiomyopathy) may not Z Vet J. 2014 May;62(3):103–9. result in an apparently enlarged cardiac 8 Maney JK, Shepard MK, Braun C, Cremer J, Hofmeister silhouette. Certainly, if cardiomegaly is apparent EH. A comparison of cardiopulmonary and anesthetic radiographically, this strengthens the effects of an induction dose of alfaxalone or propofol recommendation for echocardiography, as would in dogs. Veterinary Anaesthesia and Analgesia. 2013 the finding of an abnormal NT-proBNP level. May;40(3):237–44. 9 Warne LN, Beths T, Fogal S, Bauquier SH. The use Finally, several considerations beyond physical of alfaxalone and remifentanil total intravenous exam findings or other test results can help in anesthesia in a dog undergoing a craniectomy for determining whether a juvenile or adult tumor resection. Can Vet J. 2014 Nov;55(11):1083–8. veterinary patient should have an 10 Hasiuk MMM, Forde N, Cooke A, Ramey K, Pang echocardiogram. For example, client concern, DSJ. A comparison of alfaxalone and propofol anxiety, or desire to be as informed as possible on intraocular pressure in healthy dogs. Vet about the cause of the murmur can influence Ophthalmol. 2014 Nov;17(6):411–6. whether an echocardiogram is pursued. The 11 Costa D, Leiva M, Moll X, Aguilar A, Peña T, should also consider whether the Andaluz A. Alfaxalone versus propofol in dogs: patient requires general anesthesia in the near a randomised trial to assess effects on peri- future or any treatments with relative cardiac induction tear production, intraocular pressure contraindications. If the dog or cat is to be used and globe position. Vet Rec. BMJ Publishing Group for breeding, echocardiography to try to obtain Limited; 2015 Jan 17;176(3):73–3. a definitive diagnosis of the cause of the

MSPCA-Angell West is extremely pleased to announce that Yao Yao, VMD, has joined the Emergency and Critical Care Service in Waltham.

YAO YAO, VMD Dr. Yao received her bachelor’s degree in molecular biology with a minor in art history from Bryn Mawr and Haverford College prior to attending University of Pennsylvania, where she obtained her Doctor of Veterinary Medicine degree. After graduation, Dr. Yao completed one year internship in small animal medicine and surgery at Red Bank Veterinary Hospital in Tinton Falls, NJ. Before becoming a full time veterinarian, Dr. Yao dedicated a lot of time in academic research projects including ones involving human esophageal and pancreatic cancer. In her free time Dr. Yao enjoys traveling, cooking, painting, spending time with family, friends and her lazy grey tabby Logan. EDUCATION ππDoctor of Veterinary Medicine, University of Pennsylvania, 2012 ππBachelor of Science, Bryn Mawr and Haverford College, 2008 SPECIALTY TRAINING ππInternship in Small Animal Medicine and Surgery, Red Bank Veterinary Hospital, 2012-2013

10. Partners In Care π Summer 2016 π Volume 10:2 STAFF DOCTORS

ππWe encourage you to contact Angell’s specialists with questions. Main Phone: 617-522-7282 (Boston), 781-902-8400 (Waltham), 978-577-5992 (Angell at Nashoba) Veterinary Referrals: 617-522-5011 STAFF DOCTORS STAFF CHIEF OF STAFF CARDIOLOGY (W/B) NEUROLOGY (W/B) Ann Marie Greenleaf, DVM, DACVECC Ashley Jones, DVM, DACVIM (Cardiology) Rob Daniel, DVM, DACVIM (Neurology) [email protected] [email protected] [email protected] Nancy Laste, DVM, DACVIM (Cardiology) Allen Sisson, DVM, MS, DACVIM (Neurology) 24/7 EMERGENCY & CRITICAL CARE (W/B) [email protected] [email protected] Lauren Baker, DVM Rebecca Malakoff, DVM, DACVIM NUTRITION [email protected] (Cardiology) [email protected] Dana Hutchinson, DVM, DACVN Kiko Bracker, DVM, DACVECC [email protected] Rebecca Quinn, DVM, DACVIM [email protected] (Cardiology and Internal Medicine) ONCOLOGY Emily Finn, DVM [email protected] Lyndsay Kubicek, DVM, DACVR [email protected] (Radiation Oncology) DENTISTRY Jessica Hamilton, DVM [email protected] Erin Abrahams, DVM J. Lee Talbott, DVM [email protected] [email protected] (Practice Limited to Medical Oncology) Roxanna Khorzad, DVM William Rosenblad, DVM [email protected] [email protected] [email protected] OPHTHALMOLOGY Amanda Lohin, DVM Jessica Riehl, DVM, DAVDC Daniel Biros, DVM, DACVO [email protected] [email protected] [email protected] Courtney Peck, DVM DERMATOLOGY Martin Coster, DVM, MS, DACVO [email protected] Klaus Loft, DVM [email protected] Virginia Sinnott, DVM, DACVECC [email protected] PAIN MEDICINE [email protected] DIAGNOSTIC IMAGING* Lisa Moses, VMD, DACVIM, CVMA Catherine Sumner, DVM, DACVECC Rebecca Manley, DVM, DACVR [email protected] [email protected] [email protected] PATHOLOGY (CLINICAL & ANATOMIC)* Megan Whelan, DVM, DACVECC Steven Tsai, DVM, DACVR [email protected] Patty Ewing, DVM, MS, DACVP [email protected] [email protected] Ruth Van Hatten, DVM, DACVR Yao Yao, VMD [email protected] Pamela Mouser, DVM, MS, DACVP [email protected] [email protected] INTERNAL MEDICINE (W/B) SURGERY (W/B) ANESTHESIOLOGY Daniela Ackley, DVM, DACVIM Stephanie Krein, DVM, DACVAA [email protected] Sue Casale, DVM, DACVS [email protected] [email protected] Doug Brum, DVM [email protected] Michele Kudisch, DVM, DACVS [email protected] AVIAN & EXOTIC MEDICINE (W/B) Maureen Carroll, DVM, DACVIM Michael Pavletic, DVM, DACVS Brendan Noonan, DVM, DABVP [email protected] [email protected] (Avian Practice) Erika de Papp, DVM, DACVIM Meghan Sullivan, DVM, DACVS [email protected] [email protected] [email protected] Jean Marie Duddy, DVM Elisabeth Simone-Freilicher, DVM, DABVP Nicholas Trout, MA, VET MB, MRCVS, [email protected] (Avian Practice) DACVS, DECVS [email protected] Kirstin Johnson, DVM, DACVIM [email protected] [email protected] BEHAVIOR (W/B) Shawn Kearns, DVM, DACVIM ANGELL AT NASHOBA Terri Bright, Ph.D., BCBA-D [email protected] Laurence Sawyer, DVM [email protected] [email protected] Susan O’Bell, DVM, MPH, DACVIM [email protected] Taylor Kirby-Madden, DVM Cynthia Talbot, DVM [email protected] [email protected]

(W/B) Services available at our Waltham and Boston locations. *Boston-based radiologists and pathologists serve both Boston & Waltham locations.

Partners In Care π Summer 2016 π Volume 10:2 11. Nonprofit Org. US Postage PAID Permit No. 1141 Boston, MA

We mail one complimentary copy of our newsletter to each of our referring partners. Please circulate this copy within your practice. Summer 2016 π Volume 10:2 π angell.org π facebook.com/AngellReferringVeterinarians

350 South Huntington Avenue Boston, MA 02130 617-522-5011

MSPCA-ANGELL angell.org

293 Second Avenue Waltham, MA 02451 781-902-8400 angell.org/waltham MSPCA-ANGELL WEST MSPCA-ANGELL

Please consider adding Angell’s main numbers to your after-hours phone message.

π angell.org/directions (free parking) π angell.org/hours π angell.org/ce

44ANGELL AT NASHOBA NOW ACCEPTING APPOINTMENTS Financial Qualifications for Clients To qualify for Angell at Nashoba services, clients must present a photo ID and one of the following: Angell Animal Medical Center and Nashoba Valley Technical High School have partnered to create Angell at Nashoba, a veterinary clinic for low income pet owners that also serves as a rigorous academic and experiential training Women, Infants, and program for students enrolled at Nashoba Valley Technical High School. Children (WIC) program card Opened on February 3, 2016, the clinic provides discounted: Supplemental Nutrition Assistance Program (SNAP) card (formerly known Spay/neuter services as Food Stamps/EBT card)

Vaccinations 44Fourteen-year-old Rocky, a Spay and Neuter Assistance Jack Russell Terrier, was Angell at Nashoba’s first patient. Program certificate Basic veterinary care Letter/lease from the owner’s local To reach the clinic, please housing authority showing that the owner is a participant in public housing call 978-577-5992.

The clinic is located at: 100 Littleton Road, The person whose name is on the card or documents Westford, Massachusetts. must be present (i.e., they can’t send a relative or For more information, visit friend). The only exception is a spouse with the www.angell.org/nashoba. same last name and address.