The Canadian Veterinary Journal La Revue vétérinaire canadienne

January/Janvier 2013 Volume 54, No. 1

Laparoscopic-assisted cystotomy for urolith removal in dogs and cats — 23 cases

The Ontario Veterinary College Hip Certification Program — Assessing inter- and intra-observer repeatability and comparison of findings to those of the Orthopedic Foundation for Animals

Nutritional and microbial analysis of bully sticks and survey of opinions about pet treats

Cerebellar granuloprival degeneration in an Australian kelpie and a Labrador retriever dog

Acute renal failure in 2 adult llamas after exposure to Oak trees (Quercus spp.)

Jugular thrombophlebitis in horses: A review of fibrinolysis, thrombus formation, and clinical management

Cholesterol granuloma associated with otitis media and leptomeningitis in a cat due to a Streptococcus canis infection

Infiltrative lipoma compressing the spinal cord in 2 large-breed dogs

Respiratory disease outbreak in a veterinary hospital associated with canine parainfluenza virus infection

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JANUARY/JANVIER 2013 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

ARTICLES 36 Laparoscopic-assisted cystotomy for urolith removal in dogs and cats — 23 cases Cory B. Pinel, Eric Monnet, Michael R. Reems 42 The Ontario Veterinary College Hip Certification Program — Assessing inter- and intra-observer repeatability and comparison of findings to those of the Orthopedic Foundation for Animals Heather J. Chalmers, Stephanie Nykamp, Assaf Lerer 50 Nutritional and microbial analysis of bully sticks and survey of opinions about pet 74 Infiltrative lipoma compressing the spinal treats cord in 2 large-breed dogs Lisa M. Freeman, Nicol Janecko, J. Scott Weese Marc K. Hobert, Christina Brauer, Peter Dziallas, Ingo Gerhauser, Dorothee Algermissen, CASE REPORTS Andrea Tipold, Veronika M. Stein RAPPORTS DE CAS BRIEF COMMUNICATION 55 Cerebellar granuloprival degeneration in an COMMUNICATION BRÈVE Australian kelpie and a Labrador retriever dog 79 Respiratory disease outbreak in a veterinary Jonathan Huska, Luis Gaitero, hospital associated with canine Heindrich N. Snyman, Robert A. Foster, parainfluenza virus infection Marti Pumarola, Sergio Rodenas J. Scott Weese, Jason Stull 61 Acute renal failure in 2 adult llamas after CASE REPORT exposure to Oak trees (Quercus spp.) RAPPORT DE CAS Manuel F. Chamorro, Thomas Passler, Kellye Joiner, Robert H. Poppenga, Jenna Bayne, 83 Postsurgical segmental mesenteric Paul H. Walz ischemic thrombosis in a horse María Martín-Cuervo, Luis A. Gracia, REVIEW ARTICLE Verónica Vieitez, Joquin Jiménez, Esther Durán, COMPTE RENDU Luis J. Ezquerra 65 Jugular thrombophlebitis in horses: 21 QUIZ CORNER A review of fibrinolysis, thrombus formation, TEST ÉCLAIR and clinical management Deborah Penteado Martins Dias, José Corrêa de Lacerda Neto

CASE REPORTS RAPPORTS DE CAS 72 Cholesterol granuloma associated with otitis media and leptomeningitis in a cat due to a Streptococcus canis infection Sara Van der Heyden, Patrick Butaye, Stefan Roels

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JANUARY/JANVIER 2013 Contents Table des matières

FEATURES RUBRIQUES SPÉCIALES

LETTERS TO THE EDITOR 86 DIAGNOSTIC OPHTHALMOLOGY LETTRES À LA RÉDACTION OPHTALMOLOGIE DIAGNOSTIQUE 9 Single layer staple versus double layer Bruce H. Grahn, Bianca Bauer, Tawni Silver hand-sewn closures — A comment Marco Gandini VETERINARY PRACTICE MANAGEMENT GESTION D’UNE CLINIQUE VÉTÉRINAIRE 10 The ethical question on prolonging the life 88 Associate veterinarian salaries continue to of a cancer patient — A comment rise/La hausse des salaires des vétérinaires Valerie MacDonald, Louis-Philippe de Lorimier, se poursuit Marie-Ève Nadeau, Monique Mayer Darren Osborne, Simon Miller 12 The ethical question on prolonging the life of a cancer patient — A reply BOOK REVIEWS Gerald (Gary) Goeree COMPTES RENDUS DE LIVRES 12 The ethical question on prolonging the life 47 Medical Mathematics and Dosage of a cancer patient — A reply Calculations for Veterinary Professionals Bernard E. Rollin David Eisenbart 54 Self-Assessment Color Review: PRESIDENT’S MESSAGE Feline Infectious Diseases MOT DU PRÉSIDENT Susan Little 13 A Perfect Storm?/Une tempête parfaite? Dr. Jim Fairles NOTICES ANNONCES 17 VETERINARY MEDICAL ETHICS DÉONTOLOGIE VÉTÉRINAIRE 82 Books Available for Review Livres disponibles pour compte rendu 23 NEWS NOUVELLES 87 Index of Advertisers Heather Broughton, Isabelle Vallières Index des annonceurs 92 Classifieds Petites annonces

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net). Les «Directives à l’intention des auteurs» sont disponibles en ligne (www.veterinairesaucanada.net).

CVJ / VOL 54 / JANUARY 2013 5 FOR PERSONAL USE ONLY

The Canadian Veterinary Journal Editorial policy: All published articles including editorials and letters reflect the La Revue vétérinaire canadienne opinions of the authors and do not necessarily reflect the opinion of the publisher. Publication of an advertisement does not necessarily imply that the publisher agrees 339 rue Booth Street with or supports the claims therein. Ottawa, Ontario K1R 7K1 Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les Telephone: (613) 236-1162 lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de Fax: (613) 236-9681 l’éditeur. E-mail: [email protected] La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord Web site/Site web: www.canadianveterinarians.net avec son contenu ou qu’il l’appuie. www.veterinairesaucanada.net Editor-in-Chief/Rédacteur en chef © C anadian Veterinary Medical Association 2013 Carlton Gyles, Guelph, Ontario L’Association canadienne des médecins vétérinaires 2013 Associate Editors/Rédacteurs associés Bruce Grahn, Saskatoon, Saskatchewan The Canadian Veterinary Journal is indexed or abstracted in: Dana Allen, Guelph, Ontario La Revue vétérinaire canadienne est indexée ou ses articles sont Feature Editors/Rédacteurs des chroniques résumés dans : Stephen Raverty, Abbotsford, British Columbia AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Tim Blackwell, Fergus, Ontario Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Andrew Allen, Saskatoon, Saskatchewan Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Assistant Editors/Rédacteurs adjoints Robert Friendship, Guelph, Ontario Greg Harasen, Regina, Saskatchewan Photo by/Photo de : IStock Leigh Lamont, Charlottetown, P.E.I. Jacob Thundathil, Calgary, Alberta Typesetting/Typographie Ron Johnson, Guelph, Ontario AN Design Communications Richard Kennedy, Pincher Creek, Alberta Printed by/Imprimé par Managing Editor/Directrice de la rédaction Dollco a division of The Lowe-Martin Group Heather Broughton, Ottawa, Ontario Ottawa, Ontario Assistant Managing Editor/Directrice adjointe de la rédaction ISSN 0008-5286 Stella Wheatley, Ottawa, Ontario Editorial Coordinator/Coordonnatrice de la rédaction Beverley Kelly, Ottawa, Ontario Return undeliverable Canadian addresses to: 339 rue Booth Street Advertising Manager/Gérante de la publicité Ottawa, Ontario K1R 7K1 Laima Laffitte, Wendover, Ontario e-mail: [email protected] Published monthly by/ Subscriptions (2013). Annual: Canada $185 + applicable GST or HST; foreign Publication mensuelle de $195.00 US. Single issue/back issue: $25 each + GST or HST, if applic­able. (All prices Canadian Veterinary Medical Association subject to change.) Missing issues will be replaced if the Subscriptions Office is notified within 6 months (for requests within Canada) and 1 year (for requests from abroad) of the issue date. The pub­lisher expects to supply missing issues only when losses have been sustained in transit and when the reserve stock will permit. Telephone (613-236-1162) and fax (613-236-9681) orders accepted with a valid Visa or MasterCard number. Please advise the publisher of address changes promptly. Abonnements (2013). Annuel : Canada 185 $ + TPS ou TVH en vigueur; pays étranger 195 $ É-U. Anciens numéros (chacun) : 25 $ + TPS ou TVH en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas reçus seront remplacés si l’éditeur en est informée dans les 6 mois (pour les demandes venant du Canada) et 1 an (pour les demandes venant de l’étranger) suivant la date de parution. L’éditeur s’engage à remplacer les numéros manquants seule­ment lorsque les pertes ont été subies en transit et lorsque ses réserves le permettent. On peut payer son abonnement par téléphone (613-236-1162), par télé­copieur (613-236-9681) ou par carte de crédit (Visa ou MasterCard). Veuillez aviser le bureau de l’éditeur de tout ­changement d’adresse.

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Single layer staple versus double layer hand-sewn closures — A comment Dear Editor, patterns, while 2-layer hand-sewn techniques have a bursting I’m writing about the article, “Comparison of single layer staple pressure that is similar to that of an intact bowel. closure versus double layer hand-sewn closure for equine pel- The result might have been impaired by the limited scale of vic flexure enterotomy” by Julie M. Rosser, Sabrina Brounts, the manometer. If, for example, they had employed a manom-

Michael Livesey, Kerri Wiedmeyer (Can Vet J 2012;53:643–647). eter with a maximum pressure over 200 mmHg (272 cm H2O, I acknowledge the efforts of the authors in performing the study, more than twice the maximum value of the device they used), but not the attempt to prove that their technique is superior to they might have found that stapled techniques burst a little

the standard hand-sewn 2 layers. I have several points I’d like over 120 cm H2O, while hand-sewn techniques burst at a the authors to explain. much higher pressure, thus witnessing a statistically significant First, I have some questions about luminal measurements. difference. The authors use Figure 1 to support their findings. Figures 1a I would also like to address another concern. The authors and 1b supposedly depict the same colon before and after the state that they observed a significant difference between the enterotomy. By looking at these pictures, the shape of the colon percentages of luminal reduction and say that this is due to is evidently different and the measurements can vary widely the fact that a 2-layer hand-sewn technique features a second depending on which part is selected as the measuring spot. over-sown layer that causes constriction. Let us consider how Furthermore, when the authors state that they take 3 measure- this suture pattern is performed. The first full-thickness layer is ments for each colon, they don’t provide indications as to the sutured by apposition, yielding a minimal use of tissue that can specific point (for example, at one side, in the middle of the be estimated for example at 6 mm. The second layer (that is, enterotomy) where said measurements are taken, and Figure 1e Cushing’s) should be performed with insertions at a distance of is no help at all in understanding this. 3 to 5 mm from the edge of the wound, thus causing a tissue use Even more curious is how they managed to perform the of 6–10 mm. Total tissue consumption, therefore, ranges from measurements at the same spot before and after the enterotomy 12 to 16 mm, 20 mm if we hypothesize that it could have been without the prior placement of a marker. In Figure 1b one can performed by a resident. The TA90 staplers that the authors use clearly see that the distal part of the enterotomy causes a stenosis in their study features jaws 7 mm (8 mm for the anvil) thick. of the pelvic flexure, so I would imagine that measurements Apposing the 2 edges of the enterotomy in these jaws will cause taken at that point would be affected. In Figure 1e there are a minimum tissue usage of 14 mm, or much more if we consider 3 spots marked for measuring, but I cannot see how they can be that the surgical procedure described by the authors suggests the correlated to the measurements marked in Figure 1f. placement of a line of Allis forceps to hold the tissue in place It is not clear if all measurements were taken on X-rays as in before firing the stapler. Figures 1a through 1e or as in Figure 1f. In case of the former, I, therefore, cannot see how these techniques can produce then again Figures 1a and 1b show the same colon with different such a difference in luminal stenosis, particularly if we take into shapes, making it difficult to understand how the measurements account what has been previously said about the measurement were comparable. In case of the latter, the authors should explain spots for luminar stricture. how they can be sure to remeasure the same spots as in Figure 1e Although briefly explained in another paper on the same without interference from the superimposition of other parts subject, the authors don’t consider that 6 cm could be a short of the pelvic flexure that were not involved in the enterotomy. length for most enterotomies and that a longer incision might Second, I have some questions about bursting pressure test- be necessary, therefore requiring 2 stapler cartridges. I wonder ing. The authors used a manometer with a maximum value if in this case the time difference would still be statistically

of 120 cm H2O, or 88.27 mmHg. They found that 4 out of significant. 7 hand-sewn and 4 out of 6 stapled enterotomies burst when subjected to pressure exceeding 120 cm H2O, and therefore Marco Gandini, DMV, PhD concluded that there is no statistically significant difference in Clinica Chirurgica Veterinaria bursting pressure between the 2 techniques. But previous stud- Dipartimento di Patologia Animale ies suggest that techniques involving stapling instruments have Facoltà di Medicina Veterinaria di Torino a very low bursting pressure, particularly when using everting Grugliasco, Torino, Italia.

CVJ / VOL 54 / JANUARY 2013 9 FOR PERSONAL USE ONLY

The ethical question on prolonging the life of a cancer patient — A comment Dear Editor, situations where the patient could potentially be cured, then We read the August 2012 ethical question of the month he should state so. It seems like everything we do in veterinary (Can Vet J 2012;53:823) and the subsequent comment in medicine could be considered a “Godly intervention,” including the November 2012 issue (Can Vet J 2012;53:1154–1155), the administration of insulin to the diabetic cat or furosemide and frankly, were disappointed by the scenario presented by to the dog with congestive heart failure. Even surgeries such as Dr. Rollin. The proposed treatment plan was, in our opinion, spay, castration, and fracture repairs are imposed on animals. unrealistic. Most, if not all, veterinary oncologists would not None of our patients sign their own informed consent forms. have recommended the aggressive treatment options offered in We agree with most of Dr. Rollin’s interpretation of this this case. Thus, this ethical question to the family veterinarian scenario with the exception of a few details. In some cases, does not represent an ethical dilemma for oncologists, as the short-term discomfort may be considered worthwhile if it means advice we would give would not have allowed this situation cure or long-term control of the tumor with excellent quality LETTRERÉDACTION LA À to occur in the first place. This was our main reason for not of life ensuing. Chemotherapy in cancer-bearing pets generally responding in August. However, we felt compelled to respond is not “extremely unpleasant” as it sometimes is in humans — following certain comments published in the November issue if it were, we would not recommend it. In this case scenario, of The CVJ. however, the dog was presented with pulmonary metastases and We would like to address a few points in response to the proposed plan that included thoracotomy and splenectomy Dr. Goeree’s comments. Firstly, we believe that the decision was simply unreasonable. We can only agree that pursuing these about your patient’s care has everything to do with you, the options is not a way to demonstrate love to your companion family veterinarian. As a freethinking individual, you are allowed and we would not recommend it if that situation arose in our to formulate your own opinion that can be shared with your practices. client and the open-minded specialist. Communication is a key We considered it important to write this letter because some component between the professionals involved in the patient’s practitioners might erroneously conclude that the proposed health care needs and, obviously, the client. Why would you scenario reflects how certain oncologists think. Fortunately, just “defer, nod, and bob”? The family veterinarian is a critical the reality differs. player in this scenario — your client is looking to you for your trusted opinion as they know you best and value your insight. Valerie MacDonald, DVM, Dipl. ACVIM (Oncology) Dr. Goeree made the following statement: “The only players Associate Professor, Department of Small Animal Clinical Sciences are the oncologists who believe in clinical care heedless of (all Western College of Veterinary Medicine aspects of) cost and the owners, who are in denial of death and Saskatoon, Saskatchewan reality.” A considerable amount of time is taken with every client Louis-Philippe de Lorimier, DMV, Dipl. ACVIM (Oncology) during an oncology consultation, and a crucial point discussed Staff Medical Oncologist with all clients is the fundamental importance of quality of Hôpital Vétérinaire Rive-Sud life — the primary goal when treating cancer-bearing pets. It Brossard, Québec is typically the oncologist who educates the owner about the reality of the situation by providing evidence-based informa- Marie-Ève Nadeau, DMV, Dipl. ACVIM (Oncology) tion, and not providing false hope. Appropriately educating Professeur agrégée the owners helps them make clear, conscious, and informed Faculté de médecine vétérinaire — Département des Sciences Cliniques decisions and, in fact, helps avoid denial of death and reality. Université de Montréal Cost always remains an important factor, and suggesting that St-Hyacinthe, Québec oncologists pursue treatment “heedless of cost” is both unfair Monique Mayer, DVM, Dipl. ACVR (Radiation Oncology) and inaccurate. Associate Professor, Department of Small Animal Clinical Sciences We do not have the tendency to “pat ourselves on the back Western College of Veterinary Medicine for our Godly interventions and self-ascribed compassion.” Saskatoon, Saskatchewan If Dr. Goeree is against treating cancer-bearing pets, even in

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The ethical question on prolonging the life of a cancer patient — A reply Dear Editor, option) is the only civilized alternative. Triangulation, as sug- “Where the bulls rage, the grass suffers.” gested by the writers, would merely damage the grass even more. In human relations, triangulation rarely achieves a happy end. The ending of this situation is preordained — the dog dies Only with extreme caution should a practitioner enter the ring soon. The choices we make determine how much parched earth where the twin bulls of owner desperation and specialist agendas is left behind. are raging. If the practitioner cannot scream with enthusiastic vigour at the bull fight, then avoiding the arena (the nod-n-bob Gerald (Gary) Goeree, DVM, MSc, Kitchener, Ontario LETTRERÉDACTION LA À The ethical question on prolonging the life of a cancer patient — A reply Dear Editor, Similarly, some oncologists discuss quality of life, others Although the letter from MacDonald et al. is primarily directed don’t, rather emphasizing potential for “cure.” But the most at Dr. Goeree, I would be remiss if I failed to correct a number egregious error in this letter is the claim that “Chemotherapy in of errors therein. In the first place, the letter affirms that the cancer-bearing pets generally is not “extremely unpleasant” as it case in question is “a scenario presented by Dr. Rollin.” That sometimes is in humans. If it were, we would not recommend is simply wrong. I never create the cases that are discussed in it.” This is profoundly disingenuous. Chemotherapy is, in the the ethics column. They are always sent in by veterinarians end, selective poisoning, which by its very nature can and does who encountered them. This in itself shows that the case is not produce major and severe “side effects.” I have observed count- the straw man that the letter-writers suggest it is, when they less trials in animals to determine the nature of these effects, explain that “we considered it important to write this letter sometimes in order to extrapolate drug effects to humans. If because some practitioners might erroneously conclude that the authors really stand behind the foregoing statement, I have the proposed scenario reflects how certain oncologists think. a bridge to sell them in Brooklyn! Fortunately, the reality differs.” If the writers of the letter are simply going on record to affirm Bernard E. Rollin that they would never recommend the regimen described, that University Distinguished Professor is laudable, and very likely true, but tells us nothing about what Professor of Philosophy other oncologists do. The case itself shows otherwise, since the Professor of Animal Sciences regimen was suggested by a referring clinician; most likely an Professor of Biomedical Sciences oncologist, although we are not told explicitly. From my own University Bioethicist experience with oncologists, I know that, like any other set of humans, they run the gamut from those who would never sug- gest such a regimen to those who regularly do.

12 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY President’s Message Mot du président

A Perfect Storm? Une tempête parfaite?

hough Superstorm Sandy and its sidekick the Nor’easter ême si la super-tempête Sandy et la tempête qui a T seem a distant memory in 2013, the weather system dev- M suivi semblent un souvenir lointain en 2013, le système astated parts of the Northeastern United States and Canada. météorologique a dévasté des régions du Nord-Est des États-Unis Our thoughts go out to all of the people and animals that et du Canada. Nos pensées sont avec les personnes et les were displaced by the disaster. We hope that their situations animaux qui ont été déplacés par la catastrophe. Nous espérons have improved and life is closer to normal. We salute all those que leur situation s’est améliorée et que la vie retourne à la involved in the animal rescues and hope for a quieter new year. normale. Nous saluons toutes les personnes qui ont participé As we head into 2013 it is evident that there are many issues au sauvetage d’animaux et nous espérons que la nouvelle année facing veterinary medicine in the near and far future. As I travel sera plus calme. around the country and listen to veterinarians in various parts Tandis que nous entamons 2013, il semble évident que la of Canada, I wonder if we are at the cusp of a “perfect storm.” médecine vétérinaire doit relever de nombreux défis dans un Consider, for example, what I believe to be the top 5 issues fac- avenir rapproché et lointain. Tandis que je parcours le pays et ing veterinary medicine in Canada today. que j’écoute les vétérinaires dans diverses régions, je me demande Number 1: Stagnation of veterinary practice growth. This si nous ne sommes pas au bord d’une «tempête parfaite». Par condition was recognized in the United States much earlier exemple, considérons ce qui, selon moi, sont les cinq défis than in Canada — but the issue is certainly being discussed and les plus pressants que doit relever la médecine vétérinaire debated in this country now as well. The term I heard for this canadienne d’aujourd’hui. last weekend was “the new growth in gross revenue is simply No 1 : La stagnation de la croissance de la pratique staying at status quo and not falling behind.” There is now (and vétérinaire. Cette situation a été reconnue aux États-Unis bien always has been) more to practice viability than growth with avant qu’elle ne soit identifiée au Canada — mais la question a plethora of tools to aid in overall veterinary practice health. fait aussi certainement l’objet de discussions et de débats à Discussion is ongoing around several objectives to help “turn l’heure actuelle dans ce pays. La fin de semaine dernière, le terme things around.” These include developing programs to drive que j’ai entendu pour décrire cette situation était «la nouvelle more of the pet-owning public to veterinary care, creating well- croissance du chiffre d’affaires brut consiste à maintenir le ness programs, and advocating more effective use of social media statu quo et à ne pas afficher de recul». La viabilité s’appuie and the internet with respect to both provision of information maintenant sur plus que la croissance à l’aide d’une panoplie and addressing drug supply issues. d’outils (ce qui a toujours été le cas) pour faciliter la santé Number 2: Supply of veterinarians. There has been much globale de la pratique vétérinaire. Des discussions sont en cours written on this subject. If we look back in history most articles à propos de plusieurs objectifs visant à faciliter «un renversement pointed to undersupply of veterinarians. This is especially true de la vapeur», notamment l’élaboration de programmes pour of the food animal sector. Currently, there is some discussion attirer un plus grand nombre de propriétaires d’animaux dans that undersupply may not be the correct term. The problem may les cliniques vétérinaires, la création de programmes de bien-être be decreased animal numbers in rural areas creating a lack of et la promotion d’une meilleure utilisation des médias sociaux et economic viability for veterinarians to service these areas. This de l’Internet en ce qui a trait à la transmission de l’information is an incredibly complex subject; one that will continue to foster et à la résolution du problème de l’approvisionnement de further analysis and discussion. With the demand for veterinary médicaments.

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

CVJ / VOL 54 / JANUARY 2013 13 FOR PERSONAL USE ONLY

education still strong, academic institutions are continuing No 2 : Offre de vétérinaires. Beaucoup d’encre a coulé sur to increase supply. Have we reached the point of oversupply? ce sujet. Si nous consultons des articles antérieurs, la plupart Veterinary education is broad, which leads to an incredible signalent une pénurie de vétérinaires. Cela est particulièrement number of opportunities beyond traditional practice roles. We vrai dans le secteur des animaux destinés à l’alimentation. must continue to look at the core competencies of graduating À l’heure actuelle, l’emploi du terme «pénurie» fait l’objet veterinarians and how new veterinarians can take advantage of de discussions quant à son exactitude. Le problème pourrait all the opportunities available. Is it time for further differentia- être le nombre réduit d’animaux dans les régions rurales qui tion in education delivery? entrave la viabilité financière des vétérinaires desservant ces Number 3: New competitive pressures. There are many and régions. Il s’agit d’un sujet incroyablement complexe que varied pressures including “Dr. Google.” New non-traditional nous continuerons d’analyser et de discuter. Vu que la methods of veterinary care delivery continue to impact on the demande pour l’enseignement vétérinaire est toujours forte, les

MOT DU PRÉSIDENTDU MOT way veterinary medicine is “practised.” The commoditization of établissements d’enseignement continuent d’accroître l’offre many aspects of veterinary medicine forces us to look at new de vétérinaires. Possédons-nous maintenant un surplus de and innovative methods of service delivery including those vétérinaires? La formation vétérinaire est vaste, ce qui ouvre mentioned in my first concern. One of the new “buzz words” un nombre incroyable de possibilités au-delà des rôles d’une is that we must move beyond the “service economy” into the pratique traditionnelle. Nous devons continuer d’examiner les “experience economy” (1) and give clients an experience that compétences fondamentales des vétérinaires finissants et la façon they will remember and for which they will pay. In food ani- dont les nouveaux vétérinaires peuvent se prévaloir des occasions mal veterinary practice, changes in veterinary care delivery has offertes. Est-il temps d’établir de nouvelles différenciations dans become a topic of increased discussion. Traditional individual la présentation de l’enseignement? animal medicine is still important but does not fit as well with No 3 : Nouvelles pressions concurrentielles. Il y a des large herd and flock management. Consulting practice goes so pressions nombreuses et variées, incluant le «Dr Google». De far but still does not tie the veterinarian directly to a specific nouvelles méthodes non traditionnelles de prestation des soins farm. In some instances we must move to an integrated model vétérinaires continuent d’avoir un impact sur la façon dont la wherein our services and fees are integrated with production. médecine vétérinaire est «exercée». La banalisation de nombreux Number 4: “Disjointed” veterinary practice. While practis- aspects de la médecine vétérinaire nous force à envisager des ing I considered myself a “James Herriot” style veterinarian as méthodes nouvelles et innovatrices de prestation de services, I was exposed to and worked in a diverse veterinary medical incluant celles mentionnées dans la première préoccupation que environment. Specialization is great for veterinary medicine and j’ai signalée précédemment. L’un des concepts à la mode veut provides many more opportunities for consultation, treatment que l’on passe d’une «économie de services» à une «économie de and surgery. What we don’t want to leave behind is the “family” l’expérience» (1) et que l’on donne aux clients une expérience or herd veterinarian who is available as the point person and dont ils se souviendront et pour laquelle ils seront prêts à payer. has the broad knowledge of the patient or farm, and the ability En pratique vétérinaire des animaux destinés à l’alimentation, to “put everything together.” Veterinarians must continue to les changements dans la prestation des soins vétérinaires font promote themselves as point people and as guardians of their maintenant l’objet de discussions fréquentes. La médecine clients’ animals’ health. traditionnelle pour les animaux individuels est toujours Number 5, and my last concern, is the continued issue sur- importante, mais elle ne convient pas toujours à la gestion rounding the viability of veterinary self-regulation. Currently in d’un grand troupeau. Les pratiques de consultation facilitent all 10 provinces, the public has put its trust in the regulation of la situation mais n’établissent toujours pas un lien direct entre veterinary medicine with our peers. In some instances this can le vétérinaire et une ferme particulière. Dans certains cas, be costly and we sometimes wonder if this is the best way to go. nous devons adopter un modèle intégré où nos services et nos I would maintain that we must continue to guard that which honoraires sont intégrés à la production. the public has entrusted to us. What better way to be judged No 4 : Pratique vétérinaire «décousue». Lorsque j’exerçais la than by your peers. médecine vétérinaire, je me considérais comme un vétérinaire A perfect storm? I would suggest we have a perfect opportunity! à la James Herriot, car j’exerçais dans un environnement de As a small profession we must continue to ensure we act profes- médecine vétérinaire diversifiée. La spécialisation est excellente sionally and continue to strive to better our profession by miti- pour la médecine vétérinaire et offre de nombreuses possibilités gating all of these concerns. Developing the tools to tackle these nouvelles pour la consultation, le traitement et la chirurgie. issues can only happen with national coordination. What better Nous ne voulons toutefois pas abandonner le vétérinaire way to do this than to do this as “one voice and one profession.” «de famille» ou de troupeau qui est la personne-ressource présente possédant une vaste connaissance du patient ou Jim Fairles de la ferme capable de «réunir les morceaux du casse-tête». President, Canadian Veterinary Medical Association Les vétérinaires doivent continuer à se présenter comme les personnes-ressources et les gardiens de la santé des animaux de Reference leurs clients. o 1. Pine J, Gilmore J. The Experience Economy. Boston, Massachusetts: N 5 : Enfin, ma dernière préoccupation est la question Harvard Business School Press, 1999. ■ persistante entourant la viabilité de l’autoréglementation des

14 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY vétérinaires. Actuellement, dans les dix provinces, le public fait à l’aide d’une coordination nationale. Quoi de mieux que de confiance à la réglementation de la médecine vétérinaire avec mettre cette stratégie en œuvre sous la bannière d’«une voix et nos pairs. Dans certains cas, cela peut être coûteux et nous nous une profession»?

interrogeons parfois sur la validité de cette approche. J’estime PRESIDENT’S MESSAGE que nous devons continuer de protéger ce que le public nous a Jim Fairles confié. Quoi de mieux que d’être jugé par nos pairs? Président de l’Association canadienne des médecins Une tempête parfaite? Je suggère qu’il s’agit d’une vétérinaires occasion parfaite! À titre de profession avec un faible nombre de membres, nous devons continuer d’agir de manière Renvois professionnelle et de nous efforcer à mieux desservir notre 1. PINE, J. et J. GILMORE. «The Experience Economy», Harvard Business profession en atténuant ces préoccupations. L’élaboration School Press, Boston, Massachusetts, 1999. ■ d’outils pour aborder ces enjeux peut seulement se produire

CVJ / VOL 54 / JANUARY 2013 15 FOR PERSONAL USE ONLY

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A SANOFI COMPANY FOR PERSONAL USE ONLY Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — January 2013 You have been out several times to treat newly placed calves in a feedlot belonging to a longtime client of yours. You noticed on your first visit that the old farm dog was moving slowly and appeared a bit “rougher” than when you were last at the feedlot a year ago. You mention this in passing to the owner who agrees that the dog is getting on in years. At subsequent visits it becomes obvious the dog is deteriorating, although reportedly eating normally. You offer to take the dog back to the clinic for an examination and workup, but the owner declines. You gently make the point that the dog may be reaching a point where it is no longer enjoying itself. The owner assures you he knows when it is time to put a dog down and he will handle it himself. You suspect the dog will not be put down until it is too weak to stand. Is there a problem with this approach in an aged companion animal? Question de déontologie du mois — Janvier 2013 Vous avez visité plusieurs fois un parc d’engraissement appartenant à un de vos clients de longue date afin de traiter des veaux nouvellement arrivés. À votre première visite, vous remarquez que le vieux chien de ferme se déplace lentement et semble un peu plus «mal en point» que lors de votre dernière visite au parc d’engraissement il y a un an. Vous mentionnez ce fait au propriétaire qui convient que le chien prend de l’âge. Lors de visites subséquentes, il devient évident que l’état du chien se détériore, même si on vous dit qu’il mange normalement. Vous offrez de ramener le chien à la clinique pour faire un examen et dresser un bilan diagnostique, mais le propriétaire refuse. Vous faites valoir avec tact que le chien en est peut-être rendu au point où il ne profite plus de la vie. Le propriétaire vous affirme qu’il est capable de dire quand le moment d’euthanasier un chien est arrivé et qu’il s’en occupera lui-même. Vous soupçonnez que le chien ne sera euthanasié que lorsqu’il sera trop faible pour se tenir debout. Cette approche est-elle appropriée pour un animal de compagnie âgé?

Responses to the case presented are welcome. Please limit your Les réponses au cas présenté sont les bienvenues. Veuillez limiter reply to approximately 50 words and forward along with your votre réponse à environ 50 mots et nous la faire parvenir par name and address to: Ethical Choices, c/o Dr. Tim Blackwell, la poste avec vos nom et adresse à l’adresse suivante : Choix Veterinary Science, Ontario Ministry of Agriculture, Food déontologiques, a/s du Dr Tim Blackwell, Science vétérinaire, and Rural Affairs, 6484 Wellington Road 7, Unit 10, ministère de l’Agriculture, de l’Alimentation et des Affaires Elora, Ontario N0B 1S0; telephone: (519) 846-3413; fax: rurales de l’Ontario, 6484, chemin Wellington 7, unité 10, (519) 846-8178; e-mail: [email protected] Elora, (Ontario) N0B 1S0; téléphone : (519) 846-3413; télé­ Suggested ethical questions of the month are also welcome! All copieur : (519) 846-8178; courriel : [email protected] ethical questions or scenarios in the ethics column are based Les propositions de questions déontologiques sont toujours on actual events, which are changed, including names, loca- bienvenues! Toutes les questions et situations présentées dans tions, species, etc., to protect the confidentiality of the parties cette chronique s’inspirent d’événements réels dont nous involved. modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

CVJ / VOL 54 / JANUARY 2013 17 FOR PERSONAL USE ONLY

Ethical question of the month — October 2012 You have worked in an upscale, urban veterinary clinic since graduation 2 years ago. You enjoy the high quality of veterinary medicine that is standard practice at this clinic. An elderly client of yours on a fixed income is visually impaired and depends on a 4-year-old Labrador retriever service dog to get around. The dog is admitted to your clinic after being hit by a car. It is stable, but radiographs reveal an oblique midshaft fracture of the femur. The estimate to plate the fracture (the only repair offered) is $4400.00. The dog is uninsured and the owner cannot afford the cost, but will receive a replacement dog at no cost at some time in the future. You discuss this case with a classmate who works across town in another practice. She tells you that they use intra-medullary pins with or without circlage wire to repair such fractures for less than half of your quote, with a very high success rate. She also says they maintain a fund at the clinic to offset the cost in cases such as this. You mention this to your employer who unequivocally forbids you to refer this dog to a competing practice. You offer to do the surgery yourself during your free time at no cost but your employer

DÉONTOLOGIEVÉTÉRINAIRE refuses you permission. Nor will he discount the fee or provide for a payment plan as he feels this would set a precedent in future cases. How should you respond? Submitted by Dr. Roy Lewis, Westlock, Alberta Question de déontologie du mois — Octobre 2012 Vous travaillez dans une clinique vétérinaire urbaine de haut calibre depuis l’obtention de votre diplôme il y a deux ans. Vous appréciez la grande qualité des soins vétérinaires qui sont offerts à cette clinique. Un de vos clients âgés malvoyants gagne un revenu fixe et dépend d’un Labrador retriever d’assistance âgé de quatre ans pour se déplacer. Le chien est admis à votre clinique après avoir été heurté par une automobile. Son état est stable, mais les radiographies révèlent une fracture médiane oblique du fémur. L’estimation pour réparer la fracture à l’aide d’une plaque (la seule réparation offerte) est de 4400 $. Le chien n’est pas assuré et le propriétaire n’a pas les moyens de payer la facture, mais il recevra gratuitement un chien de remplacement à une date ultérieure indéterminée. Vous discutez ce cas avec une consœur de classe qui travaille dans une pratique située de l’autre côté de la ville. Elle vous dit que sa pratique utilise des broches intramédullaires avec ou sans fil de cerclage osseux pour réparer de telles fractures, une intervention qui coûte la moitié de votre estimation et présente un taux de succès très élevé. Elle dit aussi que la clinique possède un fonds d’aide pour des cas comme celui-ci. Vous mentionnez cela à votre employeur qui vous interdit formellement de recommander ce chien à une pratique concurrente. Vous offrez de faire vous-même la chirurgie sans frais dans vos temps libres, mais votre employeur refuse de vous donner la permission. Il refuse aussi d’offrir une réduction du tarif et d’échelonner les paiements, car il estime que cela établirait un précédent. Comment devriez-vous répondre? Soumise par le Dr Roy Lewis, Westlock (Alberta)

An ethicist’s commentary on the case of a service dog needing fracture fixation Readers of this column may recall a horrible incident in public relations for the practice implicit in restoring the animal California, where a sadistic maniac tampered with eyedrops to functional health. One cannot buy that sort of good publicity being sold over the counter, and inserted acid into the bottles. for any amount of money. By the same token, one cannot undo One of my friends was one of the first victims of this psy- the devastating negative publicity that would ensue were the chopath, and tragically lost sight in both eyes. She told me public to become aware of the practice owner’s refusal to help. many years after her eyes had been irrevocably burned that she I would, therefore, begin by making that point forcefully to my had seriously contemplated suicide shortly thereafter. What employer. If he is a reasonable person, he or she will readily see redeemed her situation, allowing her to resume a relatively nor- the advantage of treating the dog, and indeed doing so utilizing mal, productive life was the acquisition of her seeing eye dog, Cadillac medicine. whom she credited with “giving me back my life.” My good friend, legendary small animal practitioner Brian As the above anecdote attests, people who are blinded develop Forsgren, often challenges audiences of veterinary students with a uniquely powerful bond with the animals upon whom they the question of whether rich people value their animals more depend. Since the dog in this case is only 4 years old, the than do the indigent. Students invariably answer in the nega- potential for significant prolongation of their relationship is tive, a point Dr. Forsgren has repeatedly seen confirmed in his blocked only by the owner’s inability to pay for the requisite ghetto practice. He has, in fact, made it his life’s work to serve procedure on the dog’s leg. You, the veterinarian, fully recognize such clients. the incredible bond between owner and animal. On the other Were I the practitioner in this case, I would draw a line in hand, the practice owner for whom you work is myopic to an the sand with my employer. I would stress the public relations extreme, blinded by greed. Were this not the case, he or she dimension of the situation, and assure him or her of the poten- would readily understand the enormous potential for positive tial value to the practice. More importantly, I would emphasize

18 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY the moral dimension of the case, as well as my deep commit- not the last time your values clash with those of the employer, ment to saving the priceless relationship between the dog and and you might as well orchestrate a showdown relatively early the owner. In as nice a manner as possible, I would make the in your history of employment. If your employer is deaf to your ETHICS MEDICAL VETERINARY point that what I do on my own time is my own business. If the concerns and moral values, you might as well end your relation- owner values you as an employee, he or she should relent, and ship at this point, though a smart employer would applaud your perhaps demand that you disassociate your actions from your moral stance. role as his or her employee, though your employer would be plainly stupid to do so. The point is that this situation is clearly Bernard E. Rollin, PhD

CVJ / VOL 54 / JANUARY 2013 19 FOR PERSONAL USE ONLY

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Quiz Corner Test éclair

1. How long, from the time of the first breeding, does gesta- 1. En comptant à partir du premier accouplement, quelle est tion normally last in the bitch? la durée normale de la gestation chez la chienne? a. 62 to 64 days a. 62 à 64 jours; b. 70 to 75 days b. 70 à 75 jours; c. 58 to 62 days c. 58 à 62 jours; d. 62 to 68 days d. 62 à 68 jours; e. 58 to 72 days e. 58 à 72 jours. 2. You review the radiograph of a dog’s fractured tibia. The 2. Vous examinez la radiographie d’un tibia fracturé chez un cortex on one side of the bone is broken, and the other is chien. D’un côté de l’os, le cortex est fracturé alors que bent. This fracture is appropriately classified as a: de l’autre, il est courbé. Cette fracture est adéquatement a. fissure fracture classée comme étant une : b. greenstick fracture a. fêlure; c. physeal fracture b. fracture en bois vert; d. comminuted fracture c. fracture de la plaque de croissance; e. compacted fracture d. fracture comminutive; e. fracture compacte. 3. If a squamous-cell carcinoma involves the middle segment of the mandible but has not metastasized to the lungs or 3. Si un carcinome spino-cellulaire implique le segment moyen lymph nodes, what is the most appropriate surgical pro- de la mandibule mais qu’il n’a pas métastasé aux poumons cedure to decrease the chance of tumor recurrence? ni aux nœuds lymphatiques, quelle est l’intervention a. bilateral rostral mandibulectomy chirurgicale la plus appropriée pour diminuer les risques de b. hemimandibulectomy récidive de la tumeur? c. segmental mandibulectomy with a cortical bone graft a. mandibulectomie rostrale bilatérale; d. complete mandibulectomy b. hémimandibulectomie; e. excision of the mass, limited to soft tissue structures c. mandibulectomie segmentaire avec greffe osseuse overlying the hemimandible corticale; d. mandibulectomie complète; 4. Concerning diabetes mellitus in cats, which statement is e. excision de la masse limitée aux tissus mous recouvrant most accurate? l’hémimandibule. a. Diabetes mellitus is most prevalent in female cats. b. Diabetc ketoacidosis does not occur in cats. 4. À propos du diabète sucré chez le chat, lequel des énoncés c. Diabetic cats always require daily insulin injections to suivants est le plus juste? maintain normoglycemia. a. Le diabète sucré est plus répandu chez les chattes. d. Insulin injections in cats typically have a longer duration b. La céto-acidose diabétique n’affecte pas les chats. of action than in dogs. c. Les chats diabétiques exigent des injections d’insuline e. Cats do not develop diabetic cataracts. quotidiennes pour maintenir une glycémie normale. d. Chez les chats, les injections d’insuline possèdent de 5. A 3-month-old Arabian filly is presented to your hospital façon caractéristique une durée d’action plus longue for evaluation of recent onset of stertorous breathing and que chez les chiens. dysphagia. The foal appears to be generally healthy. You e. Les chats ne souffrent pas de cataractes diabétiques. observe a nonpainful distension of the left parotid region. The owner tells you that the parotid swelling has been 5. Vous examinez à votre clinique une pouliche Arabe âgée present since the foal was very young and now seems to de 3 mois, à cause de l’apparition récente de respiration be more noticeable. Radiographs of the foal’s head exhibit stertoreuse et de dysphagie. L’animal semble de façon air-density distension of the left guttural pouch. générale en santé. Vous observez une distension de la Based on the history, clinical signs, and radiographs, région parotidienne gauche. Le propriétaire vous mentionne what is the most likely diagnosis? que l’enflure de la parotide est présente depuis que la a. guttural pouch tympany pouliche est toute jeune et que présentement elle est plus b. guttural pouch empyema apparente. Les radiographies de la tête démontrent une c. guttural pouch mycosis distension aérogène de la poche gutturale gauche. À la

CVJ / VOL 54 / JANUARY 2013 21 FOR PERSONAL USE ONLY

d. retropharyngeal abscess lumière de l’anamnèse, des signes cliniques et des e. soft-palate paresis radiographies, lequel des diagnostics suivants est le plus probable? 6. What is the most appropriate treatment for the foal a. tympanisme de la poche gutturale; described in 5 above? b. empyème de la poche gutturale; a. euthanasia c. mycose de la poche gutturale; b. antibiotics d. abcès rétropharyngien de la poche gutturale; c. anti-inflammatories e. parésie du palais mou. d. tracheostomy e. median septum fenestration 6. Quel est le traitement le plus approprié pour la pouliche décrite à la question 5 précédente? TESTÉCLAIR 7. With respect to transmission, an important difference a. euthanasie; between coccidiosis and cryptosporidiosis in calves is b. antibiotiques; that: c. anti-inflammatoires; a. Cryptosporidium requires an intermediate host d. trachéostomie; b. coccidia affect calves as young as 1 week of age e. fenestration du septum médian. c. Cryptosporidium affects calves as young as 1 week of age 7. À propos de la transmission, une différence importante d. Cryptosporidium does not infect calves under 3 weeks entre la coccidiose et la cryptosporidiose chez le veau est of age que : e. coccidia do not infect calves under 3 weeks of age a. Cryptosporidium exige un hôte intermédiaire. b. Les coccidies infectent les veaux dès l’âge de 1 semaine. 8. Which clinicopathologic assay is NOT helpful in confirm- c. Cryptosporidium infecte les veaux dès l’âge de 1 semaine. ing suspected liver disease in cattle? d. Cryptosporidium n’infecte pas les veaux âgés de moins a. serum bilirubin concentration de 3 semaines. b. serum sorbitol dehydrogenase activity e. Les coccidies n’infectent pas les veaux âgés de moins c. serum aspartate aminotransferase activity de 3 semaines. d. serum gamma-glutamyltransferase activity e. serum alanine aminotransferase activity 8. Quelle épreuve clinicopathologique suivante n’est pas utile pour confirmer une suspicion de maladie hépatique 9. Anesthetic induction with propofol causes: chez les ruminants? a. bradycardia a. concentration de la bilirubine sérique; b. increased intracranial pressure b. activité de la sorbitol déshydrogénase sérique; c. hypotension in hypovolemic patients c. activité de l’aspartate aminotransférase sérique; d. hypertension in normovolemic patients d. activité de la gamma glutamyltransférase sérique; e. decreased cardiac output from myocardial depression e. activité de l’alanine aminotransférase sérique. 10. An abundance of eosinophils on a peripheral blood smear 9. L’induction anesthésique à l’aide du propofol cause : is most commonly associated with: a. de la bradycardie; a. neoplastic disease b. une augmentation de la pression intracrânienne; b. infection c. de l’hypotension chez les patients hypovolémiques; c. trauma d. de l’hypertension chez les patients normovolémiques; d. allergic conditions e. une diminution du débit cardiaque par dépression e. stress myocardique. (See p. 71 for answers./Voir les réponses à la page 71.) 10. Une abondance d’éosinophiles sur un frottis de sang périphérique est la plus communément associée à : a. une maladie néoplasique; b. une infection; c. un traumatisme; Questions and answers were derived from Review Questions and d. des conditions allergiques; Answers for Veterinary Boards 2nd ed., a 5-volume series including Basic Sciences, Clinical Sciences, Small Animal Medicine and Surgery, Large e. du stress. Animal Medicine and Surgery, and Ancillary Topics, by kind permission of the publisher, Mosby–Year Book, Inc., St. Louis, Missouri.

Les questions et les réponses sont extraites de Review Questions and Answers for Veterinary Boards 2nd ed., une série de cinq ­volu­mes qui ­comprend Basic Sciences, Clinical Sciences, Small Animal Medicine and Surgery, Large Animal Medicine and Surgery, et Ancillary Topics, avec l’aimable permission de ­l’éditeur, Mosby–Year Book, Inc. de St. Louis (Missouri).

22 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY News Nouvelles

2013 CVMA Awards Prix de l’ACMV 2013 Last Call! Nominations Close Dernier avis! Clôture des mises en January 31, 2013 candidature le 31 janvier 2013 Each year, through CVMA’s national veterinary awards program, Chaque année, dans le cadre du programme des prix vétérinaires veterinarians are honored for their exceptional contributions to nationaux de l’ACMV, des vétérinaires sont honorés pour veterinary medicine. All CVMA members are encouraged to leurs contributions exceptionnelles à la médecine vétérinaire. nominate deserving colleagues for their hard work and dedica- Nous encourageons tous les membres de l’ACMV à mettre en tion to the profession. candidature des collègues méritants pour leur travail ardu et leur CVMA Awards will be presented during the CVMA dévouement envers la profession. Convention, which takes place in Victoria, British Columbia, Les prix de l’ACMV seront présentés durant le congrès de from July 10–13, 2013. Nominations will be accepted until l’ACMV, qui déroulera du 10 au 13 juillet 2013 à Victoria January 31, 2013 for the following awards: (Colombie-Britannique). Les mises en candidature seront CVMA Humane Award (Sponsored by Merck Animal Health) acceptées jusqu’au 31 janvier 2013 pour les prix suivants : Merck Veterinary Award (Sponsored by Merck Animal Health) Prix humanitaire de l’ACMV Small Animal Practitioner Award (Commandité par Merck Santé animale) (Sponsored by Petsecure Pet Health Insurance) Prix vétérinaire Merck CVMA Industry Award (Commandité par Merck Santé animale) CVMA Life Membership Prix du praticien des petits animaux CVMA Honorary Membership (Commandité par Petsecure assurance maladie pour animaux) *NEW* CVMA Practice of the Year Award Prix de l’industrie de l’ACMV NEW! CVMA Practice of the Year Award Membre à vie de l’ACMV Membre honoraire de l’ACMV This year, the CVMA has introduced a new award to recognize *NOUVEAU* Prix de la pratique de l’année de l’ACMV a veterinary practice team for outstanding achievement within their local community. The CVMA Practice of the Year Award NOUVEAU! Prix de la pratique de l’année was established by the CVMA to recognize such achievements de l’ACMV as innovations in the provision of veterinary services, commit- Cette année, l’ACMV a introduit un nouveau prix afin de ment to work-life balance, meaningful community or charitable reconnaître une pratique vétérinaire pour des réalisations involvement, or implementation of “green” practice procedures. exceptionnelles au sein de sa collectivité locale. Le Prix de To be considered, candidates must be nominated by a CVMA la pratique de l’année de l’ACMV a été établi par l’ACMV member, and the candidate must also be a CVMA member. afin de reconnaître l’équipe d’une pratique vétérinaire pour Nomination packages must include a completed nomination des réalisations exceptionnelles comme l’innovation dans la form, a written description of the nominee’s work and support- prestation de services vétérinaires, l’engagement envers l’équilibre ing documents. travail-vie, une participation communautaire ou du travail Nomination packages should be submitted by January 31, de bienfaisance ou encore la mise en œuvre de protocoles 2013 via e-mail ([email protected]) by fax 613-236-9681, écoresponsables pour la pratique. or by mail to the CVMA office 339 Booth Street, Ottawa, ON Pour être considérés, les candidats doivent être mis en K1R 7K1. candidature par un membre de l’ACMV et le candidat doit aussi For additional information, including full descriptions of each être membre de l’ACMV. Les trousses de mise en candidature award, nomination forms, and a listing of past award recipients, doivent inclure un formulaire rempli, une description écrite du please visit the CVMA Web site (www.canadianveterinarians.net). travail du candidat et des pièces justificatives à l’appui. Les trousses de mises en candidature doivent être soumises d’ici le 31 janvier 2013 par courriel ([email protected]), par télécopieur au 613-236-9681 ou par la poste au bureau de l’ACMV, au 339, rue Booth, Ottawa (Ontario) K1R 7K1. Pour obtenir des renseignements additionnels, incluant les descriptions complètes de chaque prix, les formulaires de mise en candidature et une liste des lauréats des années précédentes, veuillez visiter le site Web de l’ACMV (www.veterinairesaucanada.net).

CVJ / VOL 54 / JANUARY 2013 23 FOR PERSONAL USE ONLY “The Best CE Value in Canada”

April 19 - 21, 2013 Halifax Marriott Harbourfront Hotel Halifax, NS www.apvc.ca

Veterinarians

Dr. Jennifer Devey Dr. Doreen Housten

• The Acute Abdomen an Overview • Dealing with Senior Patients Having Multiple Abdominal Trauma is it Surgical? Problems • Update on CPR and Emergency Preparedness Dr. David Wilkie • Electrolyte Disorders • Diagnostic Examination of the Eye Which Fluid and Does it Really Matter? ! 90 ml/kg? What about Cats? • Anterior Segment - All the Red Stuff ! • Feline Ophthalmology • Myths About Fluids and Shock • Ophthalmic Pitfalls in Practice The 4 W’s of Fluid Therapy • Vision in Animals Dr. John Rush • Diagnostic Testing for Dogs with Cardiac Disease Animal Health Technicians Cardiac Biomarkers • Cardiac Arrhythmias Dr Doreen Housten Which Ones to Treat and How? • Congestive Heart Failure Mgt in Dogs • Perfect Pee - Is it Meant to be? • Feline Cardiology Urinary Tract Disorders in the Dog and Cat Crystals/Stones and UTI’s Dr. Brian Beale Alison Gottlieb • Medial Patellar Luxations in Small Dogs and • Diabetes and DKA - What We Need to Know Cats - Tricks to Success • The Respiratory System • Medial Patellar Luxations in Large Dogs - Upper and Lower Airway Disease How Does it Differ? • Cruciate Repair in Small Dogs and Cats • Easy ECG • Crooked Leg Dogs It’s Not That Complicated When Do I Straighten and When do I Leave Alone? • Nursing Care for the Feline Patient • Minimally Invasive Fracture Repair Techniques • Feline Cases • Arthroscopy for Practitioners The Ones We will Never Forget Simple, Easy to Learn and Very Affordable • Common Emergencies • Elbow Dysplasia GDV, Blocked Cat, Respiratory, Reproductive etc. Secrets to Diagnosis and Options for Treatment • CPR • Hip Dislocation Anything is Better Than Dead Increasing Your Odds of Keeping it In • Pain Management • Stem Cells and PRP How to Recognize and Treat Accordingly Do They Really Work for Orthopedic Problems?

Join more than 800 other delegates, exhibiting companies and a world class list of speakers in an environment of true maritime hospitality FOR PERSONAL USE ONLY

A COMPLETE PACKAGE FOR THE ENTIRE VETERINARY TEAM

Animal Health Technicians

Dr. Byron de la Navarre • Nutrition in Birds • Household Hazards in Birds • Practice Tips in Small Mammals • Dental Disease in Small Mammals • Rodent Medicine

Dr. Jennifer Devey • Vascular Access and Fluid Therapy in Patients Support Staff in Shock • Constant Rate Infusions of Medications Bash Halow How, When, Why and What? • Effective Communication • Recognizing When a Patient is Going to “Get • Reducing Intra-office Bickering and Conflict into Trouble” Dr Jayne Takahashi Business Management • Managing Challenging Situations • Presenting Value Bash Halow • Pet Loss - Skills That Will Help our Clients (and Ourselves) • Don’t Do as I Do, Do as I Say And 9 Other Disastrous Mgt Practices Dr Doreen Houston • Standard of Care Parts I and II • Performance Reviews That Work • Things that are Poisonous to Your Pet Common Things You Carry That Can Cause Harm

Terry O’Neil • Get With the Program • Key Performance Indicators (KPI’s) Six Steps to Weight Loss Tools to Manage your Practice • Managing Your Two Major Expenses People and Professional Services Fees • Internal Controls Trust is Not Enough • Veterinary Practice Profit Tree Veterinarians Full $350 (3 days) Karn Nichols Lab $550 or $400 with Full Reg (Ophthalmology - includes Ophthalmic surgery kit) • Creating Awareness in Your Team Driving Productivity • On-boarding New Employees AHT’s & Vet’s Assistant’s Building a Practice Foundation Full $175 (3 days) Lab $175 or $125 with Full Reg (Parasitology) Wet Labs Managers Veterinarians: Full Day Full $275 (3 days)

Dr David Wlikie Support Staff • Eyelid, Adnexal and Corneal Surgery Full $125 (2 days) Technicians: ½ Day Dr Gary Conboy and Nicole Murphy • Parasitology - Species in the Feces For further information contact:

APVC Committee on Arrangements Email: [email protected] Dr. Ernie Prowse - Chair Tel: (902) 899-2233 106 Maple Blvd Truro, NS B2N 4N3 Register online - www.apvc.ca FOR PERSONAL USE ONLY

CVMA Attends CanWest L’ACMV assiste à la Conférence CanWest The CVMA was involved in the recent CanWest Conference L’ACMV a participé à la Conférence CanWest qui s’est in Banff, Alberta on October 13–16, 2012. Dr. Nigel Gumley récemment tenue à Banff, en Alberta, du 13 au 16 octobre gave a presentation for the companion animal stream on 2012. Le Dr Nigel Gumley a donné une présentation dans le “Antimicrobial Decision Making for Companion Animal cadre du volet sur les animaux de compagnie portant sur la «Prise Practitioners — The CVMA Approach.” Dr. Gumley gave an de décisions sur les antimicrobiens à l’intention des praticiens overview of the CVMA antimicrobial decision-making tool that pour animaux de compagnie — L’approche de l’ACMV». Le

NOUVELLES is under development, with specific focus on the urinary tract Dr Gumley a présenté un aperçu de l’outil de l’ACMV pour infection algorithm and treatment table. la prise de décisions sur les antimicrobiens qui est en voie Dr. Warren Skippon gave a presentation for the food animal d’élaboration, en s’attardant particulièrement sur l’algorithme stream on “The Role of CVMA in Livestock Antimicrobial et le tableau de traitement des infections des voies urinaires. Stewardship — What have we been doing and what needs to Le Dr Warren Skippon a donné une présentation dans be done.” An overview of the issues of antimicrobial resistance le cadre du volet sur les animaux destinés à l’alimentation in food animal veterinary medicine was presented, along with portant sur «Le Rôle de l’ACMV dans la gestion responsable des discussion about the Canadian regulatory “Black Hole“ for antimicrobiens pour le bétail — Ce que nous avons fait et ce qui antimicrobials. The CVMA guidelines for prudent use of anti- doit être réalisé». Un aperçu des enjeux liés à l’antibiorésistance microbials in livestock were featured in this presentation. en médecine vétérinaire des animaux destinés à l’alimentation The CVMA Animal Welfare Committee (AWC) visited the a été présenté, ainsi qu’une discussion à propos du «trou noir» Western College of Veterinary Medicine (WCVM) for their de la réglementation canadienne pour les antimicrobiens. Les annual fall meeting. The AWC visited the Pound Maker beef lignes directrices de l’ACMV sur l’administration judicieuse feedlot in Lanigan, Saskatchewan. The beef operation has a des antimicrobiens chez le bétail ont été présentées lors de cet 28 500-head capacity and is Canada’s first integrated feedlot/ exposé. fuel ethanol facility. The AWC meeting featured a noon-hour presentation to the WCVM students by Dr. Terry Whiting. A packed lecture theatre Dr./Dr Terry Whiting heard Dr. Whiting give a presentation titled “A Hobbit’s Tale — there and back again: How an animal welfare crisis can impact mental health wellness.” This was an open, personal discussion about Dr. Whiting’s experience with a major mental health crisis that was precipitated by a mass livestock depopulation event in Manitoba. He discussed the global statistics of suicide, and the high risk of mental illness in the veterinary profession, particu- larly in the growing female demographic.

Dr./Dr Nigel Gumley

26 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Le Comité de l’ACMV sur le bien-être des animaux (CBA) s’est rendu au Western College of Veterinary Medicine (WCVM) pour sa réunion annuelle d’automne. Le CBA a visité le parc d’engraissement des bovins Pound Maker à Lanigan, en Saskatchewan. L’exploitation bovine possède une capacité de 28 500 têtes de bétail et elle est la première installation du Canada à posséder une capacité intégrée de parc d’engraissement NEWS et d’éthanol. Dans le cadre de la réunion du CBA, une conférence du midi a été présentée aux étudiants du WCVM par le Dr Terry Whiting. Une salle comble a entendu la présentation du Dr Whiting intitulée : «L’histoire d’un Hobbit — aller-retour. Comment une crise de bien-être des animaux peut influencer la santé mentale». C’était une discussion personnelle et franche à propos des expériences du Dr Whiting vécues lors d’une crise de santé mentale majeure qui avait été précipitée par une dépopulation massive de bovins au Manitoba. Il a abordé les statistiques générales pour le suicide et le risque élevé de maladie mentale dans la profession vétérinaire, particulièrement dans le groupe grandissant de femmes.

Eastern Veterinary Technician Vétérinaire de l’année de l’Eastern Association’s Veterinarian of the Year Veterinary Technician Association Dr. Ernie Prowse received The Veterinarian of the Year Award Le Dr Ernie Prowse a reçu le Prix du vétérinaire de l’année from the Eastern Veterinary Technicians Association (EVTA). décerné par l’Eastern Veterinary Technicians Association The award was presented at the EVTA Annual Meeting in (EVTA). Le prix a été présenté lors de l’assemblée annuelle de Moncton, New Brunswick on September 22, 2012. It was pre- l’EVTA à Moncton, au Nouveau-Brunswick, le 22 septembre sented by Joye Sears, president of EVTA. 2012. Il a été remis par Joye Sears, présidente de l’EVTA.

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Bovine Welfare Award Prix pour la promotion du bien-être bovin

The Canadian Association of Bovine Veterinarians/Association Le conseil de direction de l’Association canadienne des Canadienne des Vétérinaires Bovins (CABV/ACVB) executive vétérinaires bovins/Canadian Association of Bovine Veterinarians board and Boehringer Ingelheim (Canada) Ltd. announced (ACBV/CABV) et Boehringer Ingelheim (Canada) Ltée ont Dr. Neil Anderson as the recipient of the 2012 Metacam annoncé que le Dr Neil Anderson est le lauréat du Prix pour 20 Bovine Welfare Award. Dr. Anderson is the lead veterinar- la promotion du bien-être bovin Metacam 20 de 2012. Le ian in bovine health and welfare at the Ontario Ministry of Dr Anderson est vétérinaire principal en santé et bien-être des

NOUVELLES Agriculture, Food and Rural Affairs (OMAFRA). bovins au ministère de l’Agriculture, de l’Alimentation et des “Scores of people taught and inspired me to learn about Affaires rurales de l’Ontario (MAAARO). Nature’s way, cow behavior, cattle well-being, and to share with «Un grand nombre de personnes m’ont enseigné et inculqué others. Because of them, I’ve enjoyed going to barns, helping le désir d’apprendre la façon dont la nature fonctionne, le producers and cattle in their care, and seeing their accom- comportement des vaches, le bien-être des bovins, et de partager plishments. I am grateful to the CABV/ACVB for this kind ces connaissances avec les autres. Grâce à elles, j’ai adoré me recognition and to Boehringer Ingelheim (Canada) Ltd. for rendre dans les étables, aider les producteurs à soigner leurs their generous sponsorship. I cherish this award as an honor to bovins, et constater leurs réalisations. Je remercie l’AVCB pour everyone who made it possible for me and thank each of you,” cette belle reconnaissance et Boehringer Ingelheim (Canada) said Dr. Anderson after being announced the recipient of the Ltée pour sa généreuse commandite. Ce prix me tient à cœur en 2012 Metacam 20 Bovine Welfare Award. l’honneur de tous ceux et celles qui m’ont permis de vivre cette The Metacam 20 Bovine Welfare award is given annually to a belle expérience et je désire remercier chacun d’entre vous», a veterinarian, faculty member or a graduate student of a Canadian affirmé le Dr Anderson après avoir appris qu’il était le lauréat du university to recognize his or her achievements in advancing prix pour la promotion du bien-être bovin Metacam 20 2012. the welfare of animals via leadership, public service, research/ Le prix pour la promotion du bien-être bovin Metacam 20 product development, and/or advocacy. By doing so, the CABV est décerné chaque année à un vétérinaire, à un membre du and Boehringer Ingelheim hope to raise public awareness of corps professoral ou à un étudiant de troisième cycle d’une the important role veterinarians and animal scientists play in université canadienne afin de souligner les efforts effectués en improving understanding of bovine welfare-related science and vue d’améliorer le bien-être des animaux dans une des sphères

From the left to right, Dr. John Campbell (CABV/ACVB), Dr. Neil Anderson, Dr. Rob Tremblay (Boehringer Ingelheim [Canada] Ltd.). De gauche à droite, le Dr John Campbell (CABV/ACVB), le Dr Neil Anderson, le Dr Rob Tremblay (Boehringer Ingelheim [Canada] Ltée.).

28 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY ethics; ensuring that rearing of cattle used for human purposes is d’activité suivantes : leadership, fonction publique, recherche conducted responsibly; and attending to and promoting animal et développement de produit ou défense d’intérêts. Grâce à ce welfare within the context of responsible animal use. prix, l’ACVB et Boehringer Ingelheim espèrent mieux sensibiliser Since the 1970s Dr. Neil Anderson has provided exemplary le public à l’importance du rôle joué par les vétérinaires et les services to the Ontario beef and dairy industries as a practic- scientifiques pour : améliorer la compréhension des aspects ing veterinarian and as extension veterinarian with OMAFRA. scientifiques et éthiques liés au bien-être bovin; assurer une Dr. Anderson’s work in veterinary extension is founded on the utilisation responsable des bovins à des fins humaines; assurer NEWS strong correlation between animal welfare and animal pro- et promouvoir le bien-être des animaux dans un contexte ductivity. Dr. Anderson has promoted the appropriate use of d’utilisation responsable des ressources animales. medication in livestock, the best designs for housing systems Depuis les années 1970, le Dr Neil Anderson a fourni des for dairy cattle and has crusaded for optimized feeding systems services exemplaires aux industries laitière et bovine de l’Ontario for dairy calves. He has advocated for humane treatment of à titre de vétérinaire praticien et vétérinaire de vulgarisation animals through his writings, lectures and farm visits in Ontario auprès du MAAARO. Le travail du Dr Anderson en vulgarisation as well as across Canada and internationally. Many veterinar- vétérinaire se fonde sur la forte corrélation entre le bien-être ians and dairy producers have had the pleasure to experience des animaux et la productivité des animaux. Le Dr Anderson a Dr. Anderson’s impact as a teacher, practicing veterinarian, promu l’utilisation appropriée des médicaments chez le bétail mentor, agricultural extension educator, and as a true leader in et les meilleures conceptions des étables pour les bovins laitiers, the field of cattle welfare. en plus de mener une croisade pour l’optimisation des systèmes “We are very pleased to be able to initiate this award to honor d’alimentation destinés aux veaux laitiers. Par ses écrits, ses those who have added so much to our knowledge of livestock conférences et ses visites agricoles en Ontario, partout au Canada behavior, animal welfare and animal well-being in Canada. These et ailleurs dans le monde, il préconise le traitement humain des scientific fields have expanded so rapidly in Canada in the past animaux. De nombreux vétérinaires et producteurs laitiers ont few years that Boehringer Ingelheim thought it appropriate to eu le plaisir d’apprécier le Dr Anderson en tant qu’enseignant, be able to recognize those who have made outstanding contri- vétérinaire praticien, mentor, éducateur en vulgarisation agricole butions in these research and management areas. Thank you to et comme véritable leader dans le domaine du bien-être des the membership of the CABV/ACVB for graciously agreeing bovins. to undertake the task of seeking nominations and selecting the «Nous sommes très heureux de pouvoir instaurer ce prix recipient” says Dr. Rob Tremblay, Bovine/Equine Specialist afin d’honorer les personnes qui ont grandement contribué à with Boehringer Ingelheim (Canada) Ltd. “We are particularly accroître notre connaissance du comportement et du bien-être pleased that Dr. Neil Anderson is the first recipient of the award. des animaux au Canada. Ces domaines scientifiques ont pris un Throughout his career, Dr. Anderson has been passionate about tel essor au Canada depuis les dernières années que Boehringer introducing new ideas and technologies to livestock agriculture. Ingelheim a estimé qu’il serait approprié de reconnaître le travail He has a real talent for helping people see common problems des personnes qui ont contribué de façon exceptionnelle à ces and common husbandry practices in an entirely different way, domaines de recherche et de gestion. Nous remercions l’ensemble then help people implement practical solutions. The entire des membres de l’ACVB d’avoir aimablement accepté de se Canadian livestock industry has benefited from Dr. Anderson’s charger de la recherche des candidatures et de la sélection du work. Well done.” lauréat», a précisé le Dr Rob Tremblay, vétérinaire au service technique chez Boehringer Ingelheim (Canada) Ltée. «Nous sommes particulièrement heureux que le Dr Neil Anderson soit le premier lauréat de ce prix. Tout au long de sa carrière, le Dr Anderson s’est passionné pour l’utilisation de nouvelles idées et technologies dans le secteur des animaux d’élevage. Il possède un réel talent pour aider les personnes à voir les problèmes courants et les pratiques courantes d’élevage d’une manière totalement différente, et il leur porte ensuite assistance afin de mettre en place des solutions pratiques. L’industrie canadienne des animaux d’élevage tout entière bénéficie du travail du Dr Anderson. Félicitations!»

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European Journal of Companion European Journal of Companion Animal Practitioners Animal Practitioners The 3rd online version of European Journal of Companion La troisième version en ligne de l’European Journal of Companion Animal Practitioners (EJCAP) is available now. It contains the Animal Practitioners (EJCAP) est maintenant disponible. Elle usual continuing professional development (CPD) articles from contient les articles de perfectionnement professionnel habituels all corners of Europe, as well as slideshows, quizzes, interviews de tous les coins de l’Europe ainsi que des diaporamas, des tests and other extras. éclairs, des entrevues et autres suppléments. After 21 years of bringing veterinary continuing education in La revue EJCAP, après 21 années de formation continue print to companion animal practitioners throughout Europe, the vétérinaire publiée en format imprimé à l’intention des NOUVELLES EJCAP has now become fully interactive. As the official journal praticiens pour animaux de compagnie de toute l’Europe, est of the Federation of European Companion Animal Veterinary maintenant présentée en format entièrement interactif. À titre Associations (FECAVA), it is exclusively available to FECAVA de revue officielle de la Federation of European Companion members. Animal Veterinary Associations (FECAVA), elle est disponible This issue includes reports from the FECAVA symposium on exclusivement aux membres de la FECAVA. animal-assisted interventions (AAI), with exclusive interviews Ce numéro comprend des rapports du symposium de la with the 3 keynote speakers, discussion of the “healing power” FECAVA sur les interventions à recours animalier ainsi que des of animals, and the positive impact of pets in institutions. entrevues exclusives avec les trois conférenciers principaux et la FECAVA is grateful to its Prime Partners MSD Animal discussion du «pouvoir de guérison» des animaux et de l’impact Health, Hills Pet Nutrition and Elanco Animal Health for their positif des animaux de compagnie dans les institutions. support of EJCAP online. La FECAVA remercie ses principaux partenaires MSD Santé Register now! animale, Hills Pet Nutrition et Elanco Santé animale de leur appui d’EJCAP online. Registration is easy; interested practitioners should simply go to EJCAP online (www.fecava.org/ejcap) and follow the Inscrivez-vous maintenant! instructions. Once registered and logged in, all EJCAP online Il est facile de s’inscrire; les praticiens intéressés doivent simple- and previous print volumes of EJCAP (available in pdf) can be ment aller à EJCAP online (www.fecava.org/ejcap) et suivre les accessed directly. instructions. Après l’inscription et ouverture de session, on peut The new FECAVA Web site also contains information about accéder directement à tous les volumes d’EJCAP online et aux FECAVA and its contact persons, a blog, policy statements and numéros imprimés antérieurs d’EJCAP (disponibles en format a calendar of events. pdf). Le nouveau site Web de la FECAVA contient aussi des renseignements à propos de la FECAVA et de ses porte-parole, un blogue, des énoncés de politique et un calendrier des activités.

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Around the Provinces Le tour des provinces College of Veterinarians of Ontario College of Veterinarians of Ontario

Le College of Veterinarians of Ontario (CVO) protège et dessert l’intérêt public par la réglementation de la pratique de NEWS la médecine vétérinaire en Ontario. Les associations de réglementation et de services professionnels ont beaucoup en commun, ce qui explique probablement pourquoi bon nombre de nos homologues provinciaux ont choisi un fonctionnement conjoint. En Ontario, nous avons des voix distinctes pour la profession et le public, et l’Ontario Veterinary Dr./Dr Ken Bridge Medical Association et le CVO œuvrent dans leur domaine respectif. Même si nous travaillons souvent en collaboration, The College of Veterinarians of Ontario (CVO) protects and nous sommes des organismes uniques et distincts. Il y a des serves the public interest through the regulation of the practice domaines qui se rapportent uniquement à la réglementation. of veterinary medicine in Ontario. La protection des intérêts du public s’effectue par l’octroi de Regulators and professional associations share a good deal of permis aux vétérinaires, l’agrément des installations et l’enquête common ground, which is perhaps why many of our provincial sur les plaintes et les préoccupations des vétérinaires. Le CVO counterparts have chosen to work as combined agencies. In a continué de réaliser des projets de politiques et de stratégies Ontario, we have separate voices for the profession and for the en collaboration avec la profession et les divers intervenants public, with the Ontario Veterinary Medical Association and the pendant 2012. CVO each bringing a distinct perspective. While we often work Le CVO a mis en œuvre des initiatives politiques sur un in collaboration, we are unique and separate organizations. There éventail d’enjeux, incluant un avis révisé sur la publicité et are areas that are distinctly regulatory. Protection of the public un avis pour aider les vétérinaires dans la prise de décisions interest is upheld by the licensure of veterinarians, accreditation relativement aux chirurgies vétérinaires inutiles sur le plan of facilities and investigation of complaints and concerns with médical. Le Conseil a examiné les documents de politiques sur veterinarians. The CVO has been moving forward with policy la relation vétérinaire-client-patient, les soins en dehors des and strategic projects in collaboration with the profession and heures régulières et l’accès aux services d’urgence et l’assurance various stakeholders throughout 2012. de la qualité. Le Conseil a aussi proposé des modifications The CVO has delivered policy initiatives on a range of issues, au Règlement 1093. Le Conseil apprécie la rétroaction reçue including an updated advertising advisory and an advisory to des membres, des intervenants et du public pour prendre des assist veterinarians with decisions on medically unnecessary décisions sur les orientations des politiques. Toutes les politiques veterinary surgery. Council also reviewed policy documents mises à jour se trouvent sur le site Web du CVO (www.cvo.org). on the veterinarian-client-patient relationship, after-hours care Le CVO a accueilli sa nouvelle registraire et première and access to emergency services and quality assurance. Council dirigeante, Jan Robinson, au début de 2012. Mme Robinson has also proposed amendments to Regulation 1093. Council possède une vaste expérience dans la collectivité des politiques appreciates the input received from members, stakeholders and de réglementation de la santé. Elle continue de rencontrer the public in making decisions on policy directions. All updated des membres de la profession dans leurs pratiques et lors de policies can be found on the CVO’s Web site (www.cvo.org). réunions d’associations régionales ainsi que lors des conférences The College welcomed its new registrar and Chief Executive de l’OVMA et de l’ACMV. Officer, Jan Robinson, early in 2012. Ms. Robinson has exten- Le Forum des membres 2012 a porté sur l’avenir du programme sive experience in the regulatory health policy community. d’assurance de la qualité du CVO. Le forum, qui a aussi été She continues to meet with members of the profession in their transmis aux membres par webémission, a renforcé la valeur du practices and through regional association meetings, as well as programme d’assurance de la qualité en appuyant un niveau élevé at the OVMA and CVMA conferences. de compétence dans la profession et en rehaussant la confiance du The 2012 Members’ Forum focused on the future of the public à l’égard de l’expertise des praticiens. Le CVO continue de CVO’s Quality Assurance program. The forum, which was travailler avec les membres et les intervenants tout en poursuivant also delivered to members’ via webcast, reinforced the value of son travail sur le programme d’assurance de la qualité. the Quality Assurance program in supporting a high degree of Le CVO a aussi introduit des normes minimales pour les competency across the profession and also building public con- installations vétérinaires en Ontario qui sont entrées en vigueur fidence in practitioners’ expertise. The College is continuing to le 1er septembre 2012, après une vaste consultation auprès des work with members and stakeholders while moving forward on membres. Les nouvelles normes se trouvent sur le site Web du its Quality Assurance program. CVO et les changements sont mis en évidence. The College has also introduced new Minimum Standards Le CVO continue de travailler en partenariat et en for Veterinary Facilities in Ontario, which came into effect consultation avec l’OVMA, le ministère de l’Agriculture, de

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September 1, 2012, following thorough consultation with the l’Alimentation et des Affaires rurales de l’Ontario, l’Ontario members. The new standards, highlighting the changes, can be Association of Veterinary Technicians, le Bureau du commissaire found on the College’s Web site. à l’équité et d’autres ministères assumant des responsabilités qui The CVO continues to work in partnership and consulta- influencent les aspects de la profession vétérinaire. Le CVO a tion with the OVMA, the Ontario Ministry of Agriculture, aussi fait preuve de son engagement en satisfaisant au nouveau Food and Rural Affairs, the Ontario Association of Veterinary règlement d’accessibilité pour les services à la clientèle de la Technicians, the Office of the Fairness Commissioner, and other province. ministries with responsibilities that influence or impact aspects Le CVO s’est tourné vers la technologie afin de devenir of the veterinary profession. The CVO has also demonstrated its plus efficace, écologique et flexible dans la mise en œuvre de commitment to accessible customer service with its compliance ses programmes et la distribution de ses renseignements et de NOUVELLES with the province’s new Accessible Customer Service Regulation. ses ressources. Le CVO a adopté un système de gestion des The CVO has been embracing technology in efforts to be données puissant afin de mettre à jour le registre, de réaliser more efficient, eco-friendly and flexible in delivering its pro- des renouvellements des permis en ligne et de gérer les relations grams, information and resources. The College has adopted a avec les membres. De plus, le portail CPD Cycle a été lancé en robust database management system to maintain the register, 2011, permettant aux vétérinaires de soumettre leurs données conduct on-line licence renewals and manage member relations. par voie électronique. Dans d’autres initiatives, le CVO a tenu As well, the CPD Cycle Portal was launched in 2011, enabling les élections du Conseil par voie électronique cet automne. veterinarians to submit their data electronically. In other initia- J’ai éprouvé un grand plaisir à représenter le CVO pendant tives, the College conducted its Council elections electronically la dernière année. Je me réjouis à la perspective d’un leadership this fall. continu par le CVO pour la profession vétérinaire en Ontario. It has been a distinct pleasure to represent the CVO over the (par le Dr Ken Bridge, président, College of Veterinarians of Ontario) past year. I look forward to seeing the CVO continue to provide leadership for the veterinary profession in Ontario. (by Dr. Ken Bridge, President, College of Veterinarians of Ontario)

Around the Provinces is a regular news feature in The Canadian Le tour des provinces est une chronique régulièrement publiée dans Veterinary Journal designed to inform Canadian veterinarians about La Revue vétérinaire canadienne afin d’informer les vétérinaires du the work of provincial veterinary associations across Canada. We invite Canada sur le travail des associations vétérinaires provinciales. Nous the provincial presidents of these associations to report on the activities invitons les présidents de ces associations à nous faire part des activités and issues being addressed by their respective organizations. We thank et des enjeux de leurs organismes respectifs. Nous tenons à remercier Dr. Ken Bridge for his article in this issue. CVJ eds. Dr Ken Bridge pour son article. Les rédacteurs de la RVC.

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32 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Report Card from the Dean Le bulletin du doyen University of Calgary Faculty of Faculté de médecine vétérinaire Veterinary Medicine de l’Université de Calgary The most notable event in 2012 for the University of Calgary En 2012, l’événement le plus marquant pour la Faculté de Faculty of Veterinary Medicine (UCVM) was the May 10th con- médecine de l’Université de Calgary (UCVM) a été la première

vocation of the first graduating class of 30 DVM students and collation des grades du 10 mai afin de décerner les diplômes à NEWS the 1st PhD student in our Veterinary Medical Sciences graduate 30 étudiants du D.M.V. et au premier étudiant au doctorat de program. All DVM students successfully completed the NAVLE notre programme des Sciences médicales vétérinaires. Tous les on their 1st attempt and had found employment by convocation. étudiants ont réussi le NAVLE à leur première tentative et ils Twenty-six students are working in Alberta (with 60% serving avaient trouvé un emploi au moment de la collation des grades. rural Alberta and 3 in internships) and 3 are pursuing internships Vingt-six étudiants travaillent en Alberta (60 % travaillent en in the United States. région rurale et trois suivent des internats) et trois ont accepté Dr. Ole Nielsen was inducted into the Order of the University des internats aux États-Unis. of Calgary at convocation for his contributions to the establish- Le Dr Ole Nielsen a été intronisé à l’Ordre de l’Université de ment of UCVM. The former dean of the Western College of Calgary lors de la collation des grades pour ses contributions à Veterinary Medicine and the Ontario Veterinary College used la fondation de l’UCVM. L’ancien doyen du Western College his extensive knowledge and diplomacy to engage practicing of Veterinary Medicine et de l’Ontario Veterinary College a veterinarians and academics to support the creation of UCVM. puisé dans ses vastes connaissances et talents de diplomate pour The majority of the 4th year of the DVM program is delivered mobiliser l’appui des vétérinaires praticiens et des universitaires through partner practices in a Distributed Veterinary Teaching afin de fonder l’UCVM. Hospital (DVTH). All students complete 12 weeks of general La majorité de la quatrième année du programme de veterinary practice (4 weeks each of food animal, equine, and D.M.V. est offerte par des pratiques partenaires dans le cadre small animal medicine and surgery) and 4 weeks in a rural d’un Hôpital d’enseignement vétérinaire réparti (Distributed community practice in rotations supervised by DVTH clinical Veterinary Teaching Hospital [DVTH]). Tous les étudiants instructors. The mandatory program also includes 4 weeks of terminent 12 semaines de pratique vétérinaire générale (quatre laboratory diagnostics on campus. Students select a 10-week semaines par domaine : animaux destinés à l’alimentation, program in one of 4 “areas of emphasis”: production animal équins et médecine et chirurgie des petits animaux) et health, ecosystem and public health, equine health or investiga- quatre semaines dans une pratique en région rurale avec des tive medicine. Finally, they pursue 10 weeks of open electives. rotations supervisées par des instructeurs cliniques du DVTH. Students spend 60–70% of their 4th year program off-campus Le programme obligatoire comprend aussi quatre semaines in the DVTH and core faculty are engaged in about 50% of de laboratoires diagnostiques sur le campus. Les étudiants rotations. Coupled with the extensive clinical and professional choisissent un programme de dix semaines dans l’une des quatre skills in the first 3 years, the extensive primary care exposure «concentrations» : santé des animaux d’élevage, écosystème et achieved through the DVTH program ensured that the students santé publique, santé équine ou médecine d’enquête. Enfin, ils graduated with excellent clinical reasoning and practical skills. suivent 10 semaines de cours au choix. Les étudiants passent Employment opportunities for graduates in western Canada de 60 % à 70 % de leur quatrième année en dehors du campus appear to remain strong, despite the recent discussions ­regarding dans le DVTH et les professeurs participent à environ 50 % des rotations. Jumelée aux vastes compétences cliniques et professionnelles acquises au cours des trois premières années, l’importante exposition aux soins primaires du programme DVTH a permis aux étudiants de terminer leur cours avec un excellent raisonnement clinique et des compétences pratiques. Les possibilités d’emploi pour les diplômés dans l’Ouest canadien semblent être solides, malgré les discussions récentes concernant la demande de vétérinaires en Amérique du Nord. Parallèlement, les demandes d’admission demeurent élevées, avec une hausse de 15 % des candidats admissibles en 2012. Plus de 210 étudiants ont présenté une demande pour les 32 places disponibles à l’UCVM. Le 1er juillet 2012, l’UCVM a lancé ses orientations stratégiques pour 2012–2017. L’UCVM a identifié les principaux objectifs au cours des cinq prochaines années afin de concrétiser sa vision de réunir l’innovation et la collectivité pour faire progresser la santé animale et humaine. L’UCVM a établi des buts dans cinq domaines clés : études du D.M.V.; Dr./Dr Alastair Cribb études supérieures et formation clinique avancée; recherche;

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demands for veterinarians in North American. Similarly, demand apprentissage communautaire; et retour à la collectivité. Le for program entry remains high, with a 15% increase in qualified document complet peut être lu au (www.vet.ucalgary.ca/system/ candidates in 2012. Over 210 students applied for the 32 avail- files/VetMedStrategicDirMar2012.pdf). able seats at UCVM. Dans le cadre de notre stratégie, nous nous sommes On July 1, 2012, UCVM launched its Strategic Directions engagés à démontrer l’efficacité de nos pratiques éducatives. for 2012–2017. UCVM has identified key goals for the next Nous avons investi plus de 1 million $ dans la recherche en 5 years in pursuit of its visions of bringing innovation and enseignement vétérinaire, incluant l’élaboration et l’évaluation community together to advance animal and human health. The de l’utilisation de simulateurs, de simulations et de la UCVM has established goals in 5 key areas: DVM education; technologie d’enseignement. En août, l’UCVM a accueilli plus graduate education and advanced clinical training; research; de 100 enseignants vétérinaires étrangers lors de la Conférence NOUVELLES community learning; and return to community. The complete INVEST (International Veterinary Simulation in Teaching) document can be read at (www.vet.ucalgary.ca/system/files/ 2012 qui a présenté de nouveaux simulateurs et comment ils VetMedStrategicDirMar2012.pdf). facilitent l’enseignement des compétences cliniques vétérinaires. As part of our strategy, we have committed to demonstrating Des modèles récents créés par les professeurs de l’UCVM, the effectiveness of our educational practices. We have invested en collaboration avec Veterinary Simulator Industries Ltd de over $1 million dollars in veterinary education research, includ- Calgary, incluent un simulateur de palpation équine, un modèle ing developing and assessing the use of simulators, simula- d’un membre distal pour l’enseignement de l’anesthésie d’un tions and technology in education. In August, UCVM hosted nerf et d’une articulation et un modèle pour l’enseignement des over 100 international veterinary educators at the INVEST ovariohystérectomies canines. (International Veterinary Simulation in Teaching) 2012 Nos programmes d’études supérieures et de recherche Conference that showcased new simulators and how they help continuent de croître. Les professeurs de l’UCVM supervisent teach veterinary clinical skills. Recent models created by UCVM maintenant environ 110 étudiants diplômés et rapportent faculty, in conjunction with Calgary-based Veterinary Simulator plus de 12 millions $ par année en financement extra-muros. Industries Ltd, include an equine palpation simulator, a horse Au cours des 18 derniers mois, nous avons investi près de distal limb model for teaching nerve and joint blocks, and a 2,5 millions $ pour améliorer notre recherche stratégique, model for teaching canine ovariohysterectomies. appuyer les études supérieures et encourager la recherche Our graduate education and research programs also continue interdisciplinaire. Récemment, les Drs John Gilleard, Susan to grow. UCVM faculty now supervise approximately 110 gradu- Kutz et James Wasmuth — de même que quatre autres ate students and bring in over $12 million a year in extra-mural chercheurs de l’Université de Calgary — ont reçu 1,6 million funding. In the last 18 months, we have invested nearly $2.5 mil- $ pour un Programme de formation orientée vers la nouveauté, lion to enhance our strategic research areas, support graduate la collaboration et l’expérience en recherche (FONCER) du education and encourage interdisciplinary research. Recently, CRSNGC dans les interactions hôte-parasite. Drs. John Gilleard, Susan Kutz and James Wasmuth — along Au cours de l’an dernier, nous avons recruté 12 nouveaux with 4 other U of C researchers — received $1.6 million for professeurs : Dr Cameron Knight (pathologie anatomique), an NSERC Collaborative Research and Training Experience Mark Ungrin, Ph.D. (bio-ingénierie des tissus); Dr Serge (CREATE) program in Host-Parasite Interactions. Chalhoub (médecine interne des petits animaux); Tuan Trang, Over the last year, we recruited 12 new faculty members: Ph.D. (pharmacologie de la douleur); Dr Cary Hashizume Dr. Cameron Knight (anatomic pathology), Mark Ungrin, (sciences cliniques des petits animaux); Dr Matt Read PhD (tissue bioengineering); Dr. Serge Chalhoub (small animal (anesthésiologie et thérapeutique); Dre Heidi Banse (médecine internal medicine); Tuan Trang, PhD (pharmacology of pain); interne thérapeutique et équine); Dr John Kastelic (santé de la Dr. Cary Hashizume (small animal clinical sciences); Dr. Matt reproduction des bovins); Dre Claudia Klein (thériogénologie Read (anesthesiology & therapeutics); Dr. Heidi Banse (thera- des équidés et des petits animaux); Hermann Schatzl, Ph.D. peutics & equine internal medicine); Dr. John Kastelic (cattle (immunologie; maladie à prions); Dr Mark Fuller (chirurgie reproductive health); Dr. Claudia Klein (equine & small ani- des petits animaux); et Dr Eduoard Timsit (santé des bovins). mal theriogenology); Hermann Schatzl, PhD (immunology; Deux autres aspects de nos orientations stratégiques incluent prion disease); Dr. Mark Fuller (small animal surgery); and l’apprentissage communautaire et le retour à la collectivité. Des Dr. Eduoard Timsit (cattle health). Two other aspects of our projets de recherche communautaires réalisées pendant l’été au Strategic Directions include Community Learning and Return to Stampede de Calgary comprenaient l’utilisation d’équipement the Community. Community engaged research projects conducted d’électrocardiogramme à distance du Dr Renaud Leguillette over the summer at the Calgary Stampede include Dr. Renaud pour surveiller les chevaux participant à des courses de chariots Leguillette’s use of remote electrocardiogram equipment to moni- bâchés et évaluer leur niveau de stress et leur condition physique tor horses participating in chuckwagon races in order to assess et l’étude du Dr Ed Pajor pour examiner le stress et le bien- their stress and fitness levels And Dr. Ed Pajor’s study to examine être d’animaux participant à des épreuves de ruades et autres the stress and welfare of animals engaged in bucking and other compétitions. La mobilisation et la production de preuves performance events. Engaging and generating scientific evidence scientifiques afin d’aborder la santé et le bien-être des animaux to address the health and welfare of performance animals is a way de performance est une façon d’appuyer et de produire des of supporting and leading changes in practice. changements dans la pratique.

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To support Community Learning, UCVM, in partnership Pour appuyer l’apprentissage communautaire, l’UCVM, with the ABVMA, delivered 4 hands-on clinical reasoning and en partenariat avec l’ABVMA, a présenté quatre cours skills courses in small animal anesthesia, small animal surgery, de raisonnement et de compétences cliniques pratiques en equine medicine and small animal medicine. The courses were anesthésie des petits animaux, en chirurgie des petits animaux, designed for veterinarians changing practice fields, veterinarians en médecine équine et en médecine des petits animaux. Les wanting to upgrade skills in specific areas, or for foreign-trained cours étaient conçus pour les vétérinaires changeant de domaines veterinarians who had passed the NAVLE and were preparing d’exercice, les vétérinaires désirant mettre leurs compétences à NEWS for the clinical proficiency exam. The week-long courses were niveau dans des domaines particuliers ou des vétérinaires formés highly successful and will continue to be offered in the future. à l’étranger qui ont réussi le NAVLE et se préparent à l’examen We are proud of our progress over the last year. We look for- de compétences cliniques. Les cours d’une semaine ont connu ward to continued growth and developing collaborative programs un grand succès et continueront d’être offerts à l’avenir. with our colleagues that further veterinary education and the Nous sommes fiers de nos progrès au cours de l’an dernier. Nous veterinary profession in Canada. nous réjouissons à la perspective de croissance et d’élaboration (by Dr. Alastair Cribb, Dean, de programmes concertés avec nos collègues qui avanceront University of Calgary Faculty of Veterinary Medicine) l’enseignement de la médecine vétérinaire et la profession vétérinaire au Canada. (par Dr Alastair Cribb, doyen, Faculté de médecine vétérinaire de l’Université de Calgary)

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oth The Canadian Veterinary Journal and the Canadian Journal a Revue vétérinaire canadienne et la Revue canadienne de B of Veterinary Research are accepting manuscripts through the L recherche vétérinaire acceptent des manuscrits par l’entremise du online submission system, ScholarOne, by way of the CVMA Web système de soumission ScholarOne, auquel on peut accéder sur le site site (www.canadianveterinarians.net). Go to publications, choose the Web de l’ACMV (www.veterinairesaucanada.net). Allez à publications, specific journal you want, then choose submit manuscript. This will puis à la revue particulière que vous désirez, puis soumettez l’article. take you directly to the ScholarOne site where you can log on. Vous serez acheminé directement au site ScholarOne où vous pourrez The Instructions for Authors are provided on the same Web site. Please ouvrir une session. follow these instructions carefully before submitting your manuscript. Les Directives à l’intention des auteurs sont fournies sur le même Please call 613-236-1162, ext. 117 or 1-800-567-2862, ext. 117 with any site Web. Veuillez suivre attentivement ces directives avant de questions if you are having difficulty. soumettre votre manuscrit. Veuillez composer le 613-236-1162, poste 117, ou le 1-800-567-2862, poste 117, avec vos questions si vous éprouvez des difficultés.

CVJ / VOL 54 / JANUARY 2013 35 FOR PERSONAL USE ONLY Article

Laparoscopic-assisted cystotomy for urolith removal in dogs and cats — 23 cases

Cory B. Pinel, Eric Monnet, Michael R. Reems

Abstract — This report describes the outcomes of a modified laparoscopic-assisted cystotomy for urolith removal in dogs and cats. Modifications of the original techniques included a temporary cystopexy to the abdominal wall, utilization of a laparoscope instead of cystoscope, and retrograde flow of saline in the bladder with pressurized saline. The medical records of 23 client-owned animals for which laparoscopic-assisted cystotomy was used for urolith extraction were reviewed. Twenty-six procedures were performed in 23 animals. There were intraoperative complications in 19.2% of cases leading to open conversion in 11.5%. Rate of complications directly related to the procedure was 11.5%. Four cases had documented urolith recurrence with a mean time to recurrence of 335 days.

Résumé — Cystotomie assistée par laparoscopie pour l’enlèvement des urolithes chez les chiens et les chats — 23 cas. Ce rapport décrit les résultats d’une cystotomie assistée par laparoscopie pour l’enlèvement des urolithes chez les chiens et les chats. Les modifications des techniques originales ont inclus une cystopexie temporaire à la paroi abdominale et un flux rétrograde de la solution saline dans la vessie avec une solution saline sous pression. Les dossiers médicaux de 23 animaux appartenant à des propriétaires pour lesquels la cystotomie par laparoscopie avait été utilisée pour l’extraction des urolithes ont été examinés. Vingt-six interventions ont été réalisées chez 23 animaux. Il y a eu des complications peropératoires dans 19,2 % des cas causant une conversion ouverte à 11,5 %. Le taux des complications directement reliées à l’intervention était de 11,5 %. Pour quatre cas, il y a eu une récurrence documentée des urolithes avec une durée moyenne de 335 jours. (Traduit par Isabelle Vallières) Can Vet J 2013;54:36–41

Introduction for removal. Furthermore, an open cystotomy to remove uro- cystoliths is the most common urinary procedure in veterinary he incidence of calcium oxalate uroliths in dogs has practice and is associated with a low morbidity and mortality. increased in the last 20 to 25 y for reasons that are not T A laparoscopic-assisted cystotomy has been described to clear (1,2). Persistence of uroliths within the lower urinary remove uroliths in the bladder (3). Advantages with this tech- tract may lead to urinary tract infection, cystitis, hematuria, nique were reduction of contamination of the abdominal cavity and/or urethral obstruction. Surgical extraction is the most with urine and better visualization to permit a more thorough commonly employed treatment for uroliths not amenable to evaluation of the bladder and urethra (3–5). dietary dissolution and/or those lodged in the urethra or urinary Our objectives for this study are two-fold: to describe several bladder. Frequently, urethroliths can be retropulsed into the modifications made to the original technique initially developed bladder avoiding the need for urethrotomy or a urethrostomy by Rawlings et al (3,5), and to report on the clinical experience and outcomes encountered with performing laparoscopic- Florida Veterinary Specialists, 3000 Busch Lake Blvd, Tampa, assisted cystotomy for urolith removal in a case series of dogs Florida 33614, USA (Pinel, Reems); Department of Clinical and cats. Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, Colorado 80523, USA Materials and methods (Monnet). Case selection Address all correspondence to Dr. Cory B. Pinel; e-mail: The electronic databases of Colorado State University (CSU) [email protected] and Florida Veterinary Specialists (FVS) were examined to iden- Use of this article is limited to a single copy for personal study. tify all dogs and cats in which laparoscopic-assisted cystotomy Anyone interested in obtaining reprints should contact the was utilized for the removal of uroliths. Laparoscopic-assisted CVMA office ([email protected]) for additional cystotomy has been used at CSU for urolith removal since early copies or permission to use this material elsewhere. 2005 and at FVS since mid 2008. Records were identified from

36 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

March 2005 to February 2009. Cases with incomplete medical the urinary bladder either through the suction via the ingress/ records (including detailed surgical reports and final diagnoses), egress portal or with the cannula as it was withdrawn from the or those in which case follow-up could not be done (referring urinary bladder. For uroliths too large to be removed in this veterinarian or owner phone call), were excluded from further manner, grasping forceps were introduced into the urinary investigation. bladder immediately adjacent to the scope. Following removal of all visible cystic uroliths, the urinary catheter was slowly

Medical records review withdrawn and the urethra was examined with the endoscope ARTICLE Medical records were reviewed to determine signalment, his- for remnant uroliths. Frequently, a small portion of the urinary tory, final diagnosis (i.e., urolith analysis), type and result of bladder wall was excised and submitted for bacterial culture and diagnostic imaging, duration of the surgery, intraoperative sensitivity and/or histopathology. The cystotomy incision, linea complications, postoperative management, and time to recur- alba, subcutis, and skin were closed routinely with single layer rence. Intraoperative complications were defined as any episode appositional patterns. Post-operative imaging was done at the noted in the surgical report that indicated deviation from the surgeon’s discretion and was often omitted if there was a high expected routine operative procedure (description follows). confidence in complete urolith removal. Cases in which open conversion to laparotomy was performed were also noted. Follow-up time was determined as the most Results recent time an owner was contacted regarding the urinary status Signalment of the animal. Follow-up time was determined by documented Twenty-five records were examined and 23 (17 dogs, 6 cats) were telephone communication between the referring veterinarian included in this study. Two cases were excluded due to inability and owner. The data are presented as mean and range unless to obtain follow-up information. Seventeen dogs, 14 castrated otherwise indicated. males and 3 spayed females, were included. One dog had surgery twice and one dog had surgery 3 times. The mean age of the Surgical technique dogs at the time of surgery was 8.7 y (range: 3.0 to 15.9 y). The Laparoscopic-assisted cystotomy was performed in a similar mean body weight of dogs at the time of surgery was 20.1 kg manner to the original description by Rawlings et al (3,5). All (2.5 to 54 kg). The breeds of dogs included: dalmatian (n = 3), surgeries were performed by 2 veterinarians, either EM (n = 24) Yorkshire terrier (n = 2), mixed breed (n = 2), and 1 each of bas- or MR (n = 2). Pneumoperitoneum was established either by set hound, cairn terrier, Jack Russell terrier, Lhasa apso, Maltese, Veress needle or open (Hasson) technique (6). The laparoscopic miniature schnauzer, Newfoundland, samoyed, shiba inu, and portal was established at the level of the umbilicus. A second West Highland white terrier. portal was established caudal to the first for introduction of a Six cats were included in the study. The mean age of cats at 5-mm cannula and Babcock grasping forceps. The second portal the time of surgery was 6.3 y (range: 0.7 to 10.8 y). The mean was placed cranial to the prepuce in male dogs and about 2/3 of body weight of cats at the time of surgery was 4.9 kg (range: the way between the pubis and umbilicus in male and female 3.9 to 6.1 kg). Three cat breeds were represented: domestic short cats and female dogs. The instrument cannula was placed in a hair (n = 4), domestic long hair (n = 1), and Siamese (n = 1). location to allow the urinary bladder to be grasped at or near Five cats were castrated males, 1 was a spayed female. the apex and pulled cranial to the ventral abdominal wall, under laparoscopic guidance. The instrument cannula was removed. Pre-operative diagnostic imaging An approximately 3 to 4 cm approach was made to the proposed All cases had non-contrast abdominal radiographs before surgery cystopexy site with a scalpel blade. With tension on the urinary (n = 26). Twenty-two of 26 (85%) had evidence of radiopaque bladder and slight eversion of the urinary bladder wall, a 360° uroliths. Preoperative urethrocystograms were performed in temporary cystopexy was performed using 3-0 or 4-0 polydioxa- 6 cases (4 were positive contrast alone, 2 were double contrast). none suture (PDS II; Ethicon, Somerville, New Jersey, USA) to Urethrocystograms were performed to document the presence of securely anchor the urinary bladder to the ventral body wall, radiolucent uroliths (2), show mucosal filling defects consistent creating a tight seal to prevent movement of urine and uroliths with small radiopaque uroliths (1), or as part of a retrohydro- into the abdominal cavity. The cystopexy suture passed full pulsion procedure used to move uroliths from the urethra to thickness in the bladder wall and the abdominal wall. The skin the urinary bladder (3). All 6 were diagnostic for cystic and/or was incorporated in the cystopexy for small dogs at FVS only. urethral uroliths. A small stab incision was made into the ventral mid body of the Four cases required an imaging technique in addition to urinary bladder through which the 5-mm laparoscope within its non-contrast radiographs to diagnose the presence of uroliths. cannula was then positioned within the urinary bladder. Saline In 3 cases, abdominal ultrasound showed hyperechoic foci with was infused through a preoperatively placed urinary catheter acoustic shadowing (2 discrete uroliths, 1 echogenic sediment) via a manually inflated pressure bag at 300 mmHg. An assistant when non-contrast radiographs failed to diagnose the presence maintained infusion pressure during the procedure by visually of uroliths. Double contrast urethrocystogram diagnosed large monitoring the pressure gauge. Uroliths were flushed from the radiolucent filling defects in the fourth case. urinary bladder under high pressure and removed with suction Preoperative ultrasonographic evaluation of all abdominal attached to the ingress/egress portal of the cannula. Uroliths structures was performed on 14 cases and 10 (71%) were diag- trapped within the lumen of the cannula were removed from nostic for discrete cystic uroliths.

CVJ / VOL 54 / JANUARY 2013 37 FOR PERSONAL USE ONLY

Table 1. Summary of peri-operative case complications of dogs and cats undergoing laparoscopic-assisted cystotomy for urolith removal Signalmenta Complication Conversion Outcome 8 y MC Mix Uroliths too large to be removed, laparoscopic-assisted Yes Uroliths removed by open cystotomy 11 y MC DLH Bladder too large/friable to be grasped Yes Uroliths removed by open cystotomy 5 y MC DSH Incomplete bladder distension due to poor saline flow Yes Uroliths removed by open cystotomy 9 y FS Mix Mild post-operative urinary incontinence No Resolution without management by 2 wk after surgery 16 y MC Yorkshire terrier Mild post-operative urinary incontinence No Resolution without manangement by 2 wk after surgery ARTICLE 9 y MC Siamese Chronic urinary incontinence No Improved after surgery but did not resolve completely 3 y FS Maltese Stranguria No Resolved by 1 wk after surgery without further therapy 15 y MC West Highland Pancreatitis, aspiration pneumonia after surgery No Euthanasia after surgery white terrier 1 y MC DSH Septic uroabdomen peritionitis, urethral tear No Euthanasia after surgery 5 y FS DSH Tenesmus, rectal prolapse, cranial port body wall No Primary herniorrhraphy, colopexy with resolution of dehiscence prolapse, hernia, tenesmus 5 y MC DSH Cranial port seroma No Resolution with warm compress 7 y MC DSH Acute renal failure secondary to suspected meloxicam No Resolution with discontinuation of meloxicam, oral toxicity gastroprotectants, subcutaneous fluids

a MC — male castrated, FS — female spayed, Mix — mixed breed dog, DLH — domestic longhair cat, DSH — domestic shorthair cat.

Surgery One case had intraoperative radiation therapy for transitional Uroliths were removed in 14 cases through the use of suction cell carcinoma of the urinary bladder. One cat had nasal pla- applied to the laparoscopic cannula alone (54%). Additional num biopsy, in which sporotrichosis was diagnosed. One cat grasping devices (such as laparoscopic Babcock forceps and received a perineal urethrostomy during the same anesthetic Alligator grasping forceps) were required to remove larger uro- period because of chronic lower urinary tract obstruction. liths in 8 cases (31%). Mean operative time for laparoscopic-assisted cystotomy was Intraoperative complications were reported for 5 cases (19.2%) 84.3 min 6 35.8 min (n = 17). Operative time for laparoscopic- resulting in conversion to an open procedure in 3 cases (11.5%). assisted cystotomy that was converted to open (total surgical Puncture of the spleen with mild hemorrhage occurred follow- time) was 83.3 min 6 65.3 min (n = 3). ing placement of the Veress needle in 1 case that did not require conversion to an open procedure. The laparoscopy had to be Post-operative diagnostic imaging converted during surgery to a laparotomy because of a problem Postoperative non-contrast radiographs were taken in 10 cases. related to the technique in 3 cases. In 1 case uroliths were large In one case, a single urethrolith was identified postoperatively and the window had to be enlarged at the apex of the bladder, that was successfully removed with an open laparotomy as then distention of the bladder could not be maintained to pur- described. No imaging was performed in the remaining cases. sue the procedure. In another case the urinary bladder was too inflamed and firm to be grasped with Babcock forceps. Tearing Postoperative complications of the bladder wall occurred when it was grasped with a Babcock Complications are summarized in Table 1. In the post-operative forceps. This cat had previous cystotomies for bladder uroliths period 1 cat that had urinary incontinence prior to surgery and and chronic, severe cystitis. In a third case, the laparoscopy in 1 dog developed urinary incontinence that did not require treat- a cat had to be abandoned because the flow of saline through ment. The incontinence improved or resolved on its own within the small urinary catheter was not sufficient to maintain good 2 wk of surgery. One dog developed stranguria that resolved visualization during the cystoscopy. In 1 case a single urethrolith in 1 wk. No uroliths were present on the post-operative radio- lodged in the urethra was missed during laparoscopic-assisted graphs and no urinary tract infection was present. The dog that cystotomy and was identified on postoperativ­ e radiographs. The received intraoperative radiation therapy developed pancreatitis clinician retropulsed the urolith into the bladder and pursued and aspiration pneumonia after surgery for metastatic transi- an open cystotomy instead of repeating a laparoscopic-assisted tional cell carcinoma and was euthanized at the owner’s request cystotomy because sterile laparoscopy equipment was not avail- 3 d after surgery. One cat died of septic peritonitis following a able. This case was not considered as a true conversion since it urethral tear during pre-operative management of the case. One was related to a lack of instruments to repeat the procedure. cat with tenesmus after surgery developed a rectal prolapse and Eleven cases (42%) had an additional procedure performed a herniation through one of the cannula holes. One cat had during the same anesthetic event. Three cases had a laparoscopic a seroma at 1 cannula hole. One cat developed renal failure liver biopsy, one had laparoscopic-assisted gastropexy, and 3 had following administration of non-steroidal inflammatory drugs urinary bladder wall biopsy performed following the cystoscopy. (NSAIDs) after surgery.

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Diagnostic results creation of a retrograde flow of saline helps to flush the uroliths Twenty-five bacterial cultures and sensitivities were reported. out of the bladder. The flow of saline created with a cystoscope Sixteen urinary bladder wall samples were cultured alone, is forward. The high flow of saline also improves visualization 4 uroliths were cultured alone, and in 5 cases, both urolith and because of distension of the urinary bladder wall and dilution urinary bladder wall were cultured. Five positive cultures (20%) of active bleeding. Since placing the largest red rubber or Foley were obtained. The urinary bladder wall yielded a positive bacte- urethral catheter possible is a routine procedure for a cystotomy

rial culture in 4 cases, and a urolith was positive in the other. for urolithiasis in our institutions to either retropulse urethral ARTICLE In none of the cases were the urolith and urinary bladder wall uroliths into the bladder or to prevent migration of uroliths both positive when submitted together. in the urethra at the beginning of the procedure, maintaining Urolith analysis was submitted in 25 of 26 cases. In 13 cases, placement of the catheter does not add any extra steps to the the urolith was primarily calcium oxalate (52%), in 5 cases they procedure (Figure 1). At the end of the procedure the catheter were primarily ammonium urate (20%), in 5 cases they were can be removed with a constant high flow of saline and the primarily cystine (20%), and in 2 cases they were primarily endoscope simultaneously advanced into the dilated urethra to struvite (8%). Urinary bladder wall was submitted for histopa- ensure uroliths are not left in the proximal urethra (Figure 2). thology in 4 cases. Biopsy results were: unremarkable (n = 1), The endoscope cannot advance past the ischiatic curvature in interstitial hemorrhagic cystitis (n = 1), and chronic, suppurative male dogs. This procedure cannot be performed in cats because cystitis (n = 2). of the size of the urethra. A smaller endoscope might be needed. The high flow of saline combined with a large diameter cath- Follow-up eter facilitates displacement of any uroliths lodged in the distal Eight of the 26 cases (30.8%) were discharged on additional urethra. In 1 male cat, the catheter placed was not sufficient to medications for the primary purpose of preventing recurrence of create an adequate flow of saline to flush the uroliths out of the urolithiasis [potassium citrate (n = 5), allopurinol (n = 2), N-(2- urinary bladder. Mercaptopropionyl) glycine/Thiola (n = 1)]. Follow-up time was Laparoscopic-assisted cystotomies were all performed with determined by documented telephone communication between midline incisions even in male dogs and not paramedian as the referring veterinarian and owner (n = 6), examination(s) at described by Rawlings et al (3), which allows the incisions to CSU (n = 5), and telephone contact with the owner (n = 8). be restricted to the linea alba. This reduces hemorrhage and soft Median time of follow-up was 449 d (range: 1 to 946 d). tissue trauma compared with an incision through the muscular portion of the rectus abdominis. Time to recurrence Complication rates during laparoscopy in dogs have been Four cases (6 surgeries) had return of clinical signs and non- reported in 0% to 50% of cases (7–12). The intraoperative com- contrast radiographs showed urolith recurrence. The mean time plication rate in this study (19%) is well within the range of the to recurrence was 335 d (range: 45 to 856 d). Urolith analysis complication rates reported. It is difficult to compare complica- showed cystine uroliths recovered from 4 surgeries and calcium tion rates between procedures because the levels of complexity of oxalate monohydrate from the remaining 2. the procedures are not similar. Also it is difficult to differentiate a complication truly related to laparoscopy (puncture of spleen Discussion with Veress needle) from a complication related to the surgery Three primary modifications were developed in this study com- itself (stranguria, or urinary incontinence after urolith removal). pared with the previously published technique (3). A temporary For example, Mayhew and Brown (7) reported bleeding for complete cystopexy was performed with the abdominal wall 100% of the ovarian pedicles ligated with clips during ovariec- instead of placement of 4 stay sutures to secure the bladder. The tomy; however, the cause of the bleeding was more likely related goal was to limit manipulation of the bladder and limit the risk to the kind of clips and not the laparoscopy. Complications of contamination of the peritoneal cavity with urine during the related to laparoscopy in our study were puncture of the spleen surgery. A laparoscope with a 5-mm cannula instead of a cysto- by the Veress needle, lack of flow of saline, and uroliths remain- scope was used to gain access to the bladder. The laparoscope ing in the urethra at the end of the procedure. Introduction of does not have a working channel in which to place forceps or the Veress needle to establish pneumoperitoneum resulted in a basket for capturing uroliths. However, the 5-mm cannula splenic laceration in 1 case. Hasson’s technique is an alterna- used to gain access to the bladder allows the creation of a flow tive technique to limit trauma to intra-abdominal organs (6). of saline to flush the uroliths out of the bladder without the In 1 male domestic shorthair cat, the flow of fluid was insuf- need for forceps. Larger uroliths can be grabbed with forceps ficient to provide a clear cystoscopic view. It is important to introduced along the cannula. Unlike the case with the cysto- place the largest diameter urinary catheter possible to create a scope, the forceps operate independently of the laparoscope, good retrograde flow of saline to maintain the necessary urinary making its utilization simple. The 5-mm laparoscope provides bladder inflation during the procedure; however, this might be a larger viewing window and greater image resolution than the difficult in male cats because of the diameter of the urethra. As 2.7 mm cystoscope. Also, utilization of the laparoscope used for an alternative, it would have been possible to use a cystoscope the initial inspection of the abdominal cavity and localization in lieu of the laparoscope and use one of the channels to inflate of the bladder minimizes the amount of equipment required the urinary bladder either in addition to or instead of infusion during the procedure since a cystoscope is not used. Finally, through the urinary catheter (3–5,13). Unfortunately, this

CVJ / VOL 54 / JANUARY 2013 39 FOR PERSONAL USE ONLY ARTICLE

Figure 1. Intra-operative cystoscopic image of calcium oxalate Figure 2. Intra-operative cystoscopic image of the same patient uroliths in the trigone of a 12-kg miniature schnauzer prior to as in Figure 1. The Foley catheter has been removed following extraction with graspers. An 8 French Foley urinary catheter extraction of the uroliths. Exploration of the proximal urethra is in place to provide high-pressure saline flow and bladder can be easily performed with normograde advancement of the distension. laparoscope.

­alternative does not produce a retrograde flow of saline that will A single male Newfoundland dog which had 1 previous flush the uroliths out of the urinary bladder easily. On the con- laparoscopic cystotomy for cystine uroliths, was noted to have a trary, it may also create a forward flow of saline that may push ­single remnant urolith within the urethra visible on postoperative uroliths through the urethra. In another cat the urinary bladder radiographs. This case was then managed with open cystotomy, could not be grasped due to its thickened chronically inflamed allowing successful removal of the urolith. Only 10 cases had wall. The cat had a history of repeated urinary tract obstruc- follow-up radiographs performed to confirm complete urolith tion and had a perineal urethrostomy performed following the removal because a thorough evaluation of the urinary bladder and cystotomy. The use of a more caudal cystoscopic port, placing 2/3 of the urethra in male dogs or the entire urethra in female and positioning the animal in a Trendelenberg position to allow dogs could be completed with the endoscope. At the end of the the urinary bladder to fall as cranial as possible, or placement of procedure, the urinary catheter was removed slowly with a high stay sutures for traction may help to alleviate this concern (14). flow of saline, and the endoscope was simultaneously advanced Finally, in a mixed breed dog with recurrent cystine urolithia- in the urethra to evaluate for residual uroliths. In males the sis, several uroliths were encountered that were too large to be endoscope could not pass the ischiatic curvature. Since a large removed through the cystoscopic window, necessitating conver- diameter urinary catheter and high flow of saline were used, sion to open cystotomy and enlargement of the cystotomy. This there was a high level of confidence that there were no uroliths case was complicated by the chronic cystitis causing significant remaining in the urethra. Postoperative radiographs were taken thickening of the urinary bladder wall. There is a limit to the only when the surgeons were suspicious that uroliths could have size of urolith that can be removed with laparoscopic-assisted been left in the lower urinary tract. Previous reports documented cystotomy. Patients with uroliths larger than 5 to 10 mm may incomplete removal of uroliths in 14% to 20% of cats and dogs not be good candidates for laparoscopic surgery. following routine open cystotomy (19,20). Failure to remove all Postoperative complications were present in 35% of the cases, uroliths was documented in 1 of 10 cases for which postopera- but none were directly related to the laparoscopy procedures. tive radiographs were obtained. Even after laparoscopic-assisted Rectal prolapse and abdominal wall herniation have been cystotomy post-operative radiographs are recommended to make reported previously in cats with urinary obstruction (15,16). sure no uroliths are left in the urinary system. The urethral tear likely occurred during catheterization of the Long-term postoperative recurrence of urolithiasis may be urethra to decompress the urinary bladder in the preoperative attributable to remnant uroliths (pseudorecurrence) and ref- period. Uroabdomen was not diagnosed before surgery because ormation of uroliths. Six cases had documented recurrence of a urinary catheter was maintained until the time of surgery. cystic uroliths with a mean time to recurrence of 335 d. Two The tear was not observed during the cystoscopy. Stranguria of these uroliths were calcium oxalate and 4 were cystine. The and mild urinary incontinence resulting from urethritis and formation of calcium oxalate uroliths typically takes months in cystitis have been reported (17). The animal that developed an the face of persistent lithogenic circumstances. The recurrence of acute pancreatitis underwent intraoperative abdominal radiation cystine uroliths can be very rapid and recurrence within 1 year of therapy at the time of surgery. The etiology of acute pancre- surgical removal is common due to the renal tubular defect that atitis in the dog is not entirely understood; however, surgical predisposes to urolith formation (21,22). Laparoscopic-assisted manipulation/trauma,­ anesthetic-induced ischemia, or radiation cystotomy might help prevent early recurrence/pseudorecurrence damage may all have precipitated this complication (18). of urolithiasis. Magnification of laparoscopy aids visualization of

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A prospective clinical trial would be appropriate to compare out- comes between laparoscopic assisted cystotomy and traditional open cystotomy. CVJ References . 1 Osborne CA, Lulich JP, Kruger JM, Ulrich LK, Koehler LA. Analysis of 451,891 canine uroliths, feline uroliths, and feline urethral plugs from 1981 to 2007: Perspectives from the Minnesota Urolith Center. ARTICLE Vet Clin Small Anim 2008;39:183–197. 2. Low WW, Uhl JM, Kass PH, Ruby AL, Westropp JL. Evaluation of trends in urolith composition and characteristics in dogs with urolithia- sis: 25,499 cases (1985–2006). J Am Vet Med Assoc 2010;236:193–200. 3. Rawlings CA, Mahaffey MB, Barsanti JA, Canalis C. Use of laparoscopic-­ assisted cystoscopy for removal of urinary calculi in dogs. J Am Vet Med Assoc 2003;222:759–761. 4. Rawlings CA. Resection of inflammatory polyps in dogs using laparoscopic-­ assisted cystoscopy. J Am Anim Hosp Assoc 2007;43:342–346. 5. Rawlings CA. Endoscopic Removal of Urinary Calculi. Compendium of Continuing Education for Veterinarians 2009;31:476–484. Figure 3. The laparoscope provides significant magnification 6. Hasson HM, Rotman C, Rana N, Asakura H. Experience with laparo- and increased visualization allowing for more accurate urolith scopic hysterectomy. J Am Assoc Gynecol Laparosc 1993;1:1–11. identification and extraction. Small calcium oxalate uroliths are 7. Mayhew PD, Brown DC. Comparison of three techniques for ovarian noted within the urinary bladder mucosa (black arrows). Compare pedicle hemostasis during laparoscopic-assisted ovariohysterectomy. Vet the urolith size to the tip of the 6 French urinary catheter. Surg 2007;36:541–547. 8. Jiménez Peláez MJ, Bouvy BM, Dupre GP. Laparoscopic adrenalectomy for treatment of unilateral adrenocortical carcinomas: Technique, com- plications, and results in seven dogs. Vet Surg 2008;37:444–453. smaller uroliths (Figure 3). Most of the smaller uroliths observed 9. Gower S, Mayhew PD. Canine laparoscopic and laparoscopic-assisted with cystoscopy adhered to the urinary bladder wall, and suction ovariohysterectomy and ovariectomy. Comp Cont Educ Vet 2008; 30:430–440. via the cannula was used to remove them. 10. Mayhew PD, Mehler SJ, Radhakrishnan A. Laparoscopic cholecystec- Procedural times for laparoscopic-assisted cystotomy could tomy for management of uncomplicated gall bladder mucocele in six not be calculated accurately because several other procedures dogs. Vet Surg 2008;37:625–630. 11. Mayhew PD, Brown DC. Prospective evaluation of two intracorporeally were performed during the same anesthesia in 11 cases. Discrete sutured prophylactic laparoscopic gastropexy techniques compared with procedural start and stop times were not always indicated on laparoscopic-assisted gastropexy in dogs. Vet Surg 2009;38:738–746. anesthetic case logs. The time reported in this study is longer 12. Culp WN, Mayhew PD, Brown DC. The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs. Vet Surg 2009;38: than the surgical time reported for open cystotomy (63 min 6 811–817. 30 min) (19). As with all minimally invasive procedures, there 13. Rawlings CA. Diagnostic rigid endoscopy: Otoscopy, rhinoscopy, and is a significant learning curve that must be overcome by the sur- cystoscopy. Vet Clin N Am Small Anim Pract 2009;39:849–868. 14. Mayhew PD. Advanced laparoscopic procedures (hepatobiliary, endo- geons and technical staff when implementing new techniques. crine) in dogs and cats. Vet Clin N Am Small Anim Pract 2009;39: Different surgeons with various levels of experience performed 925–939. the procedures. The total operative time was used, likely leading 15. Barrand KR. Rectal prolapse associated with urinary bladder neoplasia in a cat. J Small Anim Pract 1999;40:222–223. to an overestimate of the procedural time. 16. Zoran DL. Rectoanal disease. In: Ettinger SJ, Feldman EC, eds. Converting to an open procedure is always a possibility dur- Textbook of Veterinary Internal Medicine. 5th ed. Philadelphia, ing any minimally invasive surgery for the safety of the patient, Pennsylvania: Elsevier, 2005:1408–1420. 17. Labato MA, Acierno MJ. Micturition disorders. In: Ettinger SJ, and should be decided sooner rather than later to minimize Feldman EC, eds. Textbook of Veterinary Internal Medicine. 7th ed. surgical time. Technical difficulties such as chronic cystitis pre- St. Louis, Missouri: Elsevier, 2010:160–164. venting correct manipulation of the bladder, inadequate flow of 18. Steiner JM. Canine pancreatic disease. In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine. 7th ed. St. Louis, Missouri: saline, and size of the uroliths were the reasons for converting Elsevier, 2010:1696–1697. to an open procedure in this study. 19. Bevan JM, Lulich JP, Albasan H, Osborne CA. Comparison of laser Laparoscopic-assisted cystotomy with 3 modifications of lithotripsy and cystotomy for the management of dogs with urolithiasis. J Am Vet Med Assoc 2009;234:1286–1294. the original technique described by Rawlings et al (3,5) for 20. Grant DC, Harper TA, Werre SR. Frequency of incomplete urolith removal of uroliths was accomplished with relative safety and removal, complications, and diagnostic imaging following cystotomy efficacy in cats and dogs of a wide range of sizes. In future, most for removal of uroliths from the lower urinary tract in dogs: 128 cases (1994–2006). J Am Vet Med Assoc 2010;236:763–766. complications could be avoided with better case selection; a key 21. Hoppe A, Denneberg T, Jeppsson J-O, Kågedal B. Canine cystinuria: An factor in the success of minimally invasive surgery. Size of the extended study on the effects of 2-mercaptopropionylglycine on cystine uroliths, size of the patient (diameter of urethra in cats), and urolithiasis and urinary cystine excretion. Br Vet J 1993;149:235–251. 22. Henthorn PS, Liu J, Gidalevich T, et al. Canine cystinuria: Polymorphism chronic cystitis might be factors to consider before attempting in the canine SLC3A1 gene and identification of a nonsense mutation in a laparoscopic-assisted cystotomy for treatment of urolithiasis. cystinuric Newfoundland dogs. Hum Genet 2000;107:295–303.

CVJ / VOL 54 / JANUARY 2013 41 FOR PERSONAL USE ONLY Article

The Ontario Veterinary College Hip Certification Program — Assessing inter- and intra-observer repeatability and comparison of findings to those of the Orthopedic Foundation for Animals

Heather J. Chalmers, Stephanie Nykamp, Assaf Lerer

Abstract — In Canada, the Ontario Veterinary College (OVC) has offered radiographic screening for hip dysplasia for many years, but there are other options for this service including the Orthopedic Foundation for Animals (OFA). There are some differences between the OFA and the OVC methods, and this study compares the OVC and OFA hip certification results in 37 dogs. There was good agreement between the two programs but in some instances there was a difference in the pass/fail status of a dog. Neither the OFA nor the OVC was more likely to fail or pass a given dog. The repeatability of the OVC results was assessed by both inter- and intra-observer com- parisons in 100 dogs. There was at least 86% agreement among and within radiologists, but in 5 cases the disagree- ment resulted in a difference in the pass/fail status of the dog. These results illustrate the inherent variation in radiographic hip evaluation and highlight the importance of consensus grading practices to improve the accuracy of hip evaluation.

Résumé — Programme de certification des hanches de l’Ontario Veterinary College — Évaluation de la reproductibilité inter- et intra-observateur et comparaison des résultats à ceux de l’Orthopedic Foundation for Animals. Au Canada, l’Ontario Veterinary College (OVC) offre le dépistage radiographique de la dysplasie de la hanche depuis de nombreuses années, mais il y a d’autres options pour ce service, incluant l’Orthopedic Foundation for Animals (OFA). Il y a certaines différences entre les méthodes de l’OFA et de l’OVC et cette étude compare les résultats de certification de la hanche de l’OVC et de l’OFA chez 37 chiens. Il y avait une bonne concordance entre les deux programmes, mais dans certains cas, il y avait une différence au niveau du statut d’échec-réussite d’un chien. Ni l’OFA ni l’OVC ne présentait une probabilité accrue de donner un résultat d’échec ou de réussite à un chien particulier. La reproductibilité des résultats de l’OVC a été évaluée par des comparaisons inter- et intra-observateur chez 100 chiens. Il y avait au moins 86 % de concordance entre et parmi les radiologistes, mais dans 5 cas, la discordance s’est traduite par une différence du statut de réussite et d’échec chez le chien. Les résultats illustrent la variation inhérente à l’évaluation radiographique de la hanche et souligne l’importance de pratiques de classification par consensus afin d’améliorer l’exactitude de l’évaluation de la hanche. (Traduit par Isabelle Vallières) Can Vet J 2013;54:42–46

Introduction in reduced range of motion, pain, and lameness (7,8). Early diagnosis of hip dysplasia is essential to facilitate early manage- anine hip dysplasia (CHD) is an important and common ment strategies and to prevent breeding of affected individuals. problem for pet and breeding dogs in Canada and world- C Changes in hip joint congruity and stability may be detected wide. The disease has a known genetic basis and is heritable; on orthopedic examination including the Ortolani sign and however, environmental factors impact the phenotypic expres- Barden test (9–11); however, radiographic evidence is neces- sion and the severity of the disorder in affected individuals sary to determine the nature and severity of the hip dysplasia, (1–6). The disease is progressive, and once initiated can result to assess for secondary degenerative joint disease, and facilitate treatment planning in affected dogs. Dogs with hip dysplasia Department of Clinical Studies, Ontario Veterinary College, may exhibit a range of radiographic findings, with abnormalities University of Guelph, Guelph, Ontario N1G 2W1. including variable degrees of hip joint incongruity, subluxation, Address all correspondence to Dr. Heather J. Chalmers; e-mail: and degenerative joint disease (12). [email protected] Screening programs for hip dysplasia have traditionally Use of this article is limited to a single copy for personal study. involved radiographic assessment of the hip joints of young Anyone interested in obtaining reprints should contact the adult dogs, and there are many such programs available world- CVMA office ([email protected]) for additional wide. These include the Orthopedic Foundation for Animals copies or permission to use this material elsewhere. (OFA) program, Pennsylvania Hip Improvement Program

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(PennHIP), Fédération Cynologique Internationale (FCI), Table 1. The Ontario Veterinary College Hip Certification Program grading system. All radiographs are ventrodorsal (hip extended) the British Veterinary Association hip scheme, the Ontario view and are evaluated by a board-certified veterinary radiologist. Veterinary College Hip Certification program, and numerous The radiographs are systematically assessed for all aspects of hip other breed specific and/or country specific programs. While joint conformation including parallelism between the femoral head and acetabulum, shape of the femoral head and acetabulum, these organizations share the common goals of facilitating coverage of the fermoral head by the acetabulum, evidence of early diagnosis and reducing the incidence of CHD in the dog subluxation, and evidence of degenerative joint disease. The results population, each organization has its own specific methods and of the systematic evaluation for each dog are summarized by ARTICLE grading schemes. As a result, it can be difficult for breeders, assigning a semi-quantitative grade. pet owners, and even veterinarians to compare results between OVC the various programs. It is our impression that the most com- assessment Typical findings Result/Outcome monly used programs in Canada are the OVC Hip and Elbow PASS Certification Program (OVC-HCP), the PennHIP, and the OFA Normal No radiographic evidence of hip Certificate issued. dysplasia, including normal hip program. Of these, the OVC-HCP and the OFA have similar conformation and no evidence systems requiring a ventrodorsal hip extended radiograph of the of degenerative changes. pelvis (13). In addition to the traditional view, PennHIP utilizes FAIL a dynamic radiograph series in which the passive hip laxity is Grade I Minimal or mild change is present No certificate, calculated. In order to perform the PennHIP test, an individual including incongruity of hip joint, a report outlining or reduced coverage of femoral head, radiographic must acquire special training leading to certification (14). or enthesiophyte on femoral neck. findings and stating The OFA is a non-profit organization founded in 1966. The grade is issued. OFA maintains the world’s largest database of radiographic hip Grade II Moderate changes or more than evaluations. Radiographs submitted to the OFA are assessed by one mild change are present. 3 board-certified radiologists; once submitted, the radiographs Grade III More than one moderate change are not returned. The OFA hip grading method consists of is present. 3 main outcomes; pass, borderline, fail. Dogs which receive a Grade IV Severe changes are present. passing score are assigned to 1 of 3 categories: Excellent, Good, or Fair. Dogs which receive a fail score are assigned 1 of 3 grades: Grade 1, 2, or 3, which represent increasing severity. The OFA breeders and veterinarians use 1 program and become more provides certification services on dogs that are a minimum of familiar with interpreting results from that program than from 24 mo of age, and also offers preliminary assessment of younger others. This can create difficulty when a dog from 1 owner for dogs. which the OVC-HCP certificate is available plans a mating with The OVC-HCP has been active for over 25 y, and certifies a dog from another region for which the OFA results are avail- between 1200 and 5000 dogs per year. The program was started able. It is therefore desirable to compare results between pro- largely in response to the need for a Canadian option for breed- grams to assist breeders and veterinarians with decision-making. ers. At that time, breeders found that shipping radiographs to In some cases, it has been necessary to re-submit radiographs of the United States for OFA evaluation resulted in long delays a dog to a second program in order to satisfy all parties that the and increased costs associated with shipping and exchange rates. intended mating involves only orthopedically sound individu- In order to address this need, the OVC began to offer hip and als. This is associated with increased cost for breeders because elbow certification using an OFA style ventrodorsal hip extended of submission fees and in some cases additional radiographs. radiograph of the pelvis, which was evaluated by a board- Because the OFA and OVC-HCP utilize the same radiographic certified radiologist. The program has other distinctions when view and similar assessment criteria, it is desirable to establish compared to the OFA including that only 1 radiologist inter- some basic guidelines that can be used for extrapolation of prets each radiograph, dogs may be certified at a minimum of results between the OFA scoring and the OVC scoring systems. 18 months of age (with preliminary results available in younger The goals of the current study were to i) establish the repeat- dogs), and the original radiographs are returned to the client. ability of the OVC-HCP method by establishing the inter- and From these beginnings, the program has evolved to include an intra-observer repeatability of this method, and ii) determine online searchable database, and at present radiographs submitted the agreement between the OFA and the OVC-HCP results to the OVC-HCP are assessed by 1 of 2 board-certified radiolo- by comparing the findings between the 2 programs in a small gists. The OVC hip grading system has 2 main outcomes: Pass subset of dogs. and Fail. Dogs that receive a fail are assigned to Grade 1, 2, 3, or 4, representing increasing severity of CHD (Table 1). Despite Materials and methods being the only Canadian certification program and being a his- Inter- and intra-examiner repeatability torical favorite of many Canadian breeders, the OVC method A sample of 100 sequential cases submitted to the OVC hip of assessing hips has not been scientifically evaluated to date. screening program were enrolled in the study. Cases were Within the North American purebred dog industry, there excluded from the study if the radiographs were deemed to be is considerable breeding of dogs between provinces and states, of non-diagnostic quality or if the dog was less than 18 mo of and even internationally. Establishing the orthopedic health of a age; these cases were replaced with the next case submission until dog is an essential part of responsible breeding practice. Often, 100 cases were enrolled. These 100 cases were randomized and

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each radiologist completed the evaluation for each dog 3 times pass and received a grade of I-IV hip dysplasia were considered with a minimum of 24 h between readings (total of 6 evalua- to “fail.” The McNemar’s test was used to assess for overall bias tions per dog). For each reading, the radiologist was blinded of the 2 programs, or tendency of 1 program to rate consistently to the previous results and the results of the other radiologist. higher or lower than the other. For both study populations, the In addition to performing the hip certification procedure, the mean age, and sex distribution were compared to those for the radiologist was also asked if they would seek a second opinion general OVC-HCP submissions obtained via database query. on the case. Results Method comparison study Repeatability study

ARTICLE The comparison between the OVC method and the OFA The 100 dogs in this portion of the study consisted of method was performed on 37 subjects, which were different 68 females (64 intact and 4 spayed) and 32 males (29 intact and from the 100 dogs previously described because the method 3 castrated) with a mean age of 21.2 mo (range: 18 to 109 mo). comparison portion of the study was done after the repeat- Breeds represented included Labrador retrievers (n = 29), ability portion. These subjects were taken as a subsample of German shepherd dogs (n = 20), golden retrievers (n = 14), dogs submitted to the OVC-HCP, with the inclusion criterion Bernese mountain dogs (n = 7), rottweillers (n = 3), poodle- for participation in the study being dogs of at least 2 y of age standard berger allemande (n = 2), (n = 2), Labrador retriever and client consent during the study period (December 2010 — crosses (n = 8), and 1 dog of each of 15 other breeds (löwchen, July 2011). Participation was solicited by posting the research American cocker spaniel, bull mastiff, Alaskan malamute, project information on the OVC-HCP Web site and also by Samoyed, Portugese water dog, Irish setter, Newfoundland, direct telephone or e-mail communication to clinics with a high border terrier, rough collie, smooth collie, weimaraner, German submission rate to the program. Each radiograph was routinely wire-haired pointer, Australian kelpie, great dane, greater Swiss read and graded by the radiologist on duty without knowledge mountain dog). The mean age and gender distribution did not of enrollment in the study. The assessment method is familiar differ from the means of the general submissions for the year to both radiologists participating in the study and is unmodified of the study. from the assessment method for routine submissions. Based on For the 100 dogs evaluated, the grade assigned to the dog was the radiograph, dogs were be assigned to 1 of the OVC-HCP the same for all 6 observations a total of 86 times. Of the 14% grade categories (Table 1). of the time that there was any disagreement about the grade of The same radiographs were scanned and digitally submitted a dog, this resulted in disagreement about the pass/fail status of to the OFA for routine evaluation. This was performed with the dog in 5/14 cases (35.7%). In 12/14 (85.7%) of the cases consent of the OFA administration, and the OFA radiologist where there was disagreement regarding the grade, 1 or both reading the cases was unaware of the study. The OFA results radiologists stated that they would seek a second opinion. The were collected and categorized according to the standard OFA most common type of disagreement either between or within scale (http://www.offa.org/hd_grades.html). The OFA evalua- observers was between grade I and grade II status (64.2% of all tion was unmodified from a routine submission except that only disagreements), and of the 5 cases in which the disagreement 1 radiologist read each case. resulted in a difference in pass/fail status 4/5 were differences between grade I and normal and 1/5 was a difference between Statistical methods grade II and normal. The kappa for seeking a second opinion, For the quantification of inter-observer repeatability within representing the instances in which both radiologists sought a the OVC method, the intra-class correlation coefficient was second opinion on the same case, was 0.26. One radiologist calculated. Standard 2 3 2 tables were constructed for pass/fail was significantly more likely to seek a second opinion than between the 2 observers and for the need for a second opinion, the other (P , 0.05). The combined occurrence of seeking a and basic summary statistics were calculated. For the intra- second opinion was 19/100 (19%), with 14/19 (73.6%) being observer repeatability, the kappa statistic was calculated with sought by 1 radiologist and 5 being sought by the other radi- the most common response of each radiologist being used for ologist. There was no difference between the 2 radiologists in the comparison. With regards to the choice to seek a second the frequency of assigning the various grades. The kappa for opinion, the kappa statistic was also calculated to compare inter-observer agreement for each observation was observation the agreement between the 2 radiologists about the need for a 1: 0.742, observation 2: 0.770, and observation 3: 0.787 (Fleiss- second opinion. For the ordinal data, the OFA and OVC-HCP Cohen weighted kappa, squared weighting P , 0.0001 for all results were compared using a kappa statistic. For both the 3 observations). For the intra-observer agreement, the intra-class OVC-HCP and the OFA, the results were dichotomized for correlation coefficient was 0.78. part of the analysis to determine the differences between the hip status of “pass” or “fail” between the 2 programs. For the OFA, Method comparison study the grades were dichotomized such that OFA grade excellent, The 37 dogs consisted of 12 intact males and 25 intact females good, fair were considered equivalent to “pass” and OFA bor- with a mean age of 36.7 mo (range from 24 to 74 mo). The derline, mild, moderate, and severe were considered equivalent mean age was significantly different from the mean age of to “fail.” For the OVC-HCP, the dogs that passed and received a the general submissions of the year of the study (P = 0.002). certification were considered to “pass” and the dogs that did not Breeds represented included golden retrievers (n = 4), Labrador

44 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Table 2. Results of OVC-HCP and OFA assessment in 37 dogs submitted for certification Results of OFA assessment Excellent Good Fair Borderline Mild Moderate Results of OVC-HCP assessment Pass 2 25 2 0 0 0

Grade I 0 2 2 0 0 0 ARTICLE Grade II 0 0 0 0 2 0 Grade III 0 0 0 0 1 2

­retrievers (n = 3), Shetland sheepdogs (n = 3), Irish water (17). A study that focused on agreement of the FCI method spaniels (n = 2), Alaskan malamutes (n = 2), Nova Scotia duck showed that inexperienced observers have poor agreement tolling retrievers (n = 2), and 1 of each of 21 other medium (ICC up to 0.44), while more experienced observers have good and large breeds. agreement (ICC up to 0.72) (18). In human medicine, the ICC The OVC radiologists gave 29/37 dogs a pass and 8/37 dogs for various radiographic hip scores range from poor (0.49) to a fail. Of the dogs that received a fail score from the OVC-HCP, excellent (0.97), with most studies reporting good repeatability 4 dogs received a Grade 1 score, 2 dogs received a Grade 2, and (19,20). The wide range of results for agreement and the vari- 2 dogs received a Grade 3 score (Table 2). No dog received able interpretation of what should be considered acceptable Grade 4 score. The OFA gave 33/37 dogs a passing score and agreement complicate the interpretation of the current results. 4/37 dogs a failing score. No dog was given a borderline score. One important difference between the OFA and the OVC- Out of the dogs that received a passing score, 2 dogs received HCP is that with the OFA program, each radiograph is evalu- an excellent score, 27 dogs received a good score, and 4 dogs ated by 3 radiologists while at the OVC only 1 of 2 radiologists received a fair score. From the dogs that received an OVC-HCP performs the evaluation on any given dog although a second fail score, 3 dogs received Grade 1, and 1 dog received Grade 2. opinion may be sought informally. As such, it is important All the dogs which received a fail score by the OFA also received to establish the inter-observer repeatability of the OVC-HCP a fail score by the OVC, 4 dogs that received a passing score by scoring to ensure that the results are reliable between the 2 radi- the OFA received a fail score by the OVC; 2/4 of these dogs ologists. Of the 100 dogs evaluated here, the radiologists gave received an OFA grade score of good, and 2/4 dogs received an the same score 86% of the time. Of the 14 dogs in which the OFA grade score of fair. 2 radiologists did not agree about hip score, this resulted in a When the dichotomized pass/fail status of the dog is con- difference in the pass/fail status of 4 dogs. However, in all of sidered, the kappa between OVC-HCP and OFA = 0.6105 these cases 1 or both radiologists indicated that she/he would [P = 0.0011, 95% confidence interval (CI): 0.2785 to 0.9425]. seek a second opinion before deciding on the final score for the McNemar’s test of bias was not significant (P = 0.5). The odds dog. This reinforces the importance of the practice of seeking a ratio for passing OFA and failing OVC-HCP is 5.3 (median second opinion and implies that there may be some benefit in unbiased estimate, 95% CI: 0.66 to 157.5). implementing a more formal requirement for a second opinion as is routine with the OFA. This may include measures such as Discussion requiring 2 observers for each submission, or formalizing the Early and accurate screening for CHD is an essential component process of seeking a second opinion. of canine breeding programs and several screening options are Factors that affect inter- and intra-observer repeatability available to Canadian veterinarians and breeders. Radiographic of OVC-HCP hip certification results could include techni- assessment and measurements form the foundation of virtually cal quality of the radiographs (20), the individual set points/ all of these programs and the results are used by veterinarians criteria of a given observer, experience of the observer, and bias and breeders to advance the orthopedic status of dogs through relating to knowledge of information such as breed or age. In responsible breeding. In this study, we compared the hip joint the present study, only radiographs of adequate technical qual- grading score of the OVC-HCP and the OFA program. Both ity are accepted by OVC-HCP and were included in the study. methods are based on a semi-quantitative evaluation of an Additionally, the 2 observers are of similar experience and extended coxofemoral joint in ventrodorsal view and are com- training and were blinded to the signalment information for the monly used in Canada. dogs. The observed differences are therefore most likely attribut- Overall, the correlation between the grading score provided able to differences in the opinion and set points of the 2 radiolo- by the 2 radiologists at OVC is categorized as good, as reflected gists. This type of difference of opinion is well-­recognized in by the ICC of 0.78 (15). There have been multiple studies medical imaging as a common source of disagreement. assessing the repeatability of the various hip dysplasia scoring The comparison of various hip screening methods has been methods. For the PennHIP method, the ICC was reported by widely studied by many parties, with the aim of establishing the PennHIP researchers to be between 0.85 and 0.94 (16) and which test is a more accurate predictor of the long-term hip sta- more recently was reported to be as high as 0.96 (17). These tus of the dog in order to make a recommendation of 1 program authors have concluded that the PennHIP scores obtained by over another. In the current study, this was not the goal and various trained observers could be considered interchangeable the 2 programs are not being compared in order to determine

CVJ / VOL 54 / JANUARY 2013 45 FOR PERSONAL USE ONLY

which is superior, but rather in order to allow some understand- and between radiologists participating in the program and that ing of differences between the programs. A gold standard in where there is lack of agreement, this rarely results in a change establishing the true hip status of a given dog was not available in the pass/fail status of a dog. The needs of veterinarians and in this study; therefore, the results from the 2 programs cannot the breeding industry are best served by those programs which be compared to each other for assessing which results are more provide interpretation in an accurate and repeatable manner and correct relative to a gold standard. Rather, these comparisons are the current work demonstrates that both programs are suitable made to establish the correlations between the 2 grading schemes for this purpose. CVJ in order to broaden current understanding of both programs and facilitate extrapolation of results between the 2 programs References ARTICLE where necessary. . 1 Chase K, Lawler DF, Carrier DR, Lark KG. Genetic regulation of osteo- Guidelines for extrapolation between the 2 programs, rec- arthritis: A QTL regulating cranial and caudal acetabular osteophyte ognizing the inherent limitations, would be desirable. It is formation in the hip joint of the dog (Canis familiaris). Am J Med important to note that the current study assessed only dogs Genet A 2005;135:334–335. 2. Chase K, Lawler DF, Adler FR, et al. Bilaterally asymmetric effects of 24 mo of age or older. The OVC-HCP performs certifications quantitative trait loci (QTLs) that affect laxity in the right versus left on dogs as young as 18 mo, and the OFA performs preliminary hip joints of dogs. Am J Med Genet 2006;124:239–247. certification on dogs younger than 24 mo, but the comparison 3. Lust G, Rendano VT, Summer BA. Canine hip dysplasia: Concepts and diagnosis, J Am Vet Med Assoc 1985;187:638–640. between results for dogs younger than 24 mo has not been 4. Hedhammar A, Wu FM, Krook L, et al. Overnutrition and skeletal evaluated here. The results of this study, therefore, cannot be disease. 1974;64Suppl 5:32–45. applied to younger dogs. While the current study identified a 5. Corley EA. Role of the orthopedic foundation for animals in the control of canine hip dysplasia. Vet Clin North Am Small Anim Pract minority of dogs that received a “pass” grade at the OFA and a 1992;22:579–93. “fail” grade from OVC-HCP, the McNemar’s test of bias was not 6. Kaneene JB, Mostosky UV, Miller R. Update of a retrospective cohort significant indicating that there is no preferential direction to study of changes in hip joint phenotype of dogs evaluated by the OFA in the United States, 1989–2003. Vet Surg 2009;38:398–405. the disagreement between the OFA and the OVC-HCP. Neither 7. Alexander JW. The pathogenesis of canine hip dysplasia. Vet Clin North program is more likely to pass or fail a given dog, and there is Am Small Anim Pract 1992;22:503–511. no bias or differential rate of pass or fail between the 2 programs 8. Lust G. An overview of the pathogenesis of canine hip dysplasia. J Am Vet Med Assoc 1997;210:1443–1445. that could be detected in this sample. However, based on the 9. Lust G, Summers BA. Early, asymptomatic stage of degenerative joint odds ratio, the odds of the OFA passing a dog that was failed disease in canine hip joints. 1981;42:1849–1855. by OVC-HCP is 5.33 higher than the odds of a dog failing the 10. Lust G, Beilman WT, Dueland R, et al. Intra-articular volume and hip joint instability in dogs with hip dysplasia. J Bone Joint Surg Am OFA and passing the OVC-HCP assessment. Another important 1980;62:576–582. distinction between the 2 programs is that the OFA provides a 11. Lust G, Beilman WT, Rendano VT. A relationship between degree of grade within both passing and failing cases. This may be very laxity and synovial fluid volume in coxofemoral joints of dogs predis- posed for hip dysplasia. Am J Vet Res 1980;41:55–60. useful for breeders, who could decide what level within a pass- 12. Slatter DH, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, ing grade is acceptable for their own standards. For example, a Pennsylvania: Elsevier Science, 2002:2009–2019. dog receiving an OFA score of “fair” is considered to be a pass 13. Rendano VT, Ryan G. Canine hip dysplasia evaluation. Vet Radiol 1985;26:170–186. in the current project; however, many breeders would make 14. Fluckiger MA, Friedrick GA, Binder HA. Radiographic stress technique the commitment that only dogs of good or excellent status are for evaluation of coxofemoral joint laxity in dogs. Vet Surg 1999;28:1–9. used for breeding. The provision of a grade of normalcy within 15. Portney LG, Watkins MP. Foundations of clinical research applications to practice. Upper Saddle River, New Jersey: Prentice Hall, 2000: the OFA system is likely an advantage over the OVC system, in 560–567. which the radiologist makes a pass/fail distinction and a grade 16. Smith GK, LaFond E, Gregor TP, Lawler DF, Nie RC. Within- and is only provided for the failures. between-examiner repeatability of distraction indices of the hip joints in dogs. Am J Vet Res 1997;58:1076–1077. Among responsible breeders and veterinarians there is con- 17. Ginja MM, Ferreira AJ, Silvestre M, Gonzalo-Orden JM, Llorens-Pena MP. tinued emphasis on the prevention of heritable diseases such as Repeatability and reproducibility of distraction indices in PennHIP CHD through good breeding practices. The hip certification examinations of the hip joint in dogs. Acta Vet Hung 2006;54:387–392. 18. Verhoeven GEC, Coopman F, Duchateau L, et al. Interobserver programs play a key role in providing accurate results about agreement on the assessability of standard ventrodorsal hip-extended hip dysplasia and other heritable conditions with the common radiographs and its effects on agreement in the diagnosis of canine hip goal of improving the genetic health of dogs. The current study dysplasia and on routine FCI scoring. Vet Radiol Ultrasound 2009; 50:259–263. provides some validation of the repeatability of the OVC-HCP 19. Mast NH, Impellizzeri F, Keller S, Leunig M. Reliability and agree- and offers some examples of how the grading schemes between ment of measures used in radiographic evaluation of the adult hip. Clin the OVC-HCP and the OFA can differ, and demonstrates that Orthop Relat Res 2011;469:188–199. 20. Clohisy JC, Carlisle JC, Trousdale R, et al.. Radiographic evalu- results from 1 program consistently compare to the other with- ation of the hip has limited reliability. Clin Orthop Relat Res out bias. The findings support that there is consistency within 2009;467:666–675.

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Book Review Compte rendu de livre

Medical Mathematics and Dosage which covers calculating intravenous infusions. I had expected Calculations for Veterinary Professionals this chapter to especially cover constant rate infusions and multiple-drug CRIs (e.g., MLK drips), but was disappointed Bill R. Wiley-Blackwell, Ames, Iowa, USA. 2009. ISBN to find that this wasn’t the case. The chapter thoroughly cov- 9780-8138-2363-8. $36.79. ers calculating drip rates using an IV administration set, an absolutely essential skill that all veterinary professionals should hen I saw this book title available for review, my curios- master. It then barely skims over calculating infusion rates when W ity was piqued as I wondered how medical mathematics adding drugs to IV fluids, and does so mostly from a manual for veterinary professionals alone could fill a grand 425-page, drip rate point of view. Next, the author explores the concept of 10-chapter book. This is partly because a solid 170 pages of “shock rates” and “shock doses” — a concept in the emergency this book, chapters 1–5, painstakingly cover some of the most and critical care world whose days are numbered as this concept elementary mathematical concepts and techniques. These intro- has fallen out of favor and been replaced by small volume fluid ductory chapters cover an initial self-assessment, followed by a resuscitation and goal-oriented end points of resuscitation. review of decimal numbers, fractions, percentages, and solving Based on my disappointment in this chapter, the author would for “x”. do himself well by spending time in his teaching hospital’s ICU On many occasions throughout the first half of this book, prior to releasing the third edition of this book. I found myself questioning how any veterinary professional The last chapter cleans up some loose ends and covers the could possibly get to this point in their career and need to review very important concept of dilutions in a very appropriate and these sort of rudimentary mathematics. If you haven’t gained easy to follow manner that may be helpful to many who have these basic math skills by this point, you need a lot more help difficulty with this concept. There is then a quick review of than this book could ever offer. For example: “Add or subtract converting temperature values (Celsius versus Fahrenheit), that the following decimal numbers: 1.5 1 2 =”, “Simplify the fol- would seem to be more appropriate in chapter 6 (measurement lowing fractions: 4/16” and “Convert the following fractions units) and an explanation of Roman numerals, also something to decimal numbers: 3/4”. While I question the need for such that should be covered in earlier review chapters. an exhaustive review, these chapters are technically sound and All chapters throughout the book provide various mathemati- thorough and provide a solid base for simple medical calcula- cal techniques, methods, shortcuts, and ways to simplify math- tions to follow. ematics which may prove useful to some readers. Each chapter Chapter 6 leans towards more practical medical topics and begins with very clearly stated objectives and, for the most part, discusses measurement units (metric versus non-metric) and each chapter meets these objectives. Every section within each simple dosage calculations. However, there is still a numbing chapter provides ample practice questions replete with an answer 13 pages of how to convert body weights between pounds and key. Each chapter concludes with additional practice problems kilograms, described in exhaustive detail using the “proportion but answers are not provided. method” versus the “cancel-out method”. Overall, this is a mostly technically sound book with some After that, things start to improve practically as the author important basic medical mathematics concepts. Although this begins to explore more clinically relevant topics. Chapter 7 book will be nowhere near a bestseller in the veterinary textbook moves away from mathematical calculating and explores drug category, it may be helpful to those who have struggled with orders (dose, route, and dose interval) and drug labels replete math to this point in their career. On the negative side is the with a valuable “Best practices for writing drug orders” sugges- lack of CRI calculations, my concerns with “shock doses,” some tion and how to handle unclear drug orders that all members minor typos and the occasional confusing statement that may of the veterinary team could benefit from reviewing. Although turn off some mathematically challenged readers (e.g., “remem- this chapter moves away from the underlying theme of the book, ber to convert the amount of drug per dose into the number of there are a variety of tidbits from this chapter that will be a good dose units per dose before determining the total dose units to review for most veterinary professionals and some interesting be dispensed!”). I would find it hard to recommend this book gems that may be new to some. (or justify the cost) to anyone who has a decent grasp of basic Finally, in chapter 8, day-to-day, clinically relevant math- medical math skills and knowledge. ematical topics of dose calculation and syringe measurement are explored. These will cover many of the dose/dosage math Reviewed by David Eisenbart, DVM, CARE Centre Animal basics used by doctors and technologists in everyday practice. Hospital, 7140–12th Street SE, Calgary, Alberta T2H 2Y4. My interest, having worked in emergency small animal prac- tice for several years, was supposed to be satisfied by chapter 9

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THE ONE AND ONLY *The opinions expressed above do not necessarily reflect Boehringer Ingelheim *The opinions expressed above do not necessarily reflect Boehringer Ingelheim THE ONE AND ONLY (Canada) Ltd.’s view of dogs and cats. Choice of the greatest members of the (Canada) Ltd.’s view of dogs and cats. Choice of the greatest members of the animal animal kingdom rests solely with the pet owner. kingdom rests solely with the pet owner.

®Metacam is a trademark of Boehringer Ingelheim Vetmedica GmbH. FOR PERSONAL USE ONLY Article

Nutritional and microbial analysis of bully sticks and survey of opinions about pet treats

Lisa M. Freeman, Nicol Janecko, J. Scott Weese

Abstract — The objectives of this study were to measure the caloric density of bully sticks, to analyze the bully sticks for bacterial contamination, and to assess owner opinions about these and other pet treat products. Mean caloric density was 15 kcal/inch (38 kcal/cm) [range: 9 to 22 kcal/inch (23 to 56 kcal/cm), 2.96 to 3.07 kcal/g]. Of 26 bully sticks that were tested for bacterial contamination 1 (4%) was contaminated with Clostridium difficile, 1 was con- taminated with methicillin-resistant Staphylococcus aureus (MRSA), and 1 with a tetracycline resistant Escherichia coli.

Résumé — Analyse nutritionnelle et microbienne des bâtonnets en peau de buffle et sondage d’opinion à propos des gâteries pour animaux de compagnie. Les objectifs de cette étude consistaient à mesurer la densité calorique des bâtonnets en peau de bovin, à analyser les bâtonnets en peau de bovin pour une contamination bactérienne et à évaluer les opinions des propriétaires à propos de ces gâteries et d’autres gâteries pour animaux de compagnie. La densité calorique moyenne était de 15 kcal/pouce (38 kcal/cm) [écart : de 9 à 22 kcal/pouce (de 23 à 56 kcal/cm), de 2,96 à 3,07 kcal/g]. Parmi les 26 bâtonnets en peau de bovin qui ont été testés pour une contamination bactérienne, 1 (4 %) était contaminé par Clostridium difficile, 1 était contaminé par Staphylococcus aureus résistant à la méthicilline (SARM) et 1 par Escherichia coli résistant à la tétracycline. (Traduit par Isabelle Vallières) Can Vet J 2013;54:50–54 Introduction Obesity is a common problem in dogs and, in the authors’ clinical experience, most owners do not consider treats to con- et treats are a fast-growing segment of the pet food indus- tain a significant number of calories. Therefore, owners may try. There are many types of pet treats, including hard P be unknowingly providing additional calories to their dogs by biscuits, soft treats, and edible manufactured bones. There is a feeding bully sticks. wide variety of treats derived from parts of animals other than Another possible concern for bully sticks and other similar skeletal muscle. These include familiar products that have been treats is bacterial contamination. Outbreaks of human salmo- on the market for many years, such as cattle hooves or skin nellosis have been associated with contact with contaminated (i.e., rawhide chews) and pig ears, but now range from lungs to pig ears (contamination rates between 41% to 51%) (1–3). A tracheas to hearts. One treat for dogs is the bull or steer penis, more recent study showed that the prevalence of Salmonella commonly known as “bully” or “pizzle” sticks. contamination had decreased substantially to 4% but resis- There are a number of potential concerns with bully sticks tance remained a problem with isolates having resistance to and other treats. One is as an additional source of calories. 7 antimicrobials (4). Similar studies on bacterial contamina- tion and resistance patterns have not been published for bully sticks. Furthermore, recent identification of emerging issues Department of Clinical Sciences, Tufts Cummings School of of community-associated Clostridium difficile and methicillin- Veterinary Medicine, North Grafton, Massachusetts, USA resistant Staphylococcus aureus (MRSA) infection in humans (Freeman); Department of Population Medicine (Janecko), (5–7) and identification of these pathogens in retail food prod- Department of Pathobiology and Centre for Public Health and ucts (8–12) raise the question of whether pet treats might be Zoonoses (Weese), Ontario Veterinary College, University of sources of exposure. Guelph, Guelph, Ontario. Finally, in the authors’ clinical experience, many pet own- Address correspondence to Dr. Lisa Freeman; e-mail: ers and even veterinarians appear to be unaware of what pet [email protected] treats are made of, particularly in the case of bully sticks. Presented, in part, at the American Academy of Veterinary Understanding potential risks and owner perceptions about Nutrition Symposium, June 15, 2011, Denver, Colorado, USA. treats may enhance communication with dog owners. Therefore, Use of this article is limited to a single copy for personal study. the purpose of this study was to measure the caloric density of Anyone interested in obtaining reprints should contact the bully sticks and to analyze these products for bacterial con- CVMA office ([email protected]) for additional tamination. In addition, a survey was performed to assess owner copies or permission to use this material elsewhere. opinions about pet treats, including bully sticks.

50 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Materials and methods was conducted using Christensen’s urea, triple sugar iron, and agglutination in Salmonella O antiserum Poly A-I & Vi (all from A convenience sample of 26 bully stick treats was purchased Becton Dickinson). from retail outlets in the United States (n = 16) and Canada For E. coli, 50 mL of the BPW mixture was combined with (n = 10). Although some of the treats were produced by the 50 mL of double strength E. coli broth (Becton Dickinson) same manufacturers, all were different products (i.e., 26 differ- and incubated at 37°C for 18 to 24 h. A loopful of rinse ent brands). A sample of each available bully stick product was was plated on Eosin Methylene Blue agar (Becton Dickinson) ARTICLE purchased for each retail outlet visited to avoid selection bias. and incubated at 37°C for 18 to 24 h. Presumptive E. coli Five 5- to 7-inch (13- to 18-cm) bully sticks purchased in the colonies were transferred to MacConkey agar for purifica- United States were randomly selected and submitted for proxi- tion and incubated at 37°C for 18 to 24 h. Isolated E. coli mate analysis at a commercial laboratory (Eurofins Scientific, colonies were transferred onto tryptic soy agar plates and Des Moines, Iowa, USA). Total length, diameter, and weight incubated at 37°C for 18 to 24 h. Confirmation testing of each stick were recorded, and crude protein, crude fat, crude of E. coli was conducted using Kovac’s indole spot reagent fiber, moisture, and ash were analyzed. Non-fiber carbohydrate (Remel, Ottawa, Ontario) and Simmon’s citrate agar (Becton was calculated (100-moisture-crude protein-crude fat-crude Dickinson). Antimicrobial susceptibility testing for E. coli iso- fiber-ash), and the kilocalories (kcal) per gram were calculated lates was conducted using an automated broth microdilution using modified Atwater factors on an as-fed basis (13). Using system (Sensititre, Trek Diagnostic Systems, East Grinstead, kcal/g, weight, and length, the kcal/treat and kcal/inch (kcal/cm) West Sussex, United Kingdom). The National Antimicrobial were calculated. Resistance Monitoring System (NARMS) susceptibility panel Microbiological testing was performed on all 26 treats. Treats CMV1AGNF was used with methods described by the Canadian were tested for the primary organism of interest (Salmonella Integrated Program for Antimicrobial Resistance Surveillance spp.), but also for Clostridium difficile, MRSA, and generic (CIPARS) (14,15). The breakpoints for resistance are those Escherichia coli. Antimicrobial susceptibility testing of E. coli used by CIPARS and NARMS, which were derived from the isolates was also performed. Clinical and Laboratory Standards Institute (CSLI) where avail- A sample of approximately 10 g was inoculated into approxi- able (14,15). A lower breakpoint for ceftriaxone was used in this mately 30 mL of C. difficile moxalactam norfloxacin (CDMN) study, and is adapted from the CLSI Informational supplement broth (Oxoid, Nepean, Ontario) with 0.1% sodium taurocholate M100-S20 (16). and incubated anaerobically at 37°C for 7 d. An aliquot of the For molecular typing, C. difficile isolates were typed by PCR broth was alcohol shocked with an equal volume of anhydrous ribotyping, as described elsewhere (17). When the ribotype ethanol for 1 h. This mixture was then centrifuged for 10 min was known to be a recognized international ribotype through at 3980 3 g. The supernatant was discarded and the pellet was previous typing of reference strains from the Public Health streaked onto a CDMN agar plate and incubated anaerobically Laboratory Service Anaerobic Reference Unit, Cardiff, UK, at 37°C for 48 h. Suspicious colonies were subcultured onto the appropriate numerical designation (i.e., 078) was used. blood agar and confirmed as C. difficile by Gram stain appear- Otherwise, internal nomenclature was used. Genes encoding ance, colony morphology, characteristic odor, and production production of toxins A (tcdA) and B (tcdB) were evaluated using of L-proline aminopeptidase. polymerase chain reaction (PCR) (18,19). Detection of CDT Another sample of approximately 10 g was inoculated into (binary toxin) was performed using PCR directed at cdtB, the 30 mL of enrichment broth consisting of 10 g tryptone/L, binding component (20). 75 g sodium chloride/L, 10 g mannitol/L, and 2.5 g of yeast The MRSA isolates were typed by sequencing of the X region extract/L. After 24 h incubation at 35°C, 5 to 10 mL of broth of the protein A gene (spa typing) (21) and classified using the were inoculated onto MRSA chromogenic agar (Becton Ridom system (22). Real-time PCR was used to detect the lukF Dickinson, Franklin Lakes, New Jersey, USA). Plates were and lukS Panton-Valentine leukocidin genes (23). Positive and incubated at 35°C and read after 24 h and 48 h. Isolates were negative controls were performed with each PCR run. identified as S. aureus by colony morphology, Gram stain A 20-question Web-based survey was developed with the appearance, catalase reaction, coagulase reaction, and S. aureus assistance of the Tufts University Office for Institutional latex agglutination test (Bio-Rad Laboratories, Mississauga, Research and contained questions regarding the participant’s Ontario). Methicillin-resistance was confirmed by penicillin pet ownership, opinions regarding dog foods and treats, and par- binding protein 2a latex agglutination test (Oxoid). ticipants’ background (survey available from the corresponding Salmonella and E. coli testing was performed following author upon request). Respondents were also asked to indicate pre-enrichment of treats in buffered peptone water (BPW) at if they were a veterinarian, veterinary technician, or dog breeder; 37°C for 24 h. For Salmonella, 0.1 mL of the BPW mixture this category is referred to as “professional category” hereafter. was inoculated into modified semi-solid Rappaport-Vassiliadis The study was reviewed and approved by Tufts University’s agar (Oxoid) and incubated at 42°C for 24–72 h. Presumptive Institutional Review Board. The survey was posted online for colonies were plated on MacConkey agar (Becton Dickinson) public participation for 60 d. A survey was considered to be and xylose lysine tergitol 4 agar (Oxoid) and incubated at 37°C complete if $ 80% of the questions were answered. No incen- for 24 h, and non-lactose fermenting colonies were inoculated tive was offered for participation in the survey, and all responses on tryptic soy agar (Becton Dickinson). Biochemical testing were anonymous.

CVJ / VOL 54 / JANUARY 2013 51 FOR PERSONAL USE ONLY

Data were examined graphically. Data are presented as Table 1. Answers from 752 respondents to the question, 6 “Which of the following is an accurate description of bully sticks?” mean standard deviation (SD) (normally distributed data) (total number with percentage in parentheses) or median and range (skewed data). Results were compared by subcategories using Chi-squared analysis. Percent comparisons Bull penis 418 (55.6%) Cow tendon 154 (20.5%) were calculated from the total survey respondents answering the Cow muscle 47 (6.3%) individual question, unless otherwise stated. All analyses were Rolled up sheep skin 8 (1.1%) performed using commercial statistical software (Systat 12.0; Didn’t know 115 (15.3%) Other 10 (1.3%) SPSS, Chicago, Illinois, USA).

ARTICLE Results and 295 (37.3%) avoided grains. Sixty-nine respondents (8.7%) Mean caloric density of the 5 bully sticks was 3.01 kcal/g (range: listed other ingredients that they avoided which included artifi- 2.96 to 3.07 kcal/g). Based on the variable length (mean = cial colors, beet pulp, chicken, beef, ingredients from China, soy, 5.71 6 0.71 inches or 14.49 6 1.80 cm) and diameter (mean = lamb, genetically modified organisms, garlic, wheat gluten, sugar, 2.17 6 0.34 inches or 5.50 6 0.86 cm), this resulted in a mean dairy, carbohydrates, cheese, chemicals, citric acid, and rosemary. total caloric density of 88 kcal/treat (range: 45 to 133 kcal/treat) When asked what was contained in pet food by-products, or 15 kcal/inch (range: 9 to 22 kcal/inch). most of the 773 respondents who answered this question One of 26 samples (4%) was positive for Clostridium difficile. (n = 674; 87.2%) answered correctly that internal organs were The isolate was a toxigenic strain with a ribotype pattern that included (13). However, many also responded that ingredients has not been previously identified in the authors’ collection of that are specifically prohibited from by-products [Association isolates from animals, food, and humans. One other sample of American Feed Control Officials (AAFCO) Feed Ingredient (4%) was positive for MRSA. The isolate was spa type t011, a Definition 9.3 (13)] were included, such as hooves (466; sequence type 398 (ST398) strain. Generic E. coli were isolated 60.3%), horns (366; 47.4%), feces (167; 21.6%), road kill (103; from 7 of 26 samples (27%). Of these 7 isolates, 1 was resistant 13.3%), and euthanized pets (99; 12.8%). Veterinarians and to tetracycline and the other 6 were pan-susceptible to the veterinary technicians were less likely than other professional antibiotics tested. categories (breeders and general respondents) to incorrectly The survey was completed by 852 adults from 44 US states respond that by-products contain these other items. and 6 countries. Most respondents (791; 92.8%) were dog own- Two hundred forty-three dog owners (30.7%) fed rawhide ers and female (738; 86.6%). Professional categories included chews to their dogs and 180 (22.8%) fed bully sticks. Of the veterinarians (n = 81), veterinary technicians (n = 66), and respondents who fed bully sticks, 71% also stated that they dog breeders (n = 112). Most respondents (n = 483; 57.2%) avoided by-products. Four hundred eighteen of the 752 respon- answered that ingredients were the most important factor when dents for this question (55.6%) correctly identified that bully choosing a dog food. Other answers included recommendation sticks were derived from bull penis but a variety of other from a veterinarian (n = 205; 24.3%), recommendation from a responses also were provided (Table 1). Of the respondents who breeder (n = 60; 7.1%), the label says it is most appropriate for fed bully sticks, 28% did not correctly identify the source of the individual dog/breed (n = 29; 3.4%), convenience (n = 29; bully sticks. While a higher proportion of veterinarians (62%) 3.4%), price (n = 28; 3.3%), and recommendation from a pet correctly identified the source of bully sticks compared to gen- store (n = 10; 1.2%). Respondents’ primary source of infor- eral respondents (44%; P = 0.006), 38% of veterinarians had mation for nutritional advice was the veterinarian (n = 381; incorrect responses to this question. 45.2%), the internet (n = 133; 15.8%), breeder/trainer (n = 95; Calories in a 120 bully stick were underestimated by 50% 11.3%), books/magazines (n = 58; 6.9%), veterinary clinic of respondents. Fifty percent correctly answered 150 kcal but staff (n = 47; 5.6%), friends/family (n = 42; 5.0), pet store staff 38% answered 70 kcal, 9% answered 20 kcal, and 3% answered (n = 18; 2.1%), and other (n = 68; 8.1%). A lower propor- 0 kcal. Veterinarians had a higher rate of correct responses (62%) tion of breeders (17%) reported that their primary source of compared with all other professional categories. Potential risks information was the veterinarian compared with any of other of bully sticks were also questioned in the survey. The most professional categories (general respondents: 43%; veterinarian frequent response from the 812 respondents on this question technicians: 68%; veterinarians: 80%; P , 0.001). was that they can get stuck in the stomach or intestine (n = 697; For respondents who were dog owners (n = 791), the survey 85.8%). Response rate to other potential risks included: they asked the type of food that composed the largest proportion can be contaminated with bacteria (n = 477; 58.7%), they can of the diet and any foods that were included in the dogs’ diets. break a dog’s teeth (n = 242; 29.8%), they can contain antibiot- Most respondents fed dry food as the major component of the ics (n = 106; 13.1%), and they have no risks (n = 34; 4.2%). diet (663; 83.8%), but 85 (10.8%) fed either a commerical or homemade raw meat diet. Breeders were significantly more Discussion likely to feed a raw diet (either commercial or homemade; 23%) The number of calories measured in the 5 bully stick samples or a homemade diet (raw or cooked; 15%) compared with any was similar on a weight basis. However, the length and width of of the other professional categories (P , 0.001). When asked bully sticks varies widely so total calories in an individual treat about ingredients that they avoided in pet food, 454 (57.4%) will vary accordingly. Nonetheless, the results show that bully avoided by-products, while 450 (56.9%) avoided preservatives sticks could provide between 54 to 132 kcal for a 60 bully stick

52 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

and 108 to 264 for a 120 bully stick. These calories may not opportunity to provide objective and accurate information. For be accounted for by the dog owner (50% of respondents in the example, a large proportion of respondents (57%) stated that current study underestimated the number of calories in bully they avoided by-products in pet foods, but most incorrectly sticks), especially if bully sticks are fed frequently. If the mean identified ingredients that comprise by-products. Providing for a 60 bully stick were used (i.e., 90 kcal), 1 bully stick daily accurate information on nutrition and pet foods can assist would be equivalent to 9% of the daily calorie requirements for owners in making more informed decisions about their pet’s a 50-pound (23-kg) dog and 30% of the daily calorie require- food. While veterinarians or veterinary clinic staff were the pri- ARTICLE ments for a 10-pound (4.5-kg) dog (24). With the high rate of mary source of information for many respondents, the primary obesity in dogs, veterinarians should be aware of bully sticks and resources for other respondents (e.g., the internet) may provide other pet treats as a source of calories in a dog’s diet and should less reliable information on nutrition and pet foods. consider not only the dog food, but also pet treats and table There are a number of limitations to the current study. food. Calorie information is currently not required on pet treats Studies with a larger sample size are warranted to determine or on most pet foods so is not readily accessible for veterinarians whether the calorie content and contamination rate found in and pet owners. The calorie information from the current study this small study is representative of all bully sticks (or even other provides some information on calories in bully sticks. types of pet treats). While using an online survey allowed for a The contamination rate in the current study [1 each (4%) relatively large pool of respondents, respondents were primarily contaminated with Clostridium difficile, MRSA, or tetracy- recruited through e-mail and other electronic techniques, limit- cline resistant E. coli] was relatively low but should be studied ing the respondents to individuals with computer and internet further to understand potential risks to pets and to human access. Also, there may have been bias in the respondents, members of the household. Salmonella spp. were not isolated as those who chose to respond to the survey may have had a from any of the bully sticks in the current study but the low stronger opinion about dog foods and treats. Similarly, a larger sample size may have limited the ability to detect a low rate of proportion of respondents were dog owners, which may have contamination. The human health relevance of contamination contributed to bias. In addition, there was no way to prevent with C. difficile and MRSA is unknown. The C. difficile strain individuals taking the survey from checking answers to the identified here has not been found in the authors’ collection factual questions (e.g., what are bully sticks made from?) so it is of over 2000 human isolates; however, this does not exclude not possible to know whether these questions accurately assessed the possibility that it can cause disease. The MRSA strain that the respondents’ knowledge before taking the survey. These was identified is a livestock associated strain that is common limitations may reduce the relevance of the results for other in pigs internationally and is of concern in humans in some populations. Veterinarians and pet owners, however, should regions. Since human infection from handling Salmonella- be aware of the high calorie content and potential for bacterial contaminated treats can occur, it is plausible that bully sticks contamination of bully sticks. could be a source of infection. Additionally, bully sticks could be vehicles for MRSA colonization or extra-intestinal infection. Acknowledgments Additional information is needed on the roles of processing, The authors acknowledge the contributions of Dr. Richard packaging, and cross-contamination in the safety of pet treats. Reid-Smith of the Ontario Veterinary College and the Public Pet owners should be aware that these types of pet treats can be Health Agency of Canada. CVJ contaminated with bacteria and should follow standard recom- mendations when handling treats, particularly handwashing References after contact with treats and ensuring that high risk individuals . 1 Pitout JD, Reisbig MD, Mulvey M, et al. Association between han- (very young, elderly, pregnant, immunocompromised) avoid all dling of pet treats and infection with Salmonella enterica serotype Newport expressing the AmpC beta-lactamase, CMY-2. J Clin Microbiol contact with raw animal-product based treats. 2003;41:4578–4582. It appears from the survey results that many people have mis- 2. Clark C, Cunningham J, Ahmed R, et al. Characterization of Salmonella conceptions about bully sticks, although bully sticks were fed to associated with pig ear dog treats in Canada. J Clin Microbiol 2001;39: 3962–3968. the dogs of 23% of respondents. Seventy-one percent of people 3. White DG, Datta A, McDermott P, et al. Antimicrobial suscepti- feeding bully sticks also stated that they avoided by-products in bility and genetic relatedness of Salmonella serovars isolated from pet foods and 28% did not correctly identify what bully sticks animal-derived dog treats in the USA. J Antimicrob Chemother 2003; 52:860–863. were made of. Manufacturers of bully sticks are not required 4. Finley R, Reid-Smith R, Ribble C, et al. The occurrence and antimi- to state that bully sticks are derived from bull/steer penis, and crobial sensitivity of salmonellae isolated from commercially available often list the ingredients as “bull pizzle”or even misleadingly as pig ear pet treats. Zoonoses Public Health 2008;55:455–461. 5. Centers for Disease Control and Prevention (CDC). Surveillance for “cow muscle.” While veterinarians had a higher rate of correct community-associated Clostridium difficile — Connecticut, 2006. responses for the source of bully sticks, 38% of veterinarians MMWR Morb Mortal Wkly Rep. Apr 4 2008;57:340–343. incorrectly identified them. This suggests that both veterinar- 6. Rupnik M. Is Clostridium difficile-associated infection a potentially zoo- notic and foodborne disease? Clin Microbiol Infect 2007;13:457–459. ians and pet owners would benefit from increased awareness 7. Mulvey M, MacDougall L, Cholin B, et al. Community-associated about the source of bully sticks so that they can make informed methicillin-resistant Staphylococcus aureus, Canada. Emerg Infect Dis purchasing and feeding decisions. 2005;11:844–850. 8. de Boer E, Zwartkruis-Nahuis A, Heuvelink AE, Harmanus C, Veterinarians were the most commonly reported primary Kuijper EJ. Prevalence of Clostridium difficile in retailed meat in the source of information about nutrition so this offers an important Netherlands. Int J Food Microbiol 2011;144:561–564.

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. 9 Rodriguez-Palacios A, Staempfli H, Duffield T, Weese J. Clostridium 17. Bidet P, Barbut F, Lalande V, et al. Development of a new PCR- difficile in retail ground meat, Canada. Emerg Infect Dis 2007;13: ribotyping method for Clostridium difficile based on ribosomal RNA 485–487. gene sequencing. FEMS Microbiol Lett 1999;175:261–266. 10. Weese J, Avery B, Rousseau J, Reid-Smith R. Detection and enu- 18. Kato H, Kato N, Watanabe K, et al. Identification of a toxin A-negative, meration of Clostridium difficile in retail beef and pork. Appl Environ toxin B-positive Clostridium difficile by PCR. J Clin Microbiol 1998;36: Microbiol 2009;75:5009–5011. 2178–2182. 11. de Boer E, Zwartkruis-Nahuis J, Wit B, et al. Prevalence of methicillin- 19. Lemee L, Dhalluin A, Testelin S, et al. Multiplex PCR targeting tpi resistant Staphylococcus aureus in meat. Int J Food Microbiol 2009;134: (triose phosphate isomerase), tcdA (Toxin A), and tcdB (Toxin B) 52–56. genes for toxigenic culture of Clostridium difficile. J Clin Microbiol 12. Weese JS, Avery BP, Reid-Smith RJ. Detection and quantification of 2004;42:5710–5714. methicillin-resistant Staphylococcus aureus (MRSA) clones in retail meat 20. Stubbs S, Rupnik M, Gibert M, et al. Production of actin-specific ADP- products. Lett Appl Microbiol 2010;51:338–342. ribosyltransferase (binary toxin) by strains of Clostridium difficile. FEMS

ARTICLE 13. Association of American Feed Control Officials. Official publication. Microbiol Lett 2000;186:307–312. Oxford, Indiana: Association of American Feed Control Officials 21. Shopsin B, Gomez M, Montgomery S, et al. Evaluation of protein A 2011:141. gene polymorphic region DNA sequencing for typing of Staphylococcus 14. Government of Canada, 2009. Canadian Integrated Program for aureus strains. J Clin Microbiol 1999;37:3556–3563. Antimicrobial Resistance Surveillance (CIPARS) — Preliminary Report. 22. Ridom Web site. Available from www.spaserver.ridom.de Last accessed Public Health Agency of Canada, Guelph, Ontario. October 31, 2012. 15. Food and Drug Administration, 2010. National Antimicrobial 23. Rankin S, Roberts S, O’Shea K, et al. Panton valentine leukocidin Resistance Monitoring System — Enteric Bacteria (NARMS): 2007 (PVL) toxin positive MRSA strains isolated from companion animals. Executive Report. Rockville, MD: U.S. Department of Health and Vet Microbiol 2005;108:145–148. Human Services, Food and Drug Administration. 24. National Research Council. Nutrient Requirements of Dogs and Cats. 16. Clinical and Laboratory Standards Institute (CLSI), 2010. CLSI Washington, DC: National Academies Press, 2006:359. M100-S20 performance standards for antimicrobial susceptibility testing: Twentieth informational supplement. Clinical and Laboratory Standards Institute, Wayne, Pennsylvania, USA.

Book Review Compte rendu de livre

Self-Assessment Color Review: include a variety of feline infectious diseases — viral, bacterial, Feline Infectious Diseases fungal, and parasitic. The editors and their 13 international contributors use a practice-oriented approach to presenting the Hartmann K, Levy JK, eds. 2011. Manson Publishing/ cases, closely approximating the way such diseases would appear The Veterinary Press: London, UK. 224 pp. ISBN: 9781-8407- in clinical practice, thus reinforcing clinical skills. The front 6099-6, UK £24.95 (pbk). of the book shows the cases classified by organ system or type of infection, making it easy to find cases in particular subject he Self-Assessment Color Review series is comprised of areas. Finally, the book also contains a table of normal reference T books in various areas of veterinary medicine that use a ranges for physical examination findings, complete blood count, case-based approach. This volume presents an overview of feline coagulation and biochemistry panels, and urinalysis. infectious diseases written as 199 short illustrated cases. The This book would be most useful to veterinary students in description of each case is given in a paragraph or two and is fol- clinical rotations, but also valuable for clinicians who wish to lowed by a few questions. Cases are illustrated with one or two review and improve their knowledge of feline infectious diseases. images that may show clinical lesions, radiographs, photomicro- The book would also be useful for clinicians studying for further graphs, histology sections, etc. The detailed answer for each set qualifications. The short case format and accessible style make of questions is found by turning the page, making it convenient it easy to pick up the book, browse and view cases, and learn a to read through the cases and test one’s knowledge. For example, few new facts in the space of a few minutes free time. a case of Otodectes cyotis infection is presented with a signalment and history as well as photos of the skin lesions and the mites. The reader is then asked questions such as how the infection is Reviewed by Susan Little, DVM, Dip ABVP (Feline), Bytown transmitted and what treatment options are available. The cases Cat Hospital, Ottawa, Ontario.

54 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY Case Report Rapport de cas

Cerebellar granuloprival degeneration in an Australian kelpie and a Labrador retriever dog

Jonathan Huska, Luis Gaitero, Heindrich N. Snyman, Robert A. Foster, Marti Pumarola, Sergio Rodenas

Abstract — A 7-month-old Australian kelpie dog and a 14-month-old Labrador retriever dog were diagnosed with an uncommon form of cerebellar abiotrophy called cerebellar granuloprival degeneration. This was character- ized by a loss of the granular neurons with relative sparing of the Purkinje neurons.

Résumé — Dégénérescence cérébelleuse granuloprive chez un chien Kelpie australien et un chien Labrador retriever. Un chien Kelpie australien âgé de 7 mois et un chien Labrador retriever âgé de 14 mois ont été diagnostiqués avec une forme rare d’abiotrophie cérébelleuse appelée dégénérescence cérébelleuse granuloprive. Elle a été caractérisée par la perte de neurones granulaires en épargnant en grande partie les neurones de Purkinje. (Traduit par Isabelle Vallières) Can Vet J 2013;54:55–60

erebellar abiotrophy (CA) is defined as the premature animals being normal at birth and clinical signs occurring early C degeneration of formed cerebellar tissue, representing in life (, 6 mo of age) or late in adulthood (late-onset) with an intrinsic metabolic anomaly that results in progressive signs varying rates of progression. An autosomal recessive pattern of of cerebellar dysfunction (1). Cerebellar cortical degeneration inheritance is usually suspected (1,2,4,6,7,11,22). (CCD) is a synonymous term more recently introduced to The most frequently reported form of CA/CCD is charac- reflect the inability to completely rule out effects of extrinsic terized by a loss of Purkinje cell neurons, often with retrograde factors leading to degenerative changes. In dogs, CA/CCD degeneration of the granular cells (23). However, loss of the has been widely described in the following breeds: kerry blue granular cell layer with relative sparing of Purkinje cells, called terrier (2,3), Gordon setter (4,5), old English sheepdog (6), cerebellar granuloprival degeneration, has been sporadically Australian kelpie (7–9), American Staffordshire terrier (10–12), reported in dogs (9,22,24–28). English bulldog (13), Scottish terrier (14,15), Labrador retriever This article describes 2 cases of histopathologically confirmed (16,17), boxer (18), Rhodesian ridgeback (19), and the minia- cerebellar granuloprival degeneration in an Australian kelpie dog ture schnauzer (20). and a Labrador retriever dog. While a neonatal form has been described, for instance in the beagle (21), most cases of CA/CCD are postnatal with affected Case descriptions Case 1 Department of Clinical Studies (Huska, Gaitero), and A 7-month-old, female intact, Australian kelpie dog (Case 1) Department of Pathobiology (Snyman, Foster), Ontario was presented to the Neurology Service of the Ontario Veterinary College, University of Guelph, Guelph, Ontario Veterinary College Health Science Center (OVC-HSC) due N1G 2W1, Canada; Departament de Medicina i Cirurgia to progressive ataxia and abnormal behavior. Clinical signs Animals, Facultat de Veterinària, Universitat Autònoma de began at 6 wk of age with wide, lateral excursions of the head Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona 08193, that progressed to dysmetria, intermittent circling to the right, Spain (Pumarola); Southern Counties Veterinary Specialists, intention head tremors, and compulsive behavior (licking and Ringwood, Hampshire BH24 3JW, United Kingdom (Rodenas). fly biting). No traumatic episode was noted nor was there any Address all correspondence to Dr. Luis Gaitero; e-mail: known exposure to toxins. At 11 and 14 wk of age neuro- [email protected] logical examination revealed an absent menace response with Dr. Rodenas’ current address is Faculté de médicine vétérinaire, the left eye, and intention head tremors. Galactocerebroside Université de Montréal, Saint-Hyacinthe, Québec J2S 8H5 activity analysis was performed on whole blood for suspected (Canada). globoid cell leukodystrophy and results were within nor- Use of this article is limited to a single copy for personal study. mal reference range (0.9 nmol/h/mg protein). Toxoplasma Anyone interested in obtaining reprints should contact the gondii (IgG immuno­fluorescent test) and Neospora caninum CVMA office ([email protected]) for additional enzyme-linked immunosorbent assay (ELISA) serum titers were copies or permission to use this material elsewhere. negative.

CVJ / VOL 54 / JANUARY 2013 55 FOR PERSONAL USE ONLY

matter (Figure 2). The remaining granule cells were loosely arranged and cell nuclei of the granular layer in these areas were small and condensed with euchromatic chromatin. Purkinje cells were tightly packed with approximately 9 Purkinje neuronal cell bodies present in a 350 mm length of the Purkinje cell layer as opposed to 4 Purkinje neuronal cell bodies in an age matched normal cerebellum, suggesting collapse of the neuropil. There were randomly scattered groups of individual empty Purkinje cell baskets (empty baskets) suggesting that about 30% of Purkinje cells were missing. Varied stages of cellular degen- eration of the remaining Purkinje cells were identified, includ- RAPPORTCAS DE ing central chromatolysis, karyolysis, and pyknosis of nuclei, affecting approximately 40% of the remaining Purkinje cells (Figure 2B). Their cytoplasm commonly contained irregular, Figure 1. Mid-sagittal section of the brain of the dog in case 1. pale, homogenous and glassy, basophilic material and often had Note the dorsoventral flattening of the cerebellum. overlying clear microvesicular vacuolization. Astrocytic pro- cesses surrounding empty baskets were accentuated with a glial On presentation at the OVC-HSC, the results of a general fibrillary acidic protein (GFAP) immunohistochemical (IHC) examination were unremarkable. Neurological examination stain (Figure 2C). Baskets were occasionally filled with small revealed wide lateral head excursions, circling to the left and numbers of hypertrophic plump astrocytes with large vesicular right sides, intention head tremors, hypermetria in all 4 limbs, nuclei (Bergmann’s glia proliferation). Rare randomly scattered, and decreased menace response with the left eye. The results of small, 15 3 20 mm, angular polygonal neuronal cell bodies, the rest of the neurological examination were unremarkable. with small amounts of amphophilic, finely granular cytoplasm, Neuroanatomical localization was mostly consistent with a and large, round nuclei with euchromatic chromatin and a cerebellar lesion. The episodic compulsive behavior reported by single prominent nucleolus were present within the granular the owners suggested involvement of the thalamocortex (lim- and rarely molecular layer of the cerebellar cortex (Figure 2D). bic system), although it was uncertain if this was an unrelated Although those were interpreted as Golgi cells (appeared to be behavioral non-neurological dysfunction. Further diagnostics more prominent due to the granular cell depletion), they could were declined by the client. The patient was presented again not definitively be differentiated from Purkinje cells without 1 mo later due to progression of the described clinical signs the use of immunohistochemistry. No changes were observed including a bilateral menace response deficit. At that time, the in the cerebellar nuclei, cerebellar peduncles, pontine nuclei, owner opted for euthanasia. A postmortem examination was vestibular nuclei, olivary nuclei, spinocerebellar tracts, or the performed. limbic system. Staining with PAS and LFB-Holmes did not At postmortem examination, there was a subtle dorsoven- identify any further abnormalities. Microscopic findings were tral flattening of the cerebellum and cerebrum, both of which consistent with cerebellar granuloprival degeneration. conformed to the shape of the cranial vault (Figure 1). This suggested that the calvarium and central nervous system devel- Case 2 oped simultaneously and sequentially. The brain was otherwise A 14-month-old, spayed female, Labrador retriever dog was unremarkable. The brain was fixed in 10% neutral-buffered presented to the Neurology Service of the Southern Counties formalin, sectioned and embedded in paraffin wax. The cerebel- Veterinary Specialists due to a 4-week history of progressive lack lum was sectioned midsagittally through the vermis, followed by of coordination involving all 4 limbs. The owner reported that bilateral transverse sections in order to evaluate the respective the dog initially exhibited pelvic limb ataxia which progressed cerebellar lobes. Tissue sections were stained with hematoxylin to the thoracic limbs after approximately 1 wk. No traumatic and eosin (H&E), periodic acid Schiff (PAS), and Luxol fast episode was noted nor was there any known exposure to toxins. blue (LFB-Holmes) for histological evaluation. On initial presentation, the results of a general physical examina- Microscopically, all cerebellar folia were small and had wide tion were unremarkable. Neurological examination revealed a cerebellar sulci. There was an extensive and bilaterally asym- wide-based stance in the thoracic limbs, intermittent swaying of metrical thinning of all the cerebellar cortex, including the the body from side to side, moderate spasticity and hypermetric granular, Purkinje, and molecular layers, such that the cortex ataxia of all 4 limbs (worse in the pelvic limbs), fine intention ranged from 340 to 500 mm thick; normal thickness should tremors of the head, and decreased menace responses bilaterally. be approximately 650 mm at the end of cerebellar develop- The results of the remainder of the neurological examination ment (29). The thickness of the granular layer varied from were normal. The neuroanatomical localization was consistent 47 mm at its thinnest point to 180 mm at its widest; normal with a cerebellar lesion. thickness is approximately 200 mm (29). There was marked Complete blood (cell) count, serum biochemistry profile, hypocellularity of especially the granular layer, and also a urinalysis, and thoracic radiographs were unremarkable. A marked reduction in the number of granule neurons, Golgi magnetic resonance imaging (MRI) study of the brain was cells, Purkinje neuron axons, and myelinated fibers of the white performed (Philips Intera 1.0 T; Philips Healthcare, Guildford,

56 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 2. Photomicrographs of the cerebellum of the dog in case 1. (A,B) Severe depletion of granular neurons with secondary degeneration of the Purkinje cells (asterisk) and empty Purkinje cell baskets with Bergmann’s glia proliferation. Hematoxylin and eosin (H&E). (C) Astrocytic processes surround empty baskets (arrow). Glial fibrillary acid protein (GFAP) immunohistochemical (IHC) stain. (D) Neuronal cell body within the granular cell layer interpreted as a Golgi cell (arrow), and presence of a degenerate Purkinje cell (asterisk).

Surrey, UK). Routine T1-weighted and T2-weighted sequences unremarkable. The brain was fixed in 10% neutral-buffered in sagittal, transverse, and dorsal planes were obtained (3-mm formalin, then sectioned and embedded in paraffin wax. Tissue slice thickness) and revealed an increase in the amount of sections were stained with H&E, and PAS for histological cerebrospinal fluid (CSF) between the folia around the cerebel- evaluation. Microscopic examination revealed a generalized lum due to thinner cerebellar folia and wider sulci, suggesting and marked loss of granule neurons, affecting mainly the cerebellar cortical atrophy. Those changes were particularly vermis, and with a minor intensity, the cerebellar hemispheres evident on sagittal T2-weighted images (Figure 3). Cerebrospinal (Figures 4A–C). Few Golgi neurons were observed in the sparse fluid (CSF) analysis did not reveal abnormalities (0 nucleated granular layer without showing any morphological change. The cells/mL, reference range: 0 to 3 nucleated cells/mL; total protein Purkinje cell layer had a mild decrease in cell number, showing concentration: 0.17 g/L; reference value: , 0.3 g/L). Polymerase focal clusters of these neurons and several empty baskets. Most chain reaction (PCR) for Neospora caninum, canine distemper of the Purkinje cells showed central chromatolysis. Spheroids virus, and Toxoplasma gondii were negative on both blood and corresponding to axons of Purkinje cells were detected in the CSF samples. A presumptive diagnosis of CA/CCD was made. sparse granular layer. Bergman’s glia proliferation and hyper- The dog was presented 4 mo later due to worsening of the trophy were also present (Figure 4C). A mild spongiosis of clinical signs. At that time, the animal had severe generalized the white matter was observed affecting mainly cerebellum ataxia; the dog was still able to walk but fell down or collapsed and cerebellar peduncles. No changes were observed in the frequently. Due to the guarded prognosis the owners opted for cerebellar nuclei, pontine nuclei, and spinocerebellar tracts. euthanasia and postmortem examination. Eosinophilic, PAS-positive, granular material was detected in At the postmortem examination, the cerebellum appeared some of the remaining cerebellar granular neurons and also in small with wide cerebellar cortical sulci. The brain was otherwise the perikarya of neurons of vestibular and olivary nuclei in a

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suggest that the granuloprival form occurs in Australian kelpies as well, particularly in young individuals (9). Those authors sug- gested that Purkinje cells are lost in more severe, long-surviving dogs with more pronounced cerebellar changes secondary to the granule cell depletion since granule neurons are facilitatory to Purkinje cells. Preservation of Purkinje cells, therefore, could be found in younger puppies and depletion of both cell groups would be evident in older dogs. Nevertheless, the first descrip- tion of the CA/CCD in the Australian kelpie (7) included young puppies (8 wk of age) in which regional loss of Purkinje cells was detected. This suggests that both forms coexist in the Australian RAPPORTCAS DE kelpie, though the incidence of each one remains to be investi- gated as well as the potential for different underlying etiologies. The reason for a selective depletion of granular cells still needs Figure 3. T2-weighted sagittal magnetic resonance image to be elucidated. It is hypothesized that cerebellar granuloprival (MRI) showing an increased amount of cerebrospinal fluid within degeneration is usually the result of an inherited disturbance of the cerebellar folia suggestive of cerebellar cortical atrophy in the dog in case 2. granular cell development, but Purkinje cells survive retrograde degeneration since their major excitatory input is received from the climbing fibers coming from the olivary nucleus (1,24,28). However, the granular neurons are considered facilitatory to bilateral and symmetrical pattern (Figure 4D). Based on those Purkinje cells as well, and some authors have suggested that findings, cerebellar granuloprival degeneration was diagnosed. Purkinje cells can be lost as result of granular cell depletion in longer-affected individuals (9). Discussion Inflammatory-infectious etiologies should be considered, The clinical signs in both patients, including the loss of menace although unlikely in our cases due to the lack of evidence of response in case 1, were attributed to cerebellar disease classified inflammation. Inflammatory foci were found in coton de Tuléar as CA/CCD. Although loss of the Purkinje cell neurons is the dogs and a genetically based immune-mediated granule cell most commonly described form of CA/CCD, another form destruction pathophysiology was proposed (26). Canine herpes called cerebellar granuloprival degeneration characterized by a virus infection has been reported to cause similar reduction of specific degeneration of the granular cell neurons while spar- the granular cell layer but with associated loss of Purkinje cells ing the Purkinje cells has been sporadically reported in several and foci of infiltrating mononuclear cells and malacia (30). canine breeds: border collie (22), Brittany spaniel (24), Italian Intrauterine or perinatal infection with feline parvovirus (pan- hound (25), coton de Tuléar (26), lagotto Romagnolo (27), leukopenia virus) in cats can cause hypoplasia of the granular Bavarian mountain dog (28), and, recently, the Australian cell layer resulting in clinical signs of cerebellar dysfunction kelpie (9). Other degenerative changes affecting cerebellar and (31,32). Canine parvovirus has been identified in dogs with related brainstem nuclei, such as neuronal eosinophilic granules, cerebellar hypoplasia but not with CA/CCD (33). None of these have also been described in some of those cases (15,24,26). features were present in our 2 cases, showing changes more con- A report of 3 Labrador retriever puppies from the same lit- sistent with previous reports of a suspected non-inflammatory ter as the dog herein (16) described histological findings of probably inherited process (24,25,28). a predominantly Purkinje neuron degeneration throughout A definitive diagnosis of CA/CCD requires histopathological the entire cerebellum, with the rostral vermis most severely confirmation. Nevertheless, CA/CCD can be suspected when affected. The onset of clinical signs ranged from 9 to 17 wk of other differential diagnoses have been ruled out (as intracranial age with rapid deterioration, in contrast to the slow progression neoplasia, encephalitis, or toxicities) and supported by the of clinical signs observed in an 8-month-old Labrador retriever MRI findings. Although MRI images can be absolutely normal, with comparable selective degeneration of Purkinje cells (17). abnormalities could be particularly detected in mid-sagittal Those findings are in contrast to our cases in which sparing of T2-weighted sequences, characterized by a decreased cerebellar the Purkinje cell layer and specific degeneration of the granular size and a reduced thickness of the cerebellar folia associated cells was diagnosed, thus representing the first report of this with an increased amount of CSF in the sulci (11,12,14,28,34). cerebellar granuloprival degeneration form of CA/CCD in the Interestingly, seizures were reported in 1 of the Australian Labrador retriever. kelpie puppies included by Thomas and Robertson (7), although Thomas and Robertson (7) described the findings in a more extended description of the episodes was missing. The 5 Australian kelpie littermates with clinical signs of progressive episodic compulsive behavior reported by the owners in Case 1 ataxia, hypermetria, and head tremors beginning between 5 to herein could certainly be a seizure. However, on the postmor- 12 wk of age. Histopathologically, the more common CA/CCD tem examination no abnormal histopathological findings were form with loss of Purkinje cells and varying degrees of reduction detected in either case in the cerebrum and it is uncertain if in the granular cell layer was diagnosed in those affected pup- those episodes were truly an epileptic seizure. Interestingly, pies between 8 wk and 5.5 mo of age. However, recent findings behavioral changes, including lack of confidence and aggression

58 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 4. Photomicrographs of the cerebellum of the dog in case 2. (A-C) Severe depletion of granular neurons with mild decrease in Purkinje cell number, empty baskets, and Bermann’s glia proliferation (arrow) H&E. (D) Presence of PAS-positive material in the perikarya of vestibular nucleus neurons (arrow). PAS. towards other dogs in the household, were reported by owners (35). In the Australian kelpie, 3 candidate genes have been in 2 of the 63 dogs included in a retrospective study on CCD eliminated (8); a more recent study identified a candidate in the American Staffordshire terrier (11). Although neuronal region containing 29 genes, although none of them are known death was restricted to the cerebellar cortex in those dogs, in to cause ataxia (9). 1 dog MRI was suggestive of cerebral atrophy. Those authors To the authors’ knowledge, this is the first report of a granu- noted that cognitive deficits and a more diffusely neuronal loss loprival form of cerebellar cortical degeneration in the Labrador can occur in humans with adult-onset spinocerebellar ataxia retriever, and the first case reported in an Australian kelpie (the suggested human counterpart for CCD in the American in North America. With the search for causative mutations, Staffordshire terrier). either for screening purposes or targets for future gene therapy, Given the paucity of literature with histological descriptions the exact histological classification will be necessary to ensure of CA/CCD in the Australian kelpie and Labrador retriever, accuracy as the mutation responsible for cerebellar granuloprival these 2 cases could represent a subclass of the disease or be a degeneration might differ from that which causes CA/CCD, completely different form for these breeds. While the previously primarily affecting the Purkinje cell layer. CVJ reported CA/CCD cases in the Australian kelpie are consistent with an autosomal recessive pattern of inheritance (7), no pedi- References gree analysis was available for this case, though the bitch and . 1 De Lahunta A, Glass E, eds. Veterinary Neuroanatomy and Clinical Neurology. 3rd ed. St. Louis, Missouri: Saunders Elsevier, 2009: sire were believed to be clinically normal. 363–388. A recent study identified the mutation causing CA/CCD in 2. Deforest ME, Eger CE, Basrur PK. Hereditary cerebellar neuronal American Staffordshire terriers, confirming that CA/CCD in abiotrophy in a Kerry Blue Terrier dog. Can Vet J 1978;19:198–202. 3. Montgomery DL, Storts RW. Hereditary striatonigral and cerebello- this breed represents a model of a late-onset form of neuronal olivary degeneration of the Kerry Blue Terrier. I. Gross and light micro- ceroid lipofuscinosis, a neurodegenerative lysosomal disorder scopic central nervous system lesions. Vet Pathol 1983;20:143–159.

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. 4 De Lahunta A, Fenner WR, Indrieri RJ, Mellik PW, Gardner S, Bell JS. 19. Chieffo C, Stalis IH, Van Winkle TJ, Haskins ME, Patterson DF. Hereditary cerebellar cortical abiotrophy in the Gordon Setter. J Am Cerebellar Purkinje’s cell degeneration and coat colour dilution in a Vet Med Assoc 1980;177:538–541. family of Rhodesian Ridgeback dogs. J Vet Intern Med 1994;8:112–116. 5. Steinberg HS, Troncoso JC, Cork LC, Price DL. Clinical features of 20. Berry ML, Blas-Machado U. Cerebellar abiotrophy in a miniature inherited cerebellar degeneration in Gordon setters. J Am Vet Med Assoc schnauzer. Can Vet J 2003;44:657–659. 1981;179:886–890. 21. Kent M, Glass E, de Lahunta A. Cerebellar cortical abiotrophy in a 6. Steinberg HS, Van Winkle T, Bell JS, de Lahunta A. Cerebellar beagle. J Small Anim Pract 2000;41:321–323. degeneration in Old English Sheepdogs. J Am Vet Med Assoc 2000; 22. Sandy JR, Slocombe RE, Mitten RW, Jedwab D. Cerebellar abiotrophy 217:1162–1165. in a family of Border Collie dogs. Vet Pathol 2002;39:736–738. 7. Thomas JB, Robertson D. Hereditary cerebellar abiotrophy in Australian 23. De Lahunta A. Abiotrophy in domestic animals: A review. Can J Vet kelpie dogs. Aust Vet J 1989;66:301–302. Res 1990;54:65–76. 8. Shearman JR, Lau VM, Wilton AN. Elimination of SETX, SYNE1 24. Tatalick LM, Marks SL, Baszler TV. Cerebellar abiotrophy characterized and ATCAY as the cause of cerebellar abiotrophy in Australian Kelpies. by granular cell loss in a Brittany. Vet Pathol 1993;30:385–388. Anim Genet 2008;39:573. 25. Cantile C, Salvadori C, Modenato M, Arispici M, Fatzer R. Cerebellar

RAPPORTCAS DE 9. Shearman JR, Cook RW, McCowan C, Fletcher JL, Taylor RM, Wilton granuloprival degeneration in an Italian hound. J Vet Med A Physiol AN. Mapping cerebellar abiotrophy in Australian Kelpies. Anim Genet Pathol Clin Med 2002;49:523–525. 2011;42:675–678. 26. Tipold A, Fatzer R, Jaggy A, Moore P, Vandevelde M. Presumed 10. Hanzlicek D, Kathmann I, Bley T, et al. Cerebellar cortical abiotrophy immune-mediated cerebellar granuloprival degeneration in the Coton in American Staffordshire terriers: Clinical and pathological features of de Tuléar breed. J Neuroimmunol 2000;110:130–133. 3 cases. Schweiz Arch Tierheilkd 2003;145:369–375. 27. Jokinen TS, Rusbridge C, Steffen F, et al. Cerebellar cortical abiotrophy 11. Olby N, Blot S, Thibaud JL, et al. Cerebellar cortical degeneration in Lagotto Romagnolo dogs. J Small Anim Pract 2007;48:470–473. in adult American Staffordshire Terriers. J Vet Intern Med 2004;18: 28. Flegel T, Matiasek K, Henke D, Grevel V. Cerebellar cortical degenera- 201–208. tion with selective granule cell loss in Bavarian mountain dogs. J Small 12. Henke D, Böttcher P, Doherr MG, Oechtering G, Flegel T. Computer- Anim Pract 2007;48:462–465. assisted magnetic resonance imaging brain morphometry in American 29. Phemister RD, Young S. The postnatal development of the canine Staffordshire Terriers with cerebellar cortical degeneration. J Vet Intern cerebellar cortex. J Comp Neurol 1968;134:243–254. Med 2008;22:969–975. 30. Percy DH, Carmichael LE, Albert DM, King JM, Jonas AM. Lesions 13. Gandini G, Botteron C, Brini E, Fatzer R, Diana A, Jaggy A. Cerebellar in puppies surviving infection with canine herpesvirus. Vet Pathol cortical degeneration in three English bulldogs: Clinical and neuro- 1971;8:37–53. pathological findings. J Small Anim Pract 2005;46:291–294. 31. Johnson RH, Margolis G, Kilham L. Identity of feline ataxia virus with 14. Van der Merwe LL, Lane E. Diagnosis of cerebellar cortical degeneration feline panleucopenia virus. Nature 1967;214:175–177. in a Scottish terrier using magnetic resonance imaging. J Small Anim 32. Summers BA, Cummings JF, de Lahunta A, eds. Veterinary neuropathol- Pract 2001;42:409–412. ogy. St. Louis, Missouri: Mosby-Year Book, 1995:300–307. 15. Urkasemsin G, Linder KE, Bell JS, de Lahunta A, Olby NJ. Hereditary 33. Schatzberg SJ, Haley NJ, Barr SC, et al. Polymerase chain reaction cerebellar degeneration in Scottish Terriers. J Vet Intern Med 2010;24: (PCR) amplification of parvoviral DNA from the brains of dogs and 565–570. cats with cerebellar hypoplasia. J Vet Intern Med 2003;17:538–544. 16. Perille AL, Baer K, Joseph RJ, Carillo JM, Averill DR. Postnatal cer- 34. Thames RA, Robertson ID, Flegel T, et al. Development of a morpho- ebellar cortical degeneration in Labrador Retriever puppies. Can Vet J metric magnetic resonance image parameter suitable for distinguishing 1991;32:619–621. between normal dogs and dogs with cerebellar atrophy. Vet Radiol 17. Bildfell RJ, Mitchell SK, de Lahunta A. Cerebellar cortical degeneration Ultrasound 2010;51:246–253. in a Labrador retriever. Can Vet J 1995;36:570–572. 35. Abitbol M, Thibaud JL, Olby NJ, et al. A canine Arylsulfatase G (ARSG) 18. Gumber S, Cho DY, Morgan TW. Late onset cerebellar abiotrophy in mutation leading to a sulfatase deficiency is associated with neuronal a Boxer dog. Vet Med Int 2010;2010:Article ID 406275, 4 pages. ceroid lipofuscinosis. Proc Natl Acad Sci USA 2010;107:14775–14780.

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60 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY Case Report Rapport de cas

Acute renal failure in 2 adult llamas after exposure to Oak trees (Quercus spp.)

Manuel F. Chamorro, Thomas Passler, Kellye Joiner, Robert H. Poppenga, Jenna Bayne, Paul H. Walz

Abstract — Two adult llamas (Lama glama) previously exposed to oak trees (Quercus spp.) were presented with a history of depression and anorexia. Clinicopathological abnormalities included severe gastroenteritis, acute renal failure, and increased liver enzymes. This is believed to be the first report of oak toxicosis in South American camelids.

Résumé — Insuffisance rénale aiguë chez deux lamas adultes après l’exposition à des chênes (Quercus spp.). Deux lamas adultes (Lama glama) antérieurement exposés aux chênes (Quercus spp.) ont été présentés avec une anamnèse de dépression et d’anorexie. Les anomalies clinicopathologiques incluaient une gastroentérite grave, une insuffisance rénale aiguë et une hausse des enzymes hépatiques. On croit qu’il s’agit du premier rapport sur la toxicose du chêne chez des camélidés d’Amérique du Sud. (Traduit par Isabelle Vallières) Can Vet J 2013;54:61–64 enal damage and gastroenteritis are reported in cattle the previous month, the llama was kept in a 0.8 ha wooded R after ingestion of leaves, buds, and acorns from Oak trees paddock with a female llama, which remained unaffected. The (Quercus spp.) (1); however, oak toxicosis is not reported in animals received free-choice Bermuda grass hay and ad libitum South American camelids. Hydrolysable tannins and volatile water, but grain or mineral supplements were not provided. The phenols in oak leaves, buds, and acorns are responsible for the owner reported that the llamas had been browsing on oak trees. clinical signs observed (2,3). Hydrolysis of gallotannins into gal- The llama had not received any treatments at the farm and had lic acid occurs in the rumen, thus ruminants are most frequently not been dewormed or vaccinated in the last year. affected by oak toxicity (3,4). This case report describes findings On arrival, the llama was depressed and in sternal recum- of 2 adult llamas (Lama glama) with presumptive oak toxicosis. bency. Rectal temperature was elevated at 39.6°C [reference Both ­llamas were presented with a history of exposure to oak range (RR): 37.5°C to 38.9°C] (5), heart rate 94 beats/min trees and had developed gastroenteritis and acute renal failure. (bpm), RR: 60 to 90 bpm (5), and the respiratory rate was Early and aggressive long-term intravenous fluid therapy was elevated at 84 breaths/min (RR: 10 to 30 breaths/min) (5). associated with a favorable outcome in 1 of these cases. Dehydration was estimated at 8%. Body condition score was 5/9. Multiple ulcerative lesions on the tongue and soft pal- Case descriptions ate were identified during oral examination, and the exhaled Case 1 air had a urine-like odor. Compartment 1 contractions were Case #1 involved a 150-kg, 6-year-old male, castrated llama absent and intestinal motility was decreased. The perineum presented to Auburn University Large Animal Teaching Hospital was stained with feces. Abdominal ultrasound revealed slight (AULATH) for anorexia and diarrhea of 5 d duration. During dilation of the renal calyces and moderate bilateral perirenal edema. A free-catch urine sample had a specific gravity of 1.010. Departments of Clinical Sciences (Chamorro, Passler, Bayne, A complete blood (cell) count (CBC) indicated leukocytosis Walz) and Pathobiology (Passler, Joiner, Walz) College of (26.49 3 103/mL; RR: 8.0 to 21.4 3 103/mL) (5), with neutro- Veterinary Medicine, Auburn University, 1500 Wire Road, philia (23.57 3 103/mL; RR: 4.7 to 14.8 3 103/mL) (5), left Auburn, Alabama, USA 36849; California Animal Health & shift (bands 1.3 3 103/mL; RR: 0 to 0.147 3 103/mL) (5), and Food Safety System, Davis, California, USA (Poppenga). hyperfibrinogenemia (20.6 mmol/L; RR: 2.9 to 14.7 mmol/L) Address all correspondence to Dr. Paul H. Walz; e-mail: (5). Serum chemistry analysis showed severe azotemia [blood [email protected] urea nitrogen (BUN) 105.0 mmol/L; RR: 3.2 to 12.8 mmol/L; The work described in this manuscript was performed at Auburn creatinine 2891 mmol/L; RR: 79.6 to 247.5 mmol/L] (5), University College of Veterinary Medicine. hypermagnesemia (1.8 mmol/L; RR: 0.8 to 1.4 mmol/L) Use of this article is limited to a single copy for personal study. (5), and hyperkalemia (6.6 mmol/L; RR: 3.6 to 6.2 mmol/L) Anyone interested in obtaining reprints should contact the (5). Metabolic acidosis (bicarbonate 11.5 mmol/L; RR: 19 to CVMA office ([email protected]) for additional 31 mmol/L) (5), increased anion gap (55 mmol/L; RR: 14 to copies or permission to use this material elsewhere. 20 mmol/L), increased liver enzymes [sorbitol dehydrogenase

CVJ / VOL 54 / JANUARY 2013 61 FOR PERSONAL USE ONLY

(SDH) 16.4 U/L; RR: 0 to 15 U/L, aspartate aminotransferase (AST) 561 U/L; RR: 127 to 420 U/L] (5), and creatine kinase (CK) 1889 U/L; RR: 14 to 238 U/L, (5) were detected. Initial fluid therapy included a 1.3% sodium bicarbonate solution (Hospira, Lake Forest, Illinois, USA), in combination with polyionic crystalloids (Plasmalyte; Abbot Laboratories, Chicago, Illinois, USA), 100 mL/kg body weight (BW) per day, IV in order to promote diuresis and correct acid base and electrolyte abnormalities. Additional therapy included ceftiofur sodium (Naxcel; Pfizer Animal Health, New York, New York, USA), 4.4 mg/kg BW, IV, q12h. Ice packs were placed under RAPPORTCAS DE the abdomen and axilla to treat hyperthermia. After 20 h of therapy, the llama’s rectal temperature returned to normal (38.6°C) but the animal continued to be depressed, in sternal recumbency, and did not urinate again. The llama died after 22 h of treatment. At necropsy, multiple oak leaf fragments were interspersed Figure 1. Photomicrograph of hematoxylin and eosin-stained section of kidney (2003 magnification) demonstrating acute tubular among the ingesta in gastric compartments 1, 2, and 3. Multiple degeneration and necrosis (asterisk). Affected tubules are filled with areas of hyperemia were detected throughout the gastric mucosa. granular, proteinaceous debris and lined by discontinuous epithelium. Moderate perirenal edema was present bilaterally, and the kid- neys were swollen, wet, pale, and soft. No other gross lesions were observed. Histologic examination of the kidneys revealed pellets was observed during initial examination. Ultrasound multifocal, acute tubular degeneration and necrosis, with tubular examination of thoracic and abdominal cavities, including both epithelial regeneration (Figure 1). Degenerating tubules were kidneys was unremarkable. A CBC showed that there was leu- lined by discontinuous epithelium with sloughing into the kopenia (6.53 3 103/mL) with neutropenia (4.31 3 103/mL), tubular lumens. Other non-specific histologic changes included left shift (bands 0.261 3 103/mL), and hyperfibrinogenemia gastric mucosal congestion, vacuolar hepatocellular degenera- (23.5 mmol/L). Serum chemistry analysis demonstrated severe tion, and pulmonary congestion. Samples of urine and kidney azotemia (BUN 101.0 mmol/L; creatinine 3085 mmol/L), hypo- tissue were submitted for gas chromatography-mass spectrom- natremia (140 mmol/L; RR: 148 to 158 mmol/L) (5), hypokale- etry (GC/MS) detection of pyrogallol, a degradation product of mia (2.6 mmol/L), hypochloremia (83 mmol/L), hypocalcemia gallic acid [California Animal Health & Food Safety Laboratory (1.8 mmol/L; RR: 2.0 to 2.6 mmol/L) (5), and hyperglycemia (CAHFSL), Davis, California, USA]; however, all samples were (12.3 mmol/L; RR: 4.2 to 9.8 mmol/L) (5). Metabolic acidosis below the pyrogallol detection level (5 ppm). (bicarbonate 12.4 mmol/L), increased anion gap (47.2 mmol/L), and increased liver enzymes [SDH 44.5 U/L; AST 1196 U/L; Case 2 gamma-glutamyl transferase (GGT) 120 U/L; RR 20 to 60 U/L] Case #2 involved a 120-kg 9-year-old, male intact llama pre- and CK (1167 U/L; RR 14 to 238 U/L) (5) were present. sented to AULATH for anorexia, depression, and production Urinalysis revealed isosthenuria (urine specific gravity of 1.011), of scant amounts of dry bloody feces over a 5-day period. The glucosuria, proteinuria, and presence of red blood cells. Serum owner stated that the llama appeared to drink normal quanti- and urine samples were submitted to the CAHFSL for pyrogal- ties of water from a trough, and he had treated the llama with lol testing. The analysis determined that pyrogallol values were 100 mg flunixin meglumine (Banamine; Schering Plough below the detection level (5 ppm). Fecal evaluation for parasites Animal Health, Union, New Jersey, USA), IV for 2 d and had revealed 500 eggs/g trychostrongyles. administered 2 rectal enemas with mineral oil (Butler Schein Intravenous fluid therapy was initiated using 1.3% sodium Animal Health, Dublin, Ohio, USA) at unknown doses. The bicarbonate solution with potassium chloride, 20 mEq/L llama had been moved to the farm during the previous month (Hospira) at 100 mL/kg BW per day during the first 24 h to cor- and was placed on a mixed-grass pasture with a male goat that rect dehydration, electrolyte abnormalities, and metabolic aci- remained unaffected. The owner reported that during the last dosis. Furosemide (Salix; Intervet, Millsboro, Delaware, USA), month, the grass had been scarce and that oak trees were present 2 mg/kg BW, IV, q8h, ranitidine (Zantac; GlaxoSmithKline, in the pasture. The llama had not been vaccinated or dewormed Research Triangle Park, North Carolina, USA), 1.5 mg/kg BW, by the owner. IV, q8h, and ceftiofur sodium (Naxcel; Pfizer Animal Health), The llama was mildly depressed on presentation. The heart 4.4 mg/kg BW, IV, q12h were also given. After 24 h of treat- rate was 90 bpm, respiratory rate 44 breaths/min, and tem- ment, hydration appeared normal, and the llama appeared perature 37.6°C. Dehydration was estimated at 6%. Body brighter and was urinating, but diarrhea and anorexia continued. condition score was 4/9. Gastric compartment 1 contractions At 24 h of hospitalization, liver enzymes, sodium, and bicar- were absent and intestinal motility was decreased. During bonate concentrations were normal; however, hypochloremia examination of the oral cavity, severe halitosis was noted. An (85 mmol/L), hypokalemia (3.1 mmol/L), increased anion gap episode of diarrhea with blood clots and some formed fecal (31.3 mmol/L), and azotemia (BUN 88.5 mmol/L; creatinine

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2714 mmol/L) were still present. Ranitidine, furosemide, sodium isosthenuria, metabolic acidosis, increased liver enzymes, and ceftiofur, and isotonic saline containing potassium chloride evidence of inflammation, which are abnormalities commonly (20 mEq/L) at a rate of 100 mL/kg BW per day were continued. observed in cattle with oak toxicosis (1–3). Oak toxicosis in Forty-eight hours after hospitalization, the llama was bright cattle is associated with the high concentrations of tannins of and responsive, urination frequency was normal, and feces oak, which are hydrolyzed to gallic acid and pyrogallol in the

were more formed but still covered with mucus and blood. The rumen and are responsible for cellular damage (1–3). Tannins REPORT CASE llama was still anorectic and C1 motility was absent. A third cause direct damage to epithelial cells in the gastrointestinal tract serum chemistry panel demonstrated normokalemia, hypochlo- inducing irritation and ulceration (2,4). Pyrogallol and other remia (88 mmol/L), increased anion gap (30.3 mmol/L), and gallic acid metabolites cause acute renal tubular necrosis that severe azotemia (BUN 71.8 mmol/L; creatinine 1830 mmol/L). results in acute renal failure and uremia, which further irritates Urinalysis revealed a urine specific gravity of 1.010 with no the gastrointestinal mucosa and contributes to gastroenteritis other remarkable findings. Potassium chloride administration (1–4). In some animal species, oak toxicosis is also associ- was suspended and ruminal fluid (2 L) obtained from a donor ated with hepatic damage and increased liver enzymes (2,3). cow was administered via orogastric tube q24h for 3 d. The rest Inflammatory changes indicated by the CBC and increased liver of the therapeutic plan remained the same. On day 4 of hospi- enzymes in both llamas in this case are suggestive of bacterial talization and during the next 8 d the llama progressively started translocation and endotoxin absorption as a consequence of to eat hay and drink water. The llama recovered forestomach disruption of the gastrointestinal mucosa, and subsequent liver motility, urination continued to be normal, but unformed damage associated with effects of endotoxin and gallic acid on feces covered with blood clots were still present. Fluid therapy hepatocytes (6,9,10). Renal lesions observed at histopathology was continued. At day 10 of hospitalization, serum chemistry of the kidneys in case #1 demonstrated diffuse renal tubular demonstrated normal serum electrolyte values. A considerable degeneration and necrosis and tubular regeneration suggesting decrease in the concentrations of BUN and creatinine was also oak toxicosis (1,3,4). observed (BUN 42.6 mmol/L; creatinine 1070 mmol/L). Since Inflammation of the gastrointestinal mucosa and vacuolar the llama was eating, drinking, and urinating normally, raniti- degeneration of the liver observed in case #1 have also been dine, furosemide, and antibiotics were discontinued. Intravenous reported in cattle with oak toxicosis (2,3). Additionally, gross fluid therapy was continued using an isotonic crystalloid solu- pathology on case #1 confirmed the presence of oak leaves tion (Plasmalyte; Abbot Laboratories) at 75 mL/kg BW per day. in the 3 gastric compartments. The severity of renal damage During the next 20 d, the llama remained alert, responsive, and electrolyte and acid base abnormalities in cattle with oak eating and drinking normally. Urination was normal and feces toxicosis depends on the duration of exposure to oaks and the were free of blood and recovered their normal consistency. amount ingested (2,3). Initially, affected animals are presented Considerable decreases in BUN and creatinine values ranging with hyponatremia, hyperkalemia, hypochloremia, hyperphos- from 27.4 to 4.6 mmol/L and 778 to 389 mmol/L, respectively, phatemia, hypocalcemia, metabolic acidosis, and increased were observed. Urine specific gravity at this time varied from anion gap (1,4). Both llamas had severe azotemia and anion 1.009 to 1.023. Intravenous fluid therapy was decreased to gap metabolic acidosis. Llama #1 was hyperkalemic and hyper- 60 mL/kg BW per day on day 15 and was terminated at day 30 magnesemic while llama #2 was hyponatremic, hypokalemic, of hospitalization. The llama kept eating, drinking, urinating, hypochloremic, hypocalcemic, and hyperglycemic. The differ- and defecating normally. Values of BUN and creatinine after ences between the 2 animals may be explained by differences termination of IV fluids ranged from 5.6 to 5.5 mmol/L and in duration of exposure to oak trees, amount of dehydration, 442 to 407 mmol/L, respectively. Urine specific gravity varied and duration of the anorexia. Urine abnormalities observed in between 1.018 and 1.030. At day 45 of hospitalization, the cattle after renal tubular necrosis due to oak toxicity include llama was discharged from the hospital with instructions for a low specific gravity, proteinuria, glucosuria, and hematuria, low protein diet and adequate mineral and forage supplementa- which were consistent with changes observed in urinalysis in tion. One month after discharge, the llama was still doing well case #2. Intensive fluid therapy, furosemide, and antibiotics were and levels of serum BUN and creatinine were within reference administered to promote diuresis, correct electrolyte and acid ranges. base abnormalities, and prevent secondary bacterial infections, respectively. Llama #2 responded favorably to treatment, and Discussion the differences in treatment response may have been related to Acute renal failure in large animals usually results from hemo- duration of renal failure and degree of systemic compromise. dynamic changes in renal perfusion (hypoperfusion or ischemia) Other causes of renal tubular necrosis in ruminants include or from exposure to nephrotoxic agents (4). In this report, acute ingestion of heavy metals, antibiotic therapy, non-steroidal renal failure is described in 2 llamas that had pasture access to anti-inflammatory drugs (NSAIDs), vitamins, and toxic plants oak trees. At initial presentation, both llamas were depressed, (4,5). Reports of acute renal failure in South American camelids anorectic, and had history of constipation followed by diarrhea. are scarce; however, treatment with gentamicin, urinary tract These signs are nonspecific and commonly observed in sick cam- congenital abnormalities (renal agenesis and ureter duplication), elids (6–8). Initial clinical signs in oak toxicosis in cattle often hydronephrosis, Eimeria macusaniensis infection, oleander toxi- include anorexia and constipation or hemorrhagic diarrhea (1,3). cosis, and hypervitaminosis D are described as potential causes Laboratory data in both llamas demonstrated severe azotemia, (6–11). In this report, there was no history of exposure to heavy

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metal or other toxic plants, nor was there a history of prolonged gnesemia may be associated with poor prognosis. Initial therapy treatment with antibiotics, NSAIDs, or vitamin D, so causality should focus on rehydration, promotion of diuresis, correction wasn’t attributed to these nephrotoxic agents. Congenital abnor- of electrolyte and acid base abnormalities, and prevention of sec- malities and hydronephrosis were unlikely due to the age of the ondary bacterial infections. Long-term intravenous fluid therapy llamas and necropsy results in case #1. Eimeria macusaniensis was associated with recovery in 1 case and could be attempted infection usually presents as a chronic condition with progressive in cases of severe acute renal failure in camelids. CVJ weight loss and hypoproteinemia (6). The clinical diagnosis of oak toxicosis in this report was supported by history of expo- References sure to oak trees, clinical signs, and histopathology. Serum and . 1 Spier SJ, Smith BP, Seawright AA, Norman BB, Ostrowski SR, Oliver MN. Oak toxicosis in cattle in northern California: Clinical and patho- urine samples were evaluated for the presence of pyrogallol in logic findings. J Am Vet Med Assoc 1987;191:958–964. both cases; however, concentrations were below the detection 2. Plumlee KH, Johnson B, Galey FD. Comparison of disease in calves RAPPORTCAS DE threshold. Studies in experimental induction of oak toxicosis dosed orally with oak or commercial tannic acid. J Vet Diagn Invest 1998;10:263–267. in cattle demonstrate that after ingestion of oak leaves, calves 3. Pérez V, Doce RR, García-Pariente C, et al. Oak leaf (Quercus pyrenaica) have detectable levels of pyrogallol in serum and urine only until poisoning in cattle. Res Vet Sci 2011;91:269–277. 6 and 60 h, respectively, suggesting that pyrogallol disappears 4. Smith BP. Large Animal Internal Medicine. 4th ed. St. Louis, Missouri: Mosby Elsevier, 2009:874–876. from serum or urine before clinical signs of renal failure occur, 5. Fowler ME. Medicine and Surgery of Camelids. 2nd ed. Ames, Iowa: thus preventing definitive diagnosis (2). Differences in the Blackwell, 2010:482–486. amount and duration of oak ingestion by individual animals and 6. Cebra CK, Valentine BA, Schlipf JW, et al. Eimeria macusaniensis infection in 15 llamas and 34 alpacas. J Am Vet Med Assoc 2007;230: ability of goats to resist oak toxicity may explain the absence of 94–100. clinical signs in the pasture mates of these llamas (4). Stressful 7. Kozikowski TA, Magdesian KG, Puschner B. Oleander intoxication in conditions can contribute to susceptibility and clinical signs New World camelids: 12 cases (1995–2006). J Am Vet Med Assoc 2009; 235:305–310. of oak toxicosis (3), and in these cases, transport and forage 8. Gerspach C, Bateman S, Sherding R, et al. Acute renal failure and anuria scarcity could have played a role in individual susceptibility of associated with vitamin D intoxication in two alpaca (Vicugna pacos) the llamas to oaks. cria. J Vet Intern Med 2010;24:443–449. 9. Poulsen KP, Gerard MP, Spaulding KA, Geissler KA, Anderson KL. Acute renal failure due to oak toxicosis should be suspected Bilateral renal agenesis in an alpaca cria. Can Vet J 2006;47:159–161. in adult llamas with a history of exposure to oak trees that are 10. Cardwell JM, Thorne MH. Hydronephrosis and ureteral duplication presented with depression, anorexia, diarrhea, severe azotemia, in a young alpaca. Vet Rec 1999;145:104–107. 11. Hutchison JM, Belknap EB, Williams RJ. Acute renal failure in the and isosthenuria. The presence of severe dehydration, marked llama (Lama glama). Cornell Vet 1993;83:39–46. inflammatory changes in the CBC, hyperkalemia, and hyperma-

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64 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY Review Article Compte rendu

Jugular thrombophlebitis in horses: A review of fibrinolysis, thrombus formation, and clinical management

Deborah Penteado Martins Dias, José Corrêa de Lacerda Neto

Abstract — Thrombophlebitis of the jugular vein is commonly observed in horses, particularly during intensive care, and leads to local and systemic inflammatory responses as well as head and neck circulatory impairment. Thrombolytic therapy is widely used in human practice with the aim of thrombus dissolution and recanalization of the injured vessels. There are similarities between human and horse coagulation and fibrinolytic processes. This review examines the fibrinolytic system, thrombus formation, and the clinical management of jugular thrombo- phlebitis, including thrombolytic therapy. There is evidence that early regional thrombolytic therapy for jugular thrombophlebitis in horses may be effective to achieve sustained recanalization.

Résumé —Thrombophlébite jugulaire chez les chevaux : revue de la fibrinolyse, de la formation de thrombus et de la gestion clinique. La thrombophlébite de la veine jugulaire est communément observée chez les chevaux, particulièrement durant les soins intensifs, et cause des réactions inflammatoires locales et systémiques ainsi que des altérations de la circulation dans la tête et le cou. La thérapie thrombolytique est couramment utilisée en pratique humaine dans le but de dissoudre les thrombus et de recanaliser les vaisseaux blessés. Il y a similitudes entre les processus coagulant et fibrinolytique des humains et des chevaux. Cette revue examine le système fibrinolytique, la formation de thrombus et la gestion clinique de la thrombophlébite jugulaire, incluant la thérapie thrombolytique. Il y a des preuves que la thérapie thrombolytique régionale précoce pour la thrombophlébite jugulaire chez les chevaux peut être efficace pour la réalisation d’une recanalisation durable. (Traduit par Isabelle Vallières) Can Vet J 2013;54:65–71

Introduction The fibrinolytic system hrombophlebitis of the jugular vein in horses is a com- In 1958, Astrup (5) proposed the concept of dynamic equilib- T monly observed, undesirable iatrogenic complication, rium for coagulation and fibrinolytic systems. In this delicate particularly during intensive care. Several drugs are widely used balance, the fibrinolytic process breaks down fibrin which is for acute thrombolytic therapy in human practice but there are continuously deposited throughout the cardiovascular system few reports on the use of thrombolytic agents to treat throm- as a result of limited physiological activation of the coagulation. bosis in horses (1–4). This review examines the fibrinolytic The coagulation and fibrinolytic systems interact through feed- system, thrombus formation, and the clinical management of back mechanisms that are not fully understood (6). Fibrinolysis jugular thrombophlebitis, including thrombolytic therapy in is regulated such that unwanted fibrin thrombi are removed horses. The review also highlights the evidence supporting the from circulation, whereas fibrin in wounds persists to prevent use of streptokinase (SK) as a regional treatment for clinical blood loss and maintain hemostasis (7–9). The vascular endo- thrombosis in horses. thelium, a highly specialized multifunctional organ, is intimately involved with regulation of hemostasis, supporting anticoagulant mechanisms, including fibrinolysis and inhibition of platelets Departamento de Clínica e Cirurgia Veterinária, Faculdade de and serine proteases, to maintain blood fluidity (10). The cas- Ciências Agrárias e Veterinárias — FCAV/Unesp, Brazil. cade of reactions leading to thrombus dissolution is schemati- Address all correspondence to Dr. Deborah Penteado Martins cally illustrated in Figure 1. Dias; e-mail: [email protected] The key enzyme in the fibrinolytic system is the glycoprotein Dr. Dias’ current address is Via de acesso Prof. Paulo Donato plasminogen which is produced in the liver (6). The inactive Castellane, s/n, Jaboticabal — SP, 14884-900, Brazil. proenzyme plasminogen is converted to the active enzyme plas- Use of this article is limited to a single copy for personal study. min by 2 specific serine proteases: the tissue-type plasminogen Anyone interested in obtaining reprints should contact the activator (tPA), released from endothelial cells in response to CVMA office ([email protected]) for additional stasis or vessel wall injury, and the urokinase type plasmino- copies or permission to use this material elsewhere. gen activator (uPA), also called urokinase. The tPA-mediated

CVJ / VOL 54 / JANUARY 2013 65 FOR PERSONAL USE ONLY COMPTERENDU

Figure 1. Schematic representation of fibrinolysis showing tissue plasminogen activator (tPA) pathway. Tags: plasminogen (Pmg); plasminogen activator inhibitor-1 (PAI-1); alpha2-antiplasmin (a2-AP); activation (1); inhibition (2).

pathway is primarily involved in fibrin homeostasis, and the Tests for the assessment of fibrinolysis in horses include uPA-mediated pathway is involved in cell migration and tissue tests for fibrinogen concentration, fibrin degradation products remodeling (11). Activation of plasminogen to plasmin occurs (FDPs), D-dimer (DD) levels, and thromboelastography (TEG). by the cleavage of an arginine-valine bond, which produces Fibrinogen concentrations may be difficult to interpret in changes in conformation, leading to an increased affinity for critically ill horses as the levels change with both inflammation both degradation substrates and activators (6). Plasmin, a and coagulopathies, although low levels may support increased relatively nonspecific protease, has the capacity to hydrolyze fibrinolysis. Both FDPs and DD result from fibrinolysis, but fibrin and various plasma proteins, including fibrinogen and FDPs result from the degradation of both fibrin and fibrino- coagulation factors (6,7,12). Plasmin also activates matrix metal- gen (13), while DDs (formed only by the plasmin digestion of loproteinases that, in turn, degrade the extracellular matrix (11). cross-linked fibrin) are considered specific for fibrin (13,14). Fibrinolytic activity is modulated by plasminogen activators Fibrin monomers (FM), the initial products of fibrin forma- and inhibitors (8,10,12). The plasminogen activator inhibi- tion, form high molecular weight complexes with fibrinogen tor 1 (PAI-1) is a fast-acting inhibitor of tPA and uPA; PAI-2 and FDPs and is an accurate indicator of an activated state is secreted in small amounts under normal conditions, but may of coagulation. Fibrin monomers may be deposited locally, in be released in high concentration from damaged endothelium cases of thrombosis, or diffusely, in cases of disseminated intra- (10). The most important inhibitors that act at the plasmin vascular coagulation (DIC) in humans (15,16). In horses, FM

level are alpha2-antiplasmin and alpha2-macroglobulin (8,12). also indicates the coagulation state. Clinical studies evaluating Alpha2-antiplasmin, a single-chain glycoprotein protease inhibi- horses after colic surgery reported high levels of FM before tor, is the main physiologic inhibitor of plasmin (6). Plasma the occurrence of jugular vein thrombosis (17) and DIC (18).

concentrations of alpha2-antiplasmin are sufficient to inhibit Antithrombin (AT) inactivates thrombin and some coagulation about 50% of potential plasmin (7). The half-life of alpha2- factors, and is considered the main inhibitor of coagulation antiplasmin and plasmin complex is approximately 12 h (6). (19). In horses undergoing colic surgery, reductions in AT cor- When massive activation of plasminogen occurs, such as during responded to the severity of intestinal lesions (20). Evaluating

thrombolytic therapy, alpha2-antiplasmin is depleted, and the coagulation and fibrinolysis indicators, Feige et al (20) showed high free plasmin levels lead to a “systemic lytic state,” increasing that activation of coagulation and fibrinolysis increased after the risk of bleeding from wounds (7). The thrombin activatable the colic surgical procedure, marked by a prolonged activated fibrinolysis inhibitor (TAFI) is a plasma protein that attenuates partial thromboplastin time, and by increased concentrations the conversion of plasminogen to plasmin. During inflammatory of DD and FM. The authors also reported that surgical trauma processes, the anti-coagulant effects of protein C are impaired per se did not influence coagulation, and changes were due to and activation of TAFI is retained. Therefore, fibrinolysis is the primary disease. The study concluded that high FM and decreased, adding to the prothrombotic coagulopathy associ- DD concentrations represent an increased risk for the develop- ated with sepsis (9). ment of a coagulopathy after colic surgery.

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Thromboelastography measures global hemostatic function the most important factor of this triad in the development of of whole blood in vitro, documenting the interaction between jugular vein thrombosis (32). platelets and coagulation cascade proteins (21) and provides Thrombosis begins with platelets adhering to macromolecules information on clot kinetics and mechanical properties from in the subendothelial regions of the injured blood vessel to formation through maturation and fibrinolysis. The use of form the primary hemostatic plug. The platelets then stimulate REVIEW ARTICLE REVIEW whole blood allows the analysis of cellular and plasma compo- local activation of plasma coagulation factors, leading to the nents, providing a global assessment of hemostatic potential generation of a fibrin clot that reinforces the platelet aggregate. (22,23). Validation of TEG in horses and establishment of the Within an intact blood vessel, thrombosis is prevented by the first reference values were performed by Paltrinieri et al (24). body’s anticoagulant mechanisms. Prostacyclin (PGI2), anti- Thromboelastography may be a clinically useful tool in horses. thrombin, heparan sulfate proteoglycans, protein C, protein S, For example, in horses presenting with gastrointestinal diseases, ADPase, and TF pathway inhibitor (TFPI) are examples of TEG was an effective method to determine coagulation and natural thrombosis inhibitors (7,9,33,34). Activated protein C fibrinolysis changes, as well as to distinguish hypocoagulation and protein S, in the circulation or on the endothelium surface, and hypercoagulation states (22,25). block the inhibitory effect of PAI-1. Therefore, plasminogen may exert its function leading to fibrinolysis, thereby preventing Thrombus formation thrombotic processes (10). The equilibrium proposed by Astrup (5) is easily overwhelmed during pathologic coagulation states. In such states, the fibrino- Jugular thrombophlebitis in horses lytic system fails to maintain fluidity of the blood in the affected Thrombophlebitis is defined as venous thrombosis secondary to vessels, resulting in thrombosis (6). Equine diseases commonly inflammation of the vessel wall (35–37). Infection can complicate associated with coagulation abnormalities include gastrointes- and enhance this venous disorder. In septic thrombophlebitis, tinal diseases and sepsis, often associated with endotoxemia or there is bacterial or, rarely, fungal colonization of the vessel wall, the systemic inflammatory response syndrome (SIRS) (13,26). thrombus, and, occasionally, of the surrounding perivascular tis- Other conditions in horses associated with coagulopathies sues (38). Blood flow is impaired due to reduced vascular lumen include genetic coagulation defects, neoplasia, protein-losing by partial or complete occlusion (38,39). Thrombophlebitis enteropathy, and protein-losing nephropathy (26). most commonly affects the jugular veins in horses because they Horses with gastrointestinal disorders and sepsis may develop are the most commonly used site to access venous circulation. coagulopathies characterized by excessive activation of coagu- The disease is associated with poor venipuncture technique, lation, and impairment of the fibrinolysis and anti-coagulant prolonged or improper placement of indwelling catheters, pathways (9,13,27,28). The degree of abnormal coagulation and injections of irritating drugs that lead to mechanical or with gastrointestinal diseases may be mild to marked, depend- chemical injury of the vessel wall (30,36,40–44). An atypical ing upon the severity of the disorder. Simple obstructions and etiology of jugular thrombophlebitis, extending directly from a displacements usually produce a mild to moderate activation of penetrating buccal ulcer in a horse, was described by Matsuda the coagulation system, usually compensated by the fibrinolytic et al (45). system. More severe problems such as intestinal strangulation or The development of thrombophlebitis following catheteriza- enteritis may produce a marked prothrombotic state, which can tion is dependent on catheter composition, venipuncture tech- lead to disseminated intravascular coagulation (9,28). Medical nique, cannula size, catheter maintenance, pH of the infusate treatment of acute abdomen, or postoperative care of horses solution, duration of infusion, and presence of bacteria (46). undergoing surgery for gastrointestinal lesions is often intensive All of these factors underscore the importance of using aseptic and frequently necessitates long-term maintenance of a jugular techniques to implant and maintain venous catheters. catheter for administration of intravenous fluids and medica- A bacteriological study assessing techniques for disinfecting tions. If these horses have concurrent coagulopathies, in associa- sites prior to the insertion of jugular intravenous catheters in tion with jugular vein trauma and inflammation occurring with horses reported that chlorhexidine and povidone-iodine were catheterization, they are at increased risk for the development of equally effective when used on skin after the hair had been thrombophlebitis of the jugular vein (13,28). Mair and Smith clipped (47). The authors concluded that clipping or shaving (29) reported that 8.3% of 252 horses that underwent surgical the hair over the veins prior to disinfection is recommended, but treatment of colic developed jugular vein thrombophlebitis. there were no differences when the hair was left long, clipped, The imbalance leading to thrombus formation may be a result or shaved. Therefore, the skin can be disinfected effectively with of multiple factors, including vessel injury or other intrinsic either agent without clipping or shaving the hair when rapid vessel wall lesion, a low-flow state or venous stasis, and blood intravenous catheterization is a clinical priority. hypercoagulability (6,30). This classic triad, describing the The pharmaceuticals most frequently associated with the pathogenesis of thrombosis, was first outlined by Virchow in development of thrombophlebitis include glycerol guaiaco- 1856 (cited in reference 30). Experimentally and clinically, it is late, thiopental, calcium gluconate, phenylbutazone, and now recognized that at least 2 of these 3 postulated factors in oxytetracycline (38,39). Phenylbutazone, widely used for combination are essential in the progress of venous thrombo- ­anti-­inflammatory therapy of musculoskeletal system injuries sis. In humans, decreased blood flow or stasis seems to be the of athletic horses, is commonly associated with thrombophlebitis dominant component (31). However in horses, local trauma is when it is accidently infused in the perivascular region (39,48).

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Clinical signs associated with aseptic jugular vein thrombo- consists of hot packs and hydrotherapy applied over the swol- sis are generally limited to localized firmness and a cord-like len vein 3 or 4 times daily and the application of dimethyl jugular vein. Venous distention proximal to the thrombus site sulfoxide (DMSO) solution on the affected area. Non-steroidal is observed when there is complete occlusion. When bacteria are anti-inflammatory drugs may be useful in reducing pain and seeded in thrombi resulting in septic thrombophlebitis, horses inflammation. Systemic antibiotics are indicated for sepsis have intermittent fever, depression, and neck stiffness. Palpation (35,43,50,61). Bonagura et al (50) suggested metronidazole at elicits local swelling, heat, pain, and a cord-like jugular vein. 15 mg/kg body weight (BW), PO, q6h, or at 25 mg/kg BW, Generally, leukocytosis, neutrophilia, and hyperfibrinogen- PO, q12h in cases of anaerobic infection. If the thrombotic emia are present (49,50). As reported by Ryu et al (51), septic lesion is associated with a generalized coagulopathy, heparin thrombi in the jugular vein may also lead to pleuropneumonia therapy [unfractionated, 40 to 100 IU/kg BW, IV or SQ, q6h; via the pulmonary circulation. low molecular weight (Dalteparin), 50 to 100 IU/kg BW, SQ, COMPTERENDU The diagnosis of septic or nonseptic thrombophlebitis is q24h] may be beneficial (67). Efficacy and side effects of low primarily based on history and physical signs (38,39,49). molecular weight heparin (LMWH) compared to unfractionated The disease is evaluated with hematology tests, ultrasonog- heparin (UH) have been evaluated in horses with gastrointestinal raphy, contrast angiograms, and bacteriologic confirmation diseases. At a dose of 50 IU/kg BW, q24h, LMWH decreases (35,49,50,52,53). Ultrasonography of the vein and surrounding the incidence of jugular thrombosis compared to treatment tissue can be used to specifically characterize the thrombus and with UH in horses having colic surgery (68). Aspirin at a dose monitor the extent and progress of the lesion (37,54). The jugu- of 20 mL/kg BW every other day is also recommended for the lar vein and its valves can be readily identified (35). In cases of treatment of thrombophlebitis to inhibit platelet activation and thrombophlebitis, ultrasonography allows an evaluation of ves- aggregation (30). Scott et al (60) reported 2 cases of jugular vein sel walls, blood flow compromise, and presence, extension and thrombophlebitis successfully treated by warfarin anticoagula- shape of the thrombus, as well as compensatory vascularization tion. However, the authors recommend this therapy only in and recanalization characteristics (55). The sonographic appear- situations in which the coagulation status can be monitored by ance of the normal jugular vein is that of an anechoic circular or daily laboratory determinations of prothrombin time. tubular structure, with identification of a more hyperechoic ves- When jugular vein thrombophlebitis is refractive to medical sel wall (38). Inflamed jugular veins often appear thick-walled, treatment, surgical techniques including phlebotomy, thrombec- and the thrombus is imaged as a partially or totally occlusive tomy with Fogarty’s catheter, or venous grafts may be performed hyperechoic structure adhering to the vessel wall. In cases of to restore blood flow (40,42,62–66). Dias et al (57) performed partial obstruction, the blood flow appears as an anechoic an ultrasonographic evaluation during the acute phase of area between the thrombus and opposite vessel wall where the experimental jugular vein thrombophlebitis in horses and dem- thrombus is connected (38,56,57). If only partial obstruction onstrated that the major thrombus development occurs in the to blood flow is present, distension of the vein by distal digital early stages of injury. These findings suggest that the first 24 h occlusion helps to prevent collapse during ultrasonographic may represent the most effective intervention period. In horses, evaluation (55). A septic thrombus appears as a hyperechoic the complications associated with jugular vein thrombophlebitis heterogeneous cavitating mass in which the anechoic areas rep- include pleuropneumonia, bacterial endocarditis, pulmonary resent fluid accumulation secondary to infection and necrosis thromboembolism, septicemia, and other conditions associated (38,50,54). Anaerobic bacterial infections often show numer- with metastasis of septic thrombi (44). ous hyperechoic areas creating an acoustic shadow due to gas The long-term outcome for a thrombus is variable. production (38). Blood flow across the affected vessel may be Recanalization of the vein may take place. The thrombus may evaluated by venography, or with pulsed-wave or color-coded undergo fibrous organization without recanalization or col- Doppler (50). lateral circulation may develop (44). Hussni et al (69) observed If a catheter is still in place when a thrombosis is discov- via angiography that collateral vascularization develops within ered, the catheter should be carefully withdrawn and the tip 1 y in horses submitted to a unilateral jugular vein resection cultured (26,35). Identification of the infectious agent and its that restores the venous drainage of the head and neck. If the drug susceptibility is important for treatment (35). While the jugular venous obstruction persists and collateral vascularization catheter remains in situ, the thrombus will not dissolve, and does not occur, especially when both jugular veins are involved, it may grow (58). Furthermore, the injured vessel should be dysphagia and dyspnea due to impaired venous return from the preserved, and venipuncture should be avoided. The opposite head is likely to limit athletic performance (38,42,50). Moreau jugular vein should also be preserved to avoid the risk of bilateral and Lavoie (44) suggested that thrombophlebitis did not affect thrombophlebitis. Lateral thoracic, cephalic, and saphenous the athletic performance of horses used for pleasure riding and veins are other options for drug administration and venous other nonracing activities, even when the horses suffered bilateral blood collection (59). In a retrospective study, Dolente et al (26) occlusion. However, thrombophlebitis in racing Standardbreds reported severe intestinal disease, hypoproteinemia, salmonel- was associated with a decreased chance of return to racing. losis, and endotoxemia as potential risk factors for development of catheter-associated jugular thrombophlebitis in horses. Thrombolytic therapy and streptokinase Both medical (35,43,60,61) and surgical (40,42,62–66) The medical treatments for equine jugular vein thrombo- treatments for thrombophlebitis are reported. Local treatment phlebitis are often ineffective, and restoration of blood flow

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is typically only achieved with complex and expensive surgical thrombophlebitis in horses, showing evidence of SK fibrino- procedures. In human medicine, thrombolytic therapy involving lytic activity; however, their methods are not fully established. fibrinolytic agents has revolutionized the treatment of diverse According to Dias et al (4), regional thrombolytic therapy using circulatory disorders, such as pulmonary embolism, deep-vein a bolus administration of 100 mL of SK solution (7500 IU of thrombosis, and myocardial infarction (12). It has been possible SK per mL of 0.9% sodium chloride solution) may be effective REVIEW ARTICLE REVIEW to treat intravascular thrombosis and achieve complete dis- for resolving induced jugular vein thrombosis in horses, and solution by using drugs capable of stimulating the fibrinolytic providing transitory recanalization. system (6). Thrombolytic therapy consists of the pharmaco- Other applications for fibrinolytic therapy have been reported logical dissolution of the blood clot by intravenous infusion of besides jugular thrombophlebitis in horses. Clark-Price et al (75) plasminogen activators that activate the intrinsic fibrinolytic utilized recombinant tPA in the anterior chamber of each eye of system components (11,12). Thrombolytic drugs dissolve both a foal with fibrin accumulation associated with endotoxemia and pathological thrombi and fibrin deposits at sites of vascular septicemia, providing fibrin clot clearance and restoring normal injury, with the risk of hemorrhage as the major side effect vision. Hilton and Pusterla (76) also used fibrinolytic therapy in (7). Streptokinase (SK) is a nonenzymatic protein produced the management of septic pleuropneumonia in a horse. by strains of b-hemolytic streptococci (6,11,12). The capacity Early regional thrombolytic therapy for jugular thrombophle- of SK to promote the lysis of blood clots was first described by bitis in horses may be effective to achieve sustained recanaliza- Tillett in 1933 (cited in reference 70); the effect is thought to tion. A thorough understanding of the fibrinolytic system and be mediated by enzymatic action on fibrin (70). Streptokinase the potential complications associated with its modification is combines with plasminogen to form a stable activator complex an essential foundation for advances in thrombolytic therapy. that has enzymatic activity (71). This SK-activator complex then Additional research is needed to expand our knowledge of the activates the fibrinolytic mechanism by converting uncomplexed fibrinolytic system, and to develop new clinical applications to plasminogen to plasmin. The SK-plasminogen complex is slowly address coagulation problems in horses. The authors hope to converted to a SK-plasmin form, which can also activate and stimulate new investigations analyzing drugs capable of acti- convert plasminogen. The initial activity is mediated by the vating the fibrinolytic system in horses, and to promote future SK-plasminogen complex, whereas the later activity is mediated development of novel treatments for jugular thrombophlebitis by the SK-plasmin form (6). Streptokinase is a foreign protein, and other diseases associated with fibrin accumulation in and its introduction into the circulatory system can elicit an horses. anaphylactic response (8). Plasma antibodies against SK are normally present as a result of prior streptococcal infections. Acknowledgments Therefore, systemic lytic therapy only becomes effective when We acknowledge Fundação de Amparo à Pesquisa do Estado de enough of the drug has been administered to overcome these São Paulo (Fapesp) for financial assistance. CVJ antibodies (7). Lytic agents can be administered systemically or regionally (6). References In the attempt to avoid the hemorrhagic consequences of 1. Tillotson PJ, Kopper PH. Treatment of aortic thrombosis in a horse. J Am Vet Med Assoc 1966;149:766–767. thrombolytic therapy, Dotter et al (72) proposed a low dose, 2. Branscomb BL. Treatment of arterial thrombosis in a horse with sodium local infusion of SK for the treatment of arterial occlusive dis- gluconate. J Am Vet Med Assoc 1968;152:1643–1644. orders. Due to the smaller total dose of SK in local application, 3. Lions JA, Carette O, Broucker CA, Tainturier B, Ribot X. Utilisation de la streptokinase dans le traitement des thrombophlébites de la jugulaire there were fewer complications than with systemic therapy. chez le cheval : à propos de 2 cas cliniques. Bull Soc Vét Prat de France Regional thrombolytic therapy was further developed, and local 2008;92:17–22. targeted instillation through a catheter implanted into throm- 4. Dias DPM, Teixeira LG, Canola PA, et al. Streptokinase as a treatment for jugular vein thrombophlebitis in horses. Proc 12th World Equine botic material was proposed (6,73). The technique makes local Veterinary Association (WEVA) Congress, Hyderabad, India, 2011. fibrinolysis possible, and, importantly, this process is partially 5. Astrup T. The haemostatic balance. Thromb Diath Haemost 1958;2: protected from circulating inhibitors. Regional thrombolytic 347–357. 6. Kashyap VS, Quiñones-Baldrich WJ. Principles of thrombolytic therapy. therapy with SK has been used successfully in human practice In: Kashyap VS, Quiñones-Baldrich WJ, eds.Vascular Surgery. 5th ed. for venous thrombotic disorders of superficial veins, such as the Philadelphia, Pennsylvania: Saunders, 2000:457–475. axillosubclavian vein (6). The use of SK may be successful for 7. Majerus PW, Broze Jr. GJ, Miletich JP, Tollefsen DM. Anticoagulant, thrombolytic, and antiplatelet drugs. In: Gilman AG, Rall TW, Nies AS, jugular vein thrombophlebitis in horses, given the similarity Taylor P, eds. The Pharmacological Basis of Therapeutics. 4th ed. between horse and human thrombosis development processes New York, New York: Pergamon Press, 1990:1311–1331. (74), and the superficial localization and easy access to the 8. Banerjee A, Chisti Y, Banerjee UC. Streptokinase — a clinically useful thrombolytic agent. Biotechnol Adv 2004;22:287–307. jugular vein in horses. Nevertheless, there are few investigations 9. Hopper K, Bateman S. An updated viewof hemostasis: Mechanisms of analyzing SK fibrinolytic activity in horses. The use of SK in hemostatic dysfuntion associated with sepsis. J Vet Emerg Crit Care horses was first reported in 1966 and 1968 to treat aortic and 2005;15:83–91. 10. Duffy TC, Kirby R, Rudloff E. Critical role of the vascular endothe- left iliac thrombosis, respectively. Streptokinase was adminis- lial cell in health and disease: A review article. J Vet Emerg Crit Care trated in association with streptodornase, plasminogen, and 2004;14:84–99. sodium gluconate. Unfortunately, the authors could not specify 11. Collen D. The plasminogen (fibrinolytic) system. J Thromb Haemost 1999;82:259–270. which fibrinolytic agent led to case resolution (1,2). Lions 12. Kunamneni A, Abdelghani TTA, Ellaiah P. Streptokinase — the drug of et al (3) described the administration of SK to treat jugular choice for thrombolytic therapy. J Thromb Thrombolysis 2007;23:9–23.

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13. Schaer BLD, Epstein K. Coagulopathy of the critically ill equine patient. 42. Rijkenhuizen ABM, Van Swieten HA. Reconstruction of the jugular J Vet Emerg Crit Care 2009;19:53–65. vein in horses with post thrombophlebitis stenosis using saphenous vein 14. Dempfle CA. Use of D-dimer assays in the diagnosis of venous throm- graft. Equine Vet J 1998;30:236–239. bosis. Seminar Thromb Haemost 2000;26:631–641. 43. Divers TJ. Prevention and treatment of thrombosis, phlebitis and 15. Haselager EM, Vreeken J. Clinical significance of “circulating fibrin laminitis in horses with gastrointestinal diseases. Vet Clin North Am monomers”. J Clin Pathol 1981;34:468–472. Equine Pract 2003;19:779–790. 16. Dempfle CA. The use of soluble fibrin in evaluating the acute and 44. Moreau P, Lavoie JP. Evaluation of athletic performance in horses with chronic hypercoagulable state. Thromb Haemost 1999;82:673–683. jugular vein thrombophlebitis: 91 cases (1988–2005). J Am Vet Med 17. Feige K, Dempfle CE, Balestra E. Measurement of soluble fibrin in Assoc 2009;235:1073–1078. horses using Enzymun-Test FM. Thromb Haemost 1999;Suppl:2472. 45. Matsuda K, Suzuki H, Tsunoda N, Taniyama H. Jugular thrombophle- 18. Stern-Balestra E. Bestimmung von löslichen fibrinkomplexen beim pferd bitis developed from buccal ulcer in a thoroughbred horse. J Vet Med als möglichkeit der diagnostik einer aktivierten blutgerinnung. Doctoral Sci 2010;72:913–915. thesis. University of Zurich, Zurich, Switzerland. 2000. 46. Dickson LR, Badcoe LM, Burbidge H, Kannegieter NJ. Jugular throm- 19. Holland M, Kelly AB, Snyder JR, Steffey EP, Willits N, McNeal D. bophlebitis resulting from an anaesthetic induction technique in the

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A hematogenic pleuropneumonia Thromboelastography in healthy horses and horses with inflammatory caused by postoperative septic thrombophlebitis in a Thoroughbred gastrointestinal disorders and suspected coagulopathies. J Vet Emerg gelding. J Vet Sci 2004;5:75–77. Crit Care 2010;20:488–493. 52. Reimer JM. Vasculature (jugular vein and lymphatics). In: Reimer JM, 26. Dolente BA, Beech J, Lindborg S, Smith G. Evaluation of risk factors for ed. Atlas of Equine Ultrasonography. St. Louis, Missouri: Mosby, 1998: development of catheter-associated jugular thrombophlebitis in horses: 165–169. 50 cases (1993–1998). J Am Vet Med Assoc 2005;227:1134–1141. 53. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. 27. Monreal L, Anglés A, Espada Y, Monasterio J, Monreal M. Hyperco­ Circulation 2002;106:1874–1880. agulation and hypofibrinolysis in horses with colic and DIC. Equine 54. Gardner SY, Reef VB, Spencer PA. Ultrasonographic evaluation of Vet J 2000;32:19–25. horses with thrombophlebitis of the jugular vein: 46 cases (1985–1988). 28. Monreal L, Cesarini C. Coagulopathies in horses with colic. Vet Clin J Am Vet Med Assoc 1991;199:370–373. North Am Equine Pract 2009;25:247–258. 55. Barbosa RG, Borghesan AC, Cerqueira NF, et al. Fisiopatologia da 29. Mair TS, Smith LJ. Survival and complication rates in 300 horses trombose e tromboflebite da veia jugular de equinos: revisão. Vet Zootec undergoing surgical treatment of colic. Part 2: Short-term complica- 2009;16:26–37. tions. Equine Vet J 2005;37:303–309. 56. Reef VB. Cardiovascular ultrasonography. In: Reef VB, ed. Equine 30. Sellon DC, Wise LN. Disorders of the hematopoietic system. In: Diagnostic Ultrasound. Philadelphia, Pennsylvania: Saunders, 1998: Reed SM, Bayly WM, Sellon DC, eds. Equine Internal Medicine. 215–272. 3rd ed. St. Louis, Missouri: Saunders, 2010:730–776. 57. Dias DPM, Canola PA, Teixeira LG, Albernaz RM, Canola JC, Lacerda- 31. Mammen EF. Pathogenesis of venous thrombosis. Chest Suppl 1992; Neto JC. Ultrasonographic evaluation of experimental jugular vein 102:640S–644S. thrombophlebitis in horses. Vet Surg 2010;39:E21. 32. Lankveld DPK, Ensink JM, Van Dijk P, Klein WR. Factors influenc- 58. Geraghty TE, Love S, Taylor DJ, Heller J, Mellor DJ, Hughes KJ. ing the occurrence of thrombophlebitis after post-surgical long-term Assessment of subclinical venous catheter-related diseases in horses and intravenous catheterization of colic horses: A study of 38 cases. J Vet associated risk factors. Vet Rec 2009;164:227–231. Med A Physiol Pathol Clin Med 2001;48:545–552. 59. Gardner SY, Donawick WJ. Jugular vein thrombophlebitis. In: 33. Caprino R, Togna AR, Stella C, Togna G. An in vitro method for Robinson NE, ed. Current Therapy in Equine Medicine 3. Philadelphia, evaluating vascular endothelial ADPase activity. J Pharmacol Toxicol Pennsylvania: Saunders, 1992:406–410. Methods 1996;35:153–157. 60. Scott EA, Byars TD, Lamar AM. Warfarin anticoagulation in the horse. 34. Esmon CT. Role of coagulation inhibitors in inflammation. Thromb J Am Vet Med Assoc 1980;177:1146–1151. Haemost 2001;86:51–56. 61. Dargatz J, Dargatz D. Intravenous catheters and thrombophlebitis. 35. White II N. Intensive care, monitoring and complications of acute Reports of Equine Veterinary Meetings 1993;13:379. abdominal disease. In: White II N, ed. The Equine Acute Abdomen. 62. Ben-Chehida N, Bellagha A, Bardi K. Traitement d’une thrombo- Philadelphia, Pennsylvania: Lea & Febiger, 1990:309–335. phlébite chez un cheval par une prothèse en polyretrafluoroethylene 36. Ettlinger JJ, Palmer JE, Benson C. Bacteria found on intravenous cath- (PTFE). Prat Vét Equine 1994;26:169–173. eters removed from horses. Vet Rec 1992;130:248–249. 63. Wiemer P, Gruys E, Hoeck BV. A study of seven different types 37. Klohnen A. New perspectives in postoperative complications after of grafts for jugular vein transplantation in the horse. Res Vet Sci abdominal surgery. Vet Clin North Am Equine Pract 2009;25:341–350. 2005;79:211–217. 38. Edens LM. Iatrogenic thrombophlebitis. In: Colahan PT, Mathew IG, 64. Dornbusch PT, Hussni CA, Yoshida WB, Sequeira JL, Vulcano LC, Merritt AM, Moore JN, eds. Equine Medicine and Surgery. 5th ed. Cillo GP. Implante jugular homólogo fixado em glutaraldeído, nos Vol 1. St. Louis, Missouri: Mosby, 1999:416–419. equinos. Rev Port Ciênc Vet 2007;102:81–86. 39. Thomassian A. Afecções sanguíneas e vasculares. In: Thomassian A, 65. Hussni CA, Dornbusch PT, Yoshida WB, et al. Trombectomia com ed. Enfermidades dos Cavalos. 3rd ed. São Paulo, Brazil: Varela, 1996: cateter de Fogarty no tratamento da tromboflebite jugular experimental 519–532. em equinos. Pesqui Vet Bras 2009;29:45–51. 40. Cannon JH, Rantanen NW, Grant BD, Keck MT. Jugular venous 66. Russel TM, Kearney C, Pollock PJ. Surgical treatment of septic jugular prothesis on the horse: A preliminary study. J Equine Vet Sci 1983;3: thrombophlebitis in nine horses. Vet Surg 2010;39:627–630. 185–189. 67. Orsini JA, Divers TJ. Equine Emergencies: Treatment and Procedures. 41. Knottenbelt DC, Pascoe RR. Disorders of the cardiovascular system. 3rd ed. St. Louis, Missouri: Saunders, 2008. In: Knottenbelt DC, Pascoe RR, eds. A Color Atlas of Diseases and 68. Feige K, Schwarzwald CC, Bombeli TH. Comparison of unfractioned Disorders of the Horse. Barcelona, Spain: Wolfe, 1994:157–188. and low molecular weight heparin for prophylaxis of coagulopathies in

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52 horses with colic: A randomised double-blind clinical trial. Equine 73. Stegnar M, Kozak M, Sabovic M. (1994) D-dimer during intra-arterial Vet J 2003;35:506–513. low-dose streptokinase treatment of peripheral arterial occlusive disease. 69. Hussni CA, Dornbusch PT, Alves ALG, et al. Avaliação clínica e Fibrinolysis 1994;8:105–107. angiográfica da vascularização consecutiva à ressecção experimental da 74. Baskurt OK, Farley RA, Meiselman HJ. Erythrocyte aggregation ten- jugular de equinos. Vet Zootec 2006;13:163–168. dency and cellular properties in horse, human, and rat: A comparative 70. Sikri N, Bardia A. A history of streptokinase use in acute myocardial study. Am J Physiol 1997;273:H2604–H2612.

infarction. Tex Heart Inst J 2007;34:318–327. 75. Clark-Price SC, Cox JH, Bartoe JT, Davis EG. Use of dapsone in the ARTICLE REVIEW 71. Rang HP, Dale MM. Haemostasis and thrombosis. In: Rang HP, treatment of Pneumocystis carinii pneumonia in a foal. J Am Vet Med Dale MM. Phamacology. New York, New York: Churchill Livingstone, Assoc 2004;224:407–410. 1987:280–296. 76. Hilton H, Pusterla N. Intrapleural fibrinolytic therapy in the manage- 72. Dotter CT, Rosch J, Seaman AJ. Selective clot lysis with low-dose ment of septic pleuropneumonia in a horse. Vet Rec 2009;164:558–559. streptokinase. Radiology 1974;111:31–37.

Answers to Quiz Corner Les réponses du test éclair

1. e) Conception can occur from a mating more than 7 days 7. c) Calves can become infected with Cryptosporidium as early before ovulation to 5 days after ovulation. as 3 days of age. e) La conception peut se produire à partir du premier c) Cryptosporidium peut infecter les veaux qui sont âgés de accouplement plus de 7 jours avant jusqu’à 5 jours après moins de 3 jours. l’ovulation. 8. e) T hough a good indicator of hepatocellular damage in some 2. b) Fractures on one side of the bone, with bending of the species, serum alanine aminotransferase activity is not opposite side, are called greenstick fractures. They occur helpful in the diagnosis of liver disease in cattle. primarily in young growing dogs. e) Bien qu’un bon indicateur du dommage hépatocellulaire chez b) Les fractures sur le côté d’un os avec courbure du côté certaines espèces, l’activité de l’alanine aminotransférase opposé sont nommées fractures en bois vert. Elles se sérique n’est pas utile pour le diagnostic des maladies produisent principalement chez les jeunes chiens en hépatiques chez les ruminants. croissance. 9. c) Hypotension can be observed following the administration 3. b) Hemimandibulectomy is most likely to prevent recurrence. of propofol in healthy patients. The effect is exacerbated b) L’hémimandibulectomie est la plus susceptible de prévenir by dehydration. Propofol does not directly affect heart rate une récidive. or myocardial contractility. c) On peut observer de l’hypotension à la suite de 4. e) Unlike dogs, cats do not develop diabetic cataracts because l’administration de propofol chez les patients en santé. of a difference in their lens metabolic pathway. Les effets sont exacerbés par la déshydratation. Le propofol e) Contrairement aux chiens, les chats ne développent pas de n’affecte pas directement la fréquence cardiaque ou la cataractes diabétiques à cause d’une différence dans leur contractilité du myocarde. voie métabolique du cristallin. 10. d) Eosinophilia occurs commonly in response to antigen- 5. a) These signs describe guttural pouch tympany. antibody reactions, as well as with inflammation of certain a) Ces signes décrivent du tympanisme de la poche gutturale. organs, such as the lungs, which tend to be allergy targets. 6. e) This foal had unilateral disease, so fenestration of the d) L’éosinophilie se produit communément en réponse aux median septum would allow trapped air to exit through réactions antigène-anticorps ainsi qu’en présence d’une the normal right guttural pouch. inflammation de certains organes comme les poumons, e) Cette pouliche souffre d’une affection unilatérale, de sorte qui sont des cibles pour les allergies. que la fenestration du septum médian permettra à l’air de s’échapper par la poche gutturale droite qui n’est pas atteinte.

CVJ / VOL 54 / JANUARY 2013 71 FOR PERSONAL USE ONLY Case Report Rapport de cas

Cholesterol granuloma associated with otitis media and leptomeningitis in a cat due to a Streptococcus canis infection

Sara Van der Heyden, Patrick Butaye, Stefan Roels

Abstract — Cholesterol granuloma in the middle ear is a pathological condition often associated with otitis media in humans. Cholesterol granulomas in cats are rarely described. To our knowledge, this is the first report of middle ear cholesterol granuloma in a cat, associated with otitis media and leptomeningitis due to a Streptococcus canis septicemia.

Résumé — Granulome à cholestérol associé à une otite moyenne et à une leptoméningite chez un chat causé par une infection par Streptococcus canis. Un granulome à cholestérol dans l’oreille moyenne est une affection pathologique souvent associée à l’otite moyenne chez les humains. Les granulomes à cholestérol chez les chats sont rarement décrits. À notre connaissance, il s’agit du premier rapport d’un granulome à cholestérol de l’oreille moyenne chez un chat, associé à l’otite moyenne et à la letpoméningite, causé par une septicémie à Streptococcus canis. (Traduit par Isabelle Vallières) Can Vet J 2013;54:72–73

holesterol granulomas are non-neoplastic lesions with have recently been associated with otitis media (6). Cholesterol C characteristics of a granuloma, containing cholesterol granulomas in cats are rarely described in the uterus (7) and crystals (1). Factors necessary for the development of choles- brain (8,9). terol granuloma are hemorrhage, interference with clearance To our knowledge, this is the first report of a case of middle or drainage, and obstruction of air exchange or ventilation (1). ear cholesterol granuloma in a cat, which was associated with a Middle ear cholesterol granuloma is a pathological condition Streptococcus canis septicemia, leptomeningitis, and otitis media. often associated with otitis media in humans (1). In veterinary medicine, cholesterol granulomas are seen in the choroid plexus Case description (plexus cholesteatoma) of the ventricles in 20% of older horses A stray, adult, black female domestic long-haired cat was found as an asymptomatic aging change and incidental finding on with signs of cachexia, moaning when manipulated, apathy, necropsy (2). In dogs, cholesterol granulomas are only rarely depression and weakness, circling and ataxia. Due to poor health found in the middle ear, the maxilla, and the brain (3–5) and status the cat was euthanized. On postmortem examination, the animal was cachectic and Veterinary and Agrochemical Research Centre (CODA/ dehydrated with an unhealthy coat. Both external ears were dirty CERVA), Department of Biocontrol, Section of Pathology with thick brown granular material in the ears and the right (Van der Heyden, Roels) and Department of Bacteriology and bulla tympanic wall was wet, with thickening and white foci. Immunology, Section of Bacteriology (Butaye), Groeselenberg The gross appearance of the brain, meninges, and left tympanic 99, 1180 Brussels (Ukkel), Belgium. bulla was normal. Samples of the right bulla tympanic wall, the cerebrum, cerebellum and brainstem, liver, and spleen were Address all correspondence to Dr. Sara Van der Heyden; e-mail: collected for bacteriological and histopathological examination. [email protected] Samples for histopathology were fixed in neutral-buffered for- Drs. Van der Heyden and Roels current affiliation is Operational malin, embedded in paraffin wax, sectioned (5 mm) and stained Direction Interactions and Surveillance, Unit of Surveillance, with hematoxylin and eosin (H&E). Histological examination of Orientation and Veterinary Support, CODA/CERVA. Dr. Butaye’s the right bulla wall demonstrated predominantly fibrovascular current affiliation is Operational Bacterial Diseases, Unit of tissue with some areas of ossification. Multiple acicular empty Bacteriology, CODA/CERVA. clefts typical for cholesterol crystals were present, surrounded by Presented as a poster at the ESVP/ECVP Congress, Uppsala, aggregates of foamy macrophages. Lymphocytes, plasma cells, Sweden, September 2011. and some neutrophils were also present. The granulation tissue Use of this article is limited to a single copy for personal study. was partially covered by flattened, simple squamous epithelium. Anyone interested in obtaining reprints should contact the The leptomeninges of the cerebrum showed some infiltrating CVMA office ([email protected]) for additional mononuclear inflammatory cells, while there was no meningitis copies or permission to use this material elsewhere. at the level of the brain stem and cerebellum. Histopathological

72 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY lesions were absent in the brain parenchyma. Bacteriological 2. Jubb KVF, Huxtable CR. Degeneration in the nervous system. Jubb examination revealed the presence of b-haemolytic colonies on KVF, Kennedy PC, Palmer N, eds. Pathology of Domestic Animals. 4th ed. St. Louis, Missouri: Elsevier, 1993:334–335. blood agar plates (BioMérieux, Brussels, Belgium) and selective 3. Cox CL, Payne-Johnson CE. Aural cholesterol granuloma in a dog. Gram-positive plates (colistin aztreonam plates, CAP, Oxoid, J Small Anim Pract 1995;36:25–28. Erembodegem — Aalst, Belgium) in all tissue samples. The bac- 4. Mould JRB. Cholesterol granuloma of the maxilla in a dog. J Small Anim Pract 1990;31:208–211. terium was identified as Streptococcus canis by tDNA-polymerase 5. Steiss JE, Cox NR, Knecht CD. Electroencephalographic and histo- REPORT CASE chain reaction (PCR) (10). pathologic correlations in eight dogs with intracranial mass lesions. Am J Vet Res 1990;51:1286–1291. Discussion 6. Fliegner RA, Jubb KVF, Lording PM. Cholesterol granuloma associated with otitis media and destruction of the tympanic bulla in a dog. Vet Streptococcus canis can belong to the normal flora of the perianal Pathol 2007;44:547–549. region, oral cavity, and upper respiratory tract and has been 7. Zhangi A, Nicotina PA, Catone G, Gimbo A. Cholesterol granuloma (Xanthomatous metritis) in the uterus of a cat. J Comp Pathol 1999;121: associated with pyogenic infections of the respiratory tract, skin, 307–310. genitourinary system, eyes, bones, and cardiovascular system 8. Fluehmann G, Konar M, Jaggy A, Nicolier A, Vandevelde M. Cerebral of dogs and cats (11–13). Outbreaks with fatal infections have cholesterol granuloma in a cat. J Vet Intern Med 2006;20:1241–1244. 9. Ricci E, Abbiati G, Cantile C. Intracranial cholesterol granuloma in a been reported in intensively housed shelter cats (14) and breed- cat. J Vet Med Sci 2010;72:1475–1478. ing colonies (15). 10. Baele M, Storms V, Haesebrouck F, et al. Application and evaluation of Otitis media, inflammation of the middle ear structures, can the interlaboratory reproducibility of tRNA intergenic length polymor- phism analysis (tDNA-PCR) for identification of Streptococcus species. be initiated via rupture of the tympanic membrane (most com- J Clin Microbiol 2001;39:1436–1442. mon), through the auditory tube or rarely by hematogenous 11. Biberstein EL, Brown C, Smith T. Serogroups and biotypes among spread (16). Cats may develop otitis media, similar to piglets beta-hemolytic streptococci of canine origin. J Clin Microbiol 1980;11: 558–561. (17), through the auditory tube secondary to upper respiratory 12. DeWinter LM, Prescott JF. Relatedness of Streptococcus canis from disease (18). Spread of infection from the middle and inner ear canine streptococcal toxic shock syndrome and necrotizing fasciitis. to the brain may occur by erosion through the medial aspect of Can J Vet Res 1999;63:90–95. 13. Sykes JE, Kittleson MD, Pesavento PA, Byrne BA, McDonald KA, the petrous temporal bone, by migration of bacteria along exist- Chomel BB. Evaluation of the relationship between causative organisms ing vascular or neuronal pathways, or via hematogenous spread, and clinical characteristics of infective endocarditis in dogs: 71 cases and can result in meningitis, encephalitis, or abscess formation (1992–2055). J Am Vet Med Assoc 2006;228:1723–1734. 14. Pesavento PA, Bannasch MJ, Bachmann R, Byrne BA, Hurley KF. Fatal (19). Although considered uncommon, central nervous system Streptococcus canis infections in intensively housed shelter cats. Vet Pathol invasion as a complication of otitis media has been demonstrated 2007;44:218–221. in animals (19,20). 15. Iglauer F, Kunstyr I, Morstedt R, Farouk H, Willenweber M, Damsch S. Streptococcus canis arthritis in a cat breeding colony. J Exp Anim Sci It is generally agreed that most cases of otitis in veterinary 1991;34:59–65. patients are caused by bacteria, of which Staphylococcus and 16. Shell LG. Otitis media and otitis interna. Vet Clin North Am Small Streptococcus spp. are among the most commonly isolated Anim Pract 1988;18:885–889. 17. Morita T, Fukuda H, Awakura T, et al. Demonstration of Mycoplasma (16,21). All organ samples showed presence of S. canis and hyorhinis as a possible primary pathogen for porcine otitis media. Vet hematogenous spread is assumed. To the authors’ knowledge, Pathol 1995;32:107–111. this is the first report of middle ear cholesterol granuloma in a 18. Holzworth J. Naturally occurring upper respiratory infection in cats. J Vet Med Assoc 1971;158:964–968. cat, associated with otitis media and leptomeningitis due to a 19. Spangler EA, Dewey CW. Meningoencephalitis secondary to bacte- S. canis septicemia. rial otitis media/interna in a dog. J Am Anim Hosp Assoc 2000;36: 239–243. Acknowledgments 20. Sturges BK, Dickinson PJ, Kortz GD, et al. Clinical signs, magnetic resonance imaging features, and outcome after surgical and medical We thank the staff of the Pathology and Bacteriology (VAR) treatment of otogenic intracranial infection in 11 cats and 4 dogs. J Vet Intern Med 2006;20:648–656. section for technical assistance. CVJ 21. Lyskova P, Vydrzalova M, Mazurova J. Identification and antimicrobial susceptibility of bacteria and yeasts isolated from healthy dogs and dogs References with otitis externa. J Vet Med A 2007;54:559–563. 1. Ferlito A, Devaney KO, Rinaldo A, et al. Clinicopathological consulta- tion: Ear cholesteatoma versus cholesterol granuloma. Ann Oto Rhinol Laryn 1997;106:79–85.

CVJ / VOL 54 / JANUARY 2013 73 FOR PERSONAL USE ONLY Case Report Rapport de cas

Infiltrative lipoma compressing the spinal cord in 2 large-breed dogs

Marc K. Hobert, Christina Brauer, Peter Dziallas, Ingo Gerhauser, Dorothee Algermissen, Andrea Tipold, Veronika M. Stein

Abstract — Two cases of infiltrative lipomas compressing the spinal cord and causing nonambulatory paraparesis in 2 large-breed dogs are reported. Magnetic resonance imaging (MRI) revealed severe extradural spinal cord compression by inhomogenous masses that infiltrated the adjacent tissues and the muscles of the spine in both dogs. The presumptive clinical diagnoses were infiltrative lipomas, which were confirmed by histopathology. In rare cases infiltrative lipomas are able to compress the spinal cord by the agressive growth of invasive adipocytes causing neurological deficits.

Résumé — Lipome infiltrant comprimant la colonne vertébrale chez 2 chiens de grande race. Deux cas de lipomes infiltrants comprimant la colonne vertébrale et causant une paraparésie non ambulatoire chez 2 chiens de grande race sont signalés. L’imagerie par résonance magnétique (IRM) a révélé une compression extradurale grave de la colonne vertébrale par des masses inhomogènes qui infiltraient les tissus adjacents et les muscles de la colonne vertébrale des 2 chiens. Les diagnostics cliniques présumés étaient des lipomes infiltrants, ce qui a été confirmé par histopathologie. Une croissance agressive des cellules adipeuses a causé les déficits neurologiques. (Traduit par Isabelle Vallières) Can Vet J 2013;54:74–78

ubcutaneous tissue adipocytes are considered to be the cells 2 large-breed dogs suffering from infiltrative lipomas compress- S of origin of infiltrative lipomas and of well-demarcated ing the spinal cord. lipomas. Both tumor types, therefore, have similar histological appearance (1). Typically, lipomas are benign neoplasms that have Case descriptions no tendency to metastasize. Nevertheless, they are able to invade Case 1 adjacent tissue such as muscles and connective tissue, bones, A 5-year-old, female, intact Bernese mountain dog was presented and in rare cases peripheral nerves and the spinal cord (2,3). In to the Department of Small Animal Medicine and Surgery of the general, lipomas are poorly defined and grow slowly but they can University of Veterinary Medicine Hannover, Germany, with a also exhibit periods of rapid growth (4). The definitive diagnosis history of falling from a first floor balcony missing a balustrade of infiltrative lipoma can only be made by histological evaluation the night before. Since this accident the dog was unable to walk. (5). It is not known why some lipomas develop a locally invasive The referring veterinarian treated the dog with glucocorticoste- behavior and form the infiltrative lipomas (2). The recurrence roids. In addition to the acute trauma, the dog had a history of rate, even after aggressive surgical resection ranges from 36% to progressive weakness of the hind limbs for the past 4 to 5 wk. 50% in contrast to simple lipomas in which the local recurrence The physical examination was normal with the exception rate is , 2% (2,3,6). Therefore, adjuvant therapy such as radia- of an elevated body temperature (39.9°C). The neurological tion or chemotherapy is recommended (7,8). examination revealed a nonambulatory spastic paraparesis with This case report describes the neurological signs, magnetic accentuation to the left side and with severe deficits in the resonance imaging (MRI), and histopathological findings in postural reactions of the hind limbs. The patellar reflex was decreased in both hind limbs. The postural reactions in the front limbs were unremarkable. The dog was not in pain when the Department of Small Animal Medicine and Surgery (Hobert, spine was palpated. The cranial nerves were unremarkable. The Brauer, Dziallas, Tipold, Stein) and Department of Pathology neuroanatomical localization was L3–L4 because of the reduced (Gerhauser, Algermissen), University of Veterinary Medicine patellar reflex and T3–L3 because of the spastic paraparesis. Hannover, Bünteweg 17, 30559 Hannover, Germany. A chronic progressive disease such as neoplasia, degenerative Address all correspondence to Dr. Marc Hobert; e-mail: myelopathy, or disc disease was suspected with a superimposed [email protected] spinal cord trauma. The dog had a mild to moderate leukocyto- Use of this article is limited to a single copy for personal study. sis [20.8 3 109/L, reference interval (RI): 6.0 to 17.0 3 109/L] Anyone interested in obtaining reprints should contact the with neutrophilia 18.0 3 109/L (RI for segmented neutrophils: CVMA office ([email protected]) for additional 3.0 to 11.5 3 109/L), a mild lymphopenia (0.97 3 109/L, RI: copies or permission to use this material elsewhere. 1.0 to 4.8 3 109/L) and a monocytosis (1.7 3 109/L, RI: 0.18

74 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 1a. T2-weighted sagittal magnetic resonance image of the thoracic portion of the vertebral column of the dog in case 1. A hyperintense mass is visible in the dorsal paraspinal region extending from Th8 to Th9 with consecutive compression of the spinal cord in this region. The spinal cord and the adjacent muscles are hyperintense compared to surrounding musculature (arrowhead) and spinal cord (star), respectively. The vertebral body of Th9 is characterized by a central hyperintense area (arrow).

Figure1b. T2-weighted transverse image of the mass in the Figure 2. T2-weighted transverse image with fat saturation region of Th9 of case 1. The hyperintense mass is compressing (Spectral Adiabatic Inversion Recovery, SPAIR) of the mass in the spinal cord from the right to the left side (arrowhead). The the region of Th9 of case 1. The mass (arrowhead) compressing adjacent tissue is also hyperintense (stars). the spinal cord (arrow) from the right side exhibits signal characteristics comparable to that of subcutaneous fat tissue (star). This finding suggests that the mass has a fatty origin. to 1.35 3 109/L). The electrolyte profile showed a mild decrease enous hyperintense area in T1- and T2-weighted sequences at in ionized calcium concentration (1.22 mmol/L, RI: 1.25 to the level of the 9th thoracic vertebra (Th9) extending from the 1.47 mmol/L). Total protein was mildly increased to 71.3 g/L right Musculus longissimus and M. multifidus to the spinal cord. (RI: 60 to 70 g/L). The base excess (BE) of the venous blood gas The hyperintense area reached extradurally into the vertebral was 26.2 (RI: 24.0 to 4.0). The partial thromboplastin time canal to the right side of the spinal cord and displaced the (PTT) was 12.4 s (RI: 14.5 to 19.0 s). spinal cord to the left side. The adjacent muscles in the right Thoracic radiographs showed a mild radiolucency of the spi- paravertebral region, the M. longissimus thoracis, M. multifidus nous process of Th9. A MR scan (Philips Achieva 3.0 T; Philips lumborum, M. spinalis et semispinalis thoracis et cervicis, and Healthcare, PC Best, The Netherlands) revealed an inhomog- the M. intercostalis internus and externus showed hyperintense

CVJ / VOL 54 / JANUARY 2013 75 FOR PERSONAL USE ONLY RAPPORTCAS DE

Figure 3. Cross-section of Th10 after paramedian opening of Figure 4. Transverse T2-weighted SPAIR-sequence in the the vertebral canal and removal of the spinal cord. The infiltrative region of Th10 of case 2. The spinal cord (arrow) is compressed lipoma is visible outside the vertebral canal lateral to the arcus by a hypointense mass to the right side (dotted line). The SPAIR- vertebrae (arrowhead) and infiltrates into the vertebral canal sequence decreases the signal intensity of the mass (dotted line) (asterisk) through the vertebral arc (arrow). Hematoxylin and as the signal intensity of the subcutaneous fat is decreased eosin (H&E), decalcified, bar 10 000 mm. (arrowheads). The adjacent musculature (star) is characterized by hyperintense signal intensity (compared with the surrounding musculature) which could be linked to the histopathologic diagnosis of myositis.

areas in T2- and T1-weighted sequences. The extent of the whole hyperintense lesion was 2.6 3 3.4 cm (length 3 width) with a height of 4.0 cm. The vertebral body of Th9 exhibited a central inhomogenous hyperintense area (Figures 1a, 1b). In a T2-weighted Spectral Adiabatic Inversion Recovery (SPAIR) sequence, which is a fat saturation sequence, all alterations appeared hypointense compared to the spinal cord and isoin- tense compared to the subcutaneous fat tissue (Figure 2). After intravenous administration of contrast medium (Gadolinium ® 64Gd, “Dotarem ;” Guerbet, Roissy, France) the mass lesion showed a mild contrast enhancement. With these MR findings the infiltrating tissue was identified as fatty tissue and a tentative diagnosis of infiltrative lipoma was made. Due to the guarded prognosis the owners elected euthanasia and an infiltrative lipoma was diagnosed at necropsy. In the region of Th9 to Th10 a focal, whitish-yellowish, soft tis- sue mass with dimensions of 4.0 3 1.0 3 0.4 cm (length 3 width 3 height) was detected that reached and broke into the Figure 5. Transverse T1-weighted magnetic resonance vertebral canal and also infiltrated the neighboring muscles. image of the thoracic region of Th10 of case 2 post contrast The compression of the spinal cord resulted in degeneration administration. Both the muscles and the mass show moderate in the region of Th9 to Th10. Histological examination of contrast enhancement (arrowhead and star). The moderate compression of the spinal cord is obvious (arrow). this region verified the macroscopic findings. The paraverte- brally located lipoma focally infiltrated into the vertebral canal (Figure 3). Furthermore, acute hemorrhages were detected in Case 2 the right axillar lymph node, the pancreas, and the lung in A 10-year-old, male, entire crossbreed dog was presented to the the macroscopic pathological examination. In the histological Department of Small Animal Medicine and Surgery, University of examination the right axillar lymph node and the lung showed Veterinary Medicine Hannover, Germany with a 10-day history mild, acute, multi­focal hemorrhages. The pancreas had mild, of progressive gait abnormalities in the hind limbs finally leading acute, multifocal, interstitial hemorrhages. The hemorrhages to a nonambulatory paraparesis. The dog had received glucocor- were attributed to the acute trauma due to the falling from the ticosteroids 9 d prior to presentation as well as 200 mg carprofen balcony. (Rimadyl; Pfizer, Berlin, Germany) once a day for 7 d. Both popliteal lymph nodes were prominent and the urinary bladder

76 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 6a. Histopathology of the tru-cut biopsy of the dog Figure 6b. Histopathology of the tru-cut biopsy of the dog in in case no. 2 showing well-differentiated adipocytes (arrows) case 2 at higher magnification showing infiltration of the skeletal infiltrating skeletal muscle fibers (star, H&E, bar 60 mm). muscle with well-differentiated adipocytes resulting in dissection of the fibers (H&E, bar = 30 mm).

was filled. The neurological examination revealed a nonambula- fibers, accompanied by focal lymphohistiocytic cell infiltration tory paraparesis with reduced proprioception in both hind limbs. (Figures 6a, 6b). An infiltrative lipoma causing secondary A mild hyperesthesia was noted when the dog was palpated at the muscle degeneration and myositis in the surrounding muscles thoracolumbar junction of the spine. The cranial nerves and the was highly suspected. spinal reflexes were unremarkable. The neuroanatomical localiza- tion of the lesion was T3-L3 and a chronic progressive disease such Discussion as neoplasia or disc disease was suspected. The complete blood Infiltrative lipomas invading and compressing the spinal cord in (cell) count (CBC) showed a mild leukopenia (5.3 3 109/L). dogs are rarely described (9–11). In both dogs described herein, Radiographs of the spinal column showed decreased widths of the infiltrative masses compressed the spinal cord in the thoracic intervertebral disc spaces Th10/11, Th11/12, and Th12/13. In region causing nonambulatory paraparesis. Both, MR scans T2-weighted MR images a hypointense mass was visible in the ver- and histopathology, identified the masses as infiltrative lipomas. tebral canal at Th10/11 with a length of 2 vertebral bodies, causing Lipomas are benign neoplasms that consist of localized nod- severe spinal cord compression. The adjacent muscles (M. spinalis ules of fat and originate from adipocytes of the subcutaneous tis- and semispinalis, and M. multifidus) appeared inhomogeneous sue. Infiltrative lipomas are locally invasive and may cause pain and hyperintense in the T2-weighted sequence. In the SPAIR and/or clinical signs due to the compression of neighboring tis- sequence the mass itself was hypointense with hyperintense areas sues (11,12). Unlike lipomas, infiltrative lipomas may cause pain of the surrounding muscles and tissue (Figure 4). The compress- upon palpation (1). In humans, pain occurs when the infiltrative ing mass, the adjacent muscles and tissue showed a mild contrast lipoma compresses or involves adjacent neurovascular and/or enhancement (Figure 5). muscular structures (13). Histologically, infiltrative lipomas and The owners elected euthanasia due to the guarded prognosis lipomas both consist of well-differentiated adipocytes (14). The and declined necropsy. However, 3 tru-cut biopsies were permit- dog in Case 2 showed a mild hyperesthesia when palpated at ted and sampled from the mass to confirm the diagnosis. The the thoracolumbar junction of the spine. This could have been histopathological examination revealed well-differentiated skel- caused by compression of the adjacent neurovascular structures etal muscle as well as adipocytes infiltrating the skeletal muscle and secondary inflammation of the muscles in this region. Both

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dogs were large-breed dogs, and, although infiltrative lipomas lateral thoracic area, 1 lateral to the mandible, 1 adjacent to the can occur in any breed, there seems to be a higher incidence in caudal thoracic vertebrae, and 1 in the ventrolateral abdominal Labradors, doberman pinschers, and mixed breed dogs (11,12). wall (2). Despite the good prognosis, adjuvant therapy is advis- Whereas 1 report stated that older female dogs may also be able. Ogilvie et al (7) reported a dog treated with doxorubicin overrepresented (12) another claimed that infiltrative lipomas for an infiltrative lipoma with a documented partial response occur commonly in middle-aged dogs (15). Females are affected within 6 wk. Survival time of dogs treated with radiation alone, 3 times as often as males (12,15). The 2 dogs in this report did before and after surgery is reported by McEntee et al (8). The not have similar signalments: case 1 involved a middle-aged (5 y) patient survival time ranged from 6 to 94 mo (median of 40 mo) female Bernese mountain dog, whereas case 2 was a relatively and 92% of the dogs benefited from radiation therapy (8). old (10 y) large male mixed-breed dog. Both dogs were not In the histopathological examination, mitotic figures were not overweight, which is consistent with the thesis of Kramek that detected in either case. These findings confirmed the diagnosis of RAPPORTCAS DE obesity does not appear to be a prerequisite for the disease (15). an infiltrative lipoma as these neoplasms do not produce mitotic The 2 patients reported here clearly demonstrate the strength of figures and are characterized by well-differentiated adipocytes. MR imaging as a diagnostic tool for soft tissue masses compress- These 2 cases of infiltrative lipomas compressing the spinal ing the spinal cord such as infiltrative lipomas. Radiographs led cord and causing severe neurological deficits show that MR imag- to suspicion of a neoplastic lesion in 1 dog, but did not provide ing is a sensitive diagnostic tool for soft tissue neoplasms such as definitive findings. Computed tomography (CT) was not per- infiltrative lipomas when the spinal cord is involved (2). Spinal formed. In 1 report, an infiltrative lipoma invading the pelvic canal cord compression by infiltrative lipomas, as described here, is and tendon sheath in a dog was diagnosed by CT scan (9,5,16). extremely rare. For surgical planning the MR imaging is irreplace- In both cases described here the MR imaging showed high signal able, as the margins of the neoplasm can be depicted as precisely intensity (hyperintensity) of the masses in T1- and T2-weighted as possible by this technique. Magnetic resonance imaging can sequences. The muscles and the mass lesions were both character- be helpful to distinguish lipomas from infiltrative lipomas and a ized by high signal intensity. Noticeably, both neoplasms were in special fat saturation sequence, such as the SPAIR sequence, can the distal thoracic region and without any indication, such as a provide the evidence that the neoplasms were of fatty origin. CVJ lump or swelling, at the surface of the body. In case 1, the neopla- sia was in the region of Th9/10 with severe extradural compression References of the spinal cord to the left side over a length of 2.0 cm. The . 1 Thomas RC, Fox LE. Tumors of the skin and subcutis. In: Morrison muscles involved showed a mild contrast enhancement. The dog in WB, ed. Cancer in Dogs and Cats. Baltimore, Maryland: Lippincott, Williams and Wilkins, 1998:500–501. Case 2 had extradural compression of the spinal cord in the region 2. Bergman PJ, Withrow SJ, Straw RC, Powers BE. Infiltrative lipoma in of Th10/11. The adjacent paraspinal muscles were characterized by dogs: 16 cases (1981–1992). J Am Vet Med Assoc 1994;205:322–324. high signal intensities in T2-weighted images. In both dogs, these 3. McChesney AE, Stephens LC, Lebel J, Snyder S, Ferguson HR. Infiltrative lipoma in dogs. Vet Pathol 1980;17:316–322. muscles showed a moderate contrast enhancement which could 4. Moulton JE. Tumors in Domestic Animals, 3rd ed. Berkeley, California: indicate local inflammation. University of California Press, 1990:31–33, 98. To corroborate these findings a fat saturation sequence 5. McEntee MC, Thral DE. Computed tomographic imaging of infiltrative lipoma in 22 dogs. Vet Radiol Ultrasound 2001;42:221–225. (SPAIR) was chosen. The SPAIR is a powerful technique for 6. Strafuss AC, Smith JE, Kennedy GA, Dennis SM. Lipomas in dogs. fat suppression which offers advantages over conventional J Am Anim Hosp Assoc 1973;9:555–561. fat suppression techniques. This technique suppresses/inverts 7. Ogilvie GK, Reynolds HA, Richardson RC, et al. Phase II evaluation of doxorubicin for treatment of various canine neoplasms. J Am Vet Med only fat spins and uses a spectrally selective adiabatic inversion Assoc 1989;195:1580–1583. pulse to invert the fat spins in the imaging volume. Due to this 8. McEntee MC, Page RL, Mauldin GN, Thrall DE. Results of irradia- suppression the fat spins do not contribute to the MR signal. tion of infiltrative lipoma in 13 dogs. Vet Radiol Ultrasound 2000;41: 554–556. Thus, fat appears hypointense (17). In this SPAIR sequence 9. Morgan LW, Toal R, Siemering G, Gavin P. Imaging diagnosis-­ both neoplasms had the same appearance as fat, supporting the Infiltrative lipoma causing spinal cord compression in a dog. Vet Radiol tentative diagnosis of an infiltrative lipoma. Ultrasound 2007;48:35–37. 10. O’Driscoll JL, McDonnell JJ. What is your neurologic diagnosis. J Am Unfortunately, the owners of both dogs elected euthanasia Vet Med Assoc 2006;229:933–935. due to the guarded prognosis. There are 2 reports, however, 11. Kim HJ, Chang HS, Choi CB, et al. Infiltrative lipoma in cervical bones of large-breed dogs with infiltrative lipomas compressing the in a dog. J Vet Med Sci 2005;67:1043–1046. 12. Goldschmidt M, Shofer F. Skin tumors of the dog and cat. Oxford, spinal cord that underwent surgery and had satisfactory results United Kingdom: Pergamon Press, 1992. (9,10). Those dogs did not show severe neurological deficits. 13. Austin RM, Mack GR, Townsend CM, et al. Infiltrating (intramuscular) Thus, surgery might be a therapeutic option for infiltrative lipomas and angiolipomas. Arch Surg 1980;115:281–284. 14. Thomson MJ, Withrow SJ, Dernell WS, Powers BE. Intermuscular lipo- lipomas compressing the spinal cord because it can be cura- mas of the thigh region in dogs: 11 cases. J Am Anim Hosp Assoc 1999; tive if the infiltrative lipoma can be completely excised. In a 35:165–167. retrospective study of infiltrative lipomas in different parts of 15. Kramek BA, Spackman CJA, Hayden DW. Infiltrative lipoma in three dogs. J Am Vet Med Assoc 1985;186:81–82. the body, Bergman et al (2) showed that only 5 dogs out of 16. Pereira JM, Sirlin CB, Pinto PS, Casaola G. CT and MR imaging of 13 had recurrence after aggressive surgical excision, while the extrahepatic fatty masses of the abdomen and pelvis: Techniques, diag- other 8 dogs were cured. Among 16 tumors, 5 were located in nosis, differential diagnosis, and pitfalls. RadioGraphics 2005;25:69–85. 17. Lauenstein TC. Spectral Adiabatic Inversion Recovery (SPAIR) MR the hind limb, 3 in the forelimb, 2 in the perianal area, 1 in the imaging of the Abdomen. MAGNETOM Flash 2/2008. Available from periocular region, 1 adjacent to the coxofemoral joint, 1 in the www.siemens.com/magnetom-world Last accessed November 5, 2012.

78 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY Brief Communication Communication brève

Respiratory disease outbreak in a veterinary hospital associated with canine parainfluenza virus infection

J. Scott Weese, Jason Stull

Abstract — A cluster of canine parainfluenza virus infections was identified in a veterinary referral hospital. While hospital-associated outbreaks of canine parainfluenza virus infection have not been previously reported, veterinary hospitals possess some of the same risk factors that may be present in traditional high-risk sites such as kennels. Hospital-associated transmission of canine respiratory pathogens, therefore, must be considered.

Résumé — Éclosion de maladies respiratoires dans une clinique vétérinaire associée à l’infection par le virus parainfluenza canin. Un groupe d’infections par le virus parainfluenza canin a été identifié dans une clinique vétérinaire spécialisée. Même si des éclosions d’infections par le virus parinfluenza canin n’ont pas été signalées antérieurement, les cliniques vétérinaires présentent certains des mêmes facteurs de risque qui peuvent être présents dans des lieux à risque traditionnellement élevé, comme les chenils. Par conséquent, il est nécessaire de considérer comme possible la transmission d’agents pathogènes respiratoires canins associée aux cliniques. (Traduit par Isabelle Vallières) Can Vet J 2013;54:79–82 ospital-associated (HA) infections are an ever-present Canine infectious respiratory disease complex is most com- H risk in veterinary healthcare facilities, and there has been mon in situations in which large numbers of dogs are kept increasing concern about these infections in recent years, largely together, and outbreaks are classically associated with kennels due to the emergence and dissemination of multidrug resistant and shelters (10,11). Because veterinary clinics may present pathogens such as methicillin-resistant staphylococci and multi­ the same opportunities for mixing of large numbers of dogs, drug resistant Gram-negative bacteria (1–4). There are limited HA-CIRDC is also a potential problem, and HA-CIRDC reports of HA transmission and outbreaks of other pathogens caused by canine herpesvirus has recently been reported (8). This such as Clostridium difficile (5) and Salmonella (6,7) but a wide report describes an outbreak of respiratory disease in a veterinary range of potential HA pathogens can be encountered. hospital associated with CPiV infection. Canine infectious respiratory disease complex (CIRDC) On September 20, 2011, a 1-year-old male castrated standard (previously referred to as infectious tracheobronchitis or kennel poodle dog was presented to the Ontario Veterinary College cough) is a syndrome that can be caused by a variety of patho- Health Sciences Centre (OVC-HSC) for an ophthalmological gens, most notably canine adenovirus type 2, canine parainflu- examination (Figure 1). He was an otherwise healthy dog that enza virus (CPiV), canine influenza, canine herpesvirus, canine had been vaccinated against canine distemper, canine adenovirus respiratory coronavirus, Bordetella bronchiseptica, Streptococcus type 2, CPiV, and canine parvovirus (DA2PP) with a 3-dose zooepidemicus, and Mycoplasma spp., sometimes in combination parenteral series on February 28, March 30, and May 12, 2011. (8,9). This disease complex (CIRDC) typically causes mild to He had not recently been at a kennel or shelter, but had direct moderate, self-limiting upper respiratory tract infection, mainly contact with other dogs at a dog park 5 days earlier and had characterized by cough with a relatively small percentage of cases been at a grooming facility 4 days earlier. No evidence of respira- developing complications such as pneumonia. Fatal infections tory disease was present at initial examination. He was housed are uncommon (8). in a general hospital ward in a floor-level cage and discharged later that day. On September 24, 2011, he was re-admitted for examination of an acute onset of fever and cough. He was Department of Pathobiology (Weese, Stull) and Centre for housed in an isolation unit during this visit and handled with Public Health and Zoonoses (Weese), Ontario Veterinary contact barrier precautions. Radiographic changes suggestive College, University of Guelph, Guelph, Ontario N1G 2W1. of bacterial pneumonia were noted, as was esophageal dilation. Address all correspondence to Dr. J. Scott Weese; e-mail: Empirical treatment with amoxicillin/clavulanic acid (Clavamox, [email protected] Pfizer, Mississauga, Ontario), 14 mg/kg body weight (BW), Use of this article is limited to a single copy for personal study. PO, q12h for 10 d was initiated. Pasteurella sp. susceptible to Anyone interested in obtaining reprints should contact the amoxicillin/clavulanic acid was isolated from a pharyngeal swab, CVMA office ([email protected]) for additional although given the sampling site, the relevance was unclear. At copies or permission to use this material elsewhere. recheck, 10 days later, the dog was improving both clinically and

CVJ / VOL 54 / JANUARY 2013 79 FOR PERSONAL USE ONLY

Table 1. Canine parainfluenza virus specific antibody titers as determined by hemagglutination inhibition Dog Acute Convalescenta Titer increase 1 1:384 1:1536 4-fold 2 1:32 1:1536 48-fold 3 1:96 1:1536 16-fold 4 1:96 1:512 5.3-fold

a Collected 10 to 14 d after acute phase samples.

however, it cannot be completely excluded. Dog 4 had received its triennial vaccination booster, which included CPiV, 3 wk

COMMUNICATIONBRÈVE prior to presentation. Coughing was reported to have started on Figure 1. Outbreak timeline. September 25. The dog was returned for collection of diagnostic samples, but because disease was mild, he was not admitted and no further diagnostic testing was performed. No treatment was radiographically. Esophageal dilation was no longer present. Full prescribed and no complications developed. recovery, occurring approximately 6 wk after disease onset, was Dog 5 was not at the OVC-HSC but was a suspected sec- subsequently uneventful. ondary case. This dog was owned by the neighbor of Dog 2 Dog 2, a 1-year-old spayed female bulldog, was hospitalized and there was periodic direct contact between the dogs in their September 19 to 23 because of diffuse urticaria of unknown yards. This dog was suspected to have had contact with Dog 5 origin. The dog had diarrhea, pyrexia, facial swelling, and hives. on September 24 and had an onset of cough on October 3. No It had received an appropriate initial series of DA2PP in 2010 further clinical information was available. and a booster on June 4, 2011. No signs of respiratory disease An infection control response was initiated on September 26 were identified. It was housed in the same ward in which Dog 1 immediately after reports of potential infections of dogs 2 and 3. had spent the day during its initial visit (September 20), in a The ward that had housed dogs 1, 2, and 4 was identified and floor-level cage approximately 3 m from Dog 1. Brief nose-to- quarantined. Patient follow-up was intensified and monitoring nose contact with Dog 1 occurred through the cage bars when of hospitalized patients for signs of respiratory disease or fever Dog 1 was walked through the ward. On September 25, 5 days of unknown origin was increased. Acute and convalescent serum after exposure to Dog 1, there was an acute onset of cough samples were collected from dogs 1–4 and tested for canine without fever. As with dog 1, this dog was isolated immediately influenza and CPiV antibodies by hemagglutination inhibition. upon re-admission on September 25 and handled with contact Nasal swabs were also collected for canine influenza polymerase barrier precautions. Thoracic radiographs were unremark- chain reaction (PCR) and pharyngeal swabs were collected for able. Treatment with hydrocodone (Pharmascience, Montreal, aerobic bacterial culture. Canine parainfluenza infection was Quebec), 0.2 mg/kg BW, PO, q6h for 14 d and doxycycline diagnosed through identification of a 4-fold or greater increase (Apo-Doxy; Apotex, Toronto, Ontario), 20 mg/kg BW, PO, in CPiV antibody titer in all tested dogs (Table 1). Antibodies q12h for 10 d was administered. Recovery was uneventful, with against canine influenza were not detected on acute or convales- cough persisting for approximately 14 d. cent samples and canine influenza virus PCR was negative. No Dog 3 was a 1-year-old male standard poodle which was a bacterial pathogens were identified. No samples were collected littermate to Dog 1 but owned by a separate owner in a different from dog 5. household. The dog was at the OVC-HSC on September 20 for Canine parainfluenza virus is an enveloped RNA virus that castration and was housed in a different ward; however, contrary belongs to the Paramyxoviridae family (12). It is highly con- to facility policy, it was allowed to play with Dog 1 in its run tagious, being excreted from the respiratory tract of acutely for approximately 5 min on September 20. It had received an infected animals, and is an important component of CIRDC appropriate initial DA2PP series, with the 3rd dose adminis- (10,12,13). Signs of disease typically occur 2 to 8 d after expo- tered on May 25, 2011. Cough was noted on September 26 sure (12), and the typical clinical presentation is the presence and Dog 3 was presented for examination on September 28. of a dry, hacking cough that persists for 2 to 6 d (14). Nasal The dog was housed in isolation and handled with contact discharge, pharyngitis, and tonsillitis may also be present, but barrier precautions. Harsh coughing was the only clinical pyrexia is usually mild or absent (12,14). Viral shedding typi- abnormality. Thoracic radiographs were normal. Doxycycline cally starts 2 to 10 d after exposure and typically begins prior to and hydrocodone were prescribed as for Dog 2. Clinical signs the onset of clinical signs (12,14). Therefore, while the clinical abated after 3 d. syndrome of CIRDC is readily identifiable, not all dogs shed- Dog 4 was a 12-year-old castrated male cocker spaniel dog ding the causative agents display signs of infection. CPiV is that was hospitalized September 20 to 21 for surgical excision highly transmissible and infection rates among exposed suscep- of a limb mass and was housed in the same ward as Dog 1 in tible individuals are high (15,16). Transmission is predominantly a floor-level cage approximately 2 m from Dog 1. No direct through infectious aerosols, although the role of fomites may be contact with Dogs 1, 2, or 3 was recalled by hospital personnel; underestimated (14). There is no long-term carrier state.

80 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Given the common involvement of CPiV in CIRDC and the to Dog 4 in the community and a timeframe and clinical pre- potentially large number of dogs in close proximity in veterinary sentation consistent with CPiV infection. The dog was exposed hospitals, either as outpatients in common areas or as inpatients, 9 d prior to the onset of clinical signs, which is near the end of

it is perhaps surprising that there are few reports of HA-CIRDC, the incubation period window, but transmission from Dog 4 is BRIEF COMMUNICATION particularly in light of the widespread reports of human PiV certainly possible. outbreaks in human hospitals (17–19). It is unclear whether In this outbreak, all of the suspected HA-associated trans­ this is because they rarely occur (perhaps because a vaccine is mission occurred before the onset of disease in the first case. available for dogs, as opposed to humans), are rarely diagnosed First generation transmission (transmission of the infectious or are rarely reported. Under-identification could certainly be agent from the index case to the first group of subsequent cases) possible considering the infrequent testing of dogs with respi- can be difficult to prevent with a virus that can be shed prior ratory disease, the likelihood that onset of disease would be in to the onset of clinical signs. However an outbreak assessment the community (and therefore be less likely to be recognized by is critical to determine if any measures could have prevented veterinary hospitals), and the possible reluctance of facilities to transmission in some or all cases. The breaches of standard report HA infections. Regardless, this report indicates that CPiV infection control practices, with direct contact allowed between transmission can occur within a veterinary facility, including dogs 1, 2, and 3, may have played a role in this outbreak. Once between dogs with no known direct contact. the outbreak was recognized, no further cases were identified. The origin of CPiV in this case series cannot be definitively This may have been, in part, because of the short duration of established. The 4 to 6 day onset of clinical signs after expo- hospitalization of the index case; however, immediate isolation sure of Dogs 2–4 to Dog 1 is consistent with CPiV infection of dogs upon re-admission and enhancement of infection con- acquired during hospitalization. No other cases of potentially trol practices may have played a role. Despite a lack of proof infectious respiratory disease were identified in dogs at the of efficacy of outbreak interventions, these data suggest that a OVC-HSC in the preceding month. Considering the typical rapid yet practical response may help contain this infectious incubation period (with the potential for shedding of CPiV for agent within a facility. Second generation transmission was 4 or more days prior to the onset of disease) (14), the timing suspected outside of the hospital, with potential infection of a of this dog’s exposure to other dogs of unknown health status neighbor’s dog (Dog 5). While not involving the hospital, this is at the grooming facility or dog park is consistent with exposure of concern because of the potential for facilitating further com- at that time. However, it cannot be definitively established that munity spread of CPiV. Although in this situation Dog 4 was this was the index case or that the dog park or grooming facility not showing signs of illness when it was permitted to interact was the origin of infection. with Dog 5, the suggested occurrence of disease spread into the Two of the 3 dogs (dogs 2 and 3) with HA-infections had community highlights the importance of counseling owners direct, albeit relatively short-term, contact with the index case of infectious animals that are being discharged from hospitals. (Dog 1). This was against standard hospital infection con- Modified live CPiV is included in common parenteral vac- trol protocols and highlights the need for preventing contact cines. While CPiV is not itself considered a “core” vaccine between animals within facilities. Certainly, one cannot guaran- component (20), the other agents in the combination vaccine tee that transmission would not have occurred if direct contact are; therefore, CPiV vaccination is common. Dogs 1–4 had been was prevented, particularly since one other affected dog had no vaccinated appropriately, with boosters within the preceding known direct contact; however, the closeness and duration of 5 mo. Parenteral vaccination is used to prevent clinical disease contact are presumably key factors in determining the likelihood but has not been shown to have an impact on CPiV shedding of pathogen transmission. Indirect transmission via personnel, and does not confer absolute protection from disease, as was from hands or clothing, must also be considered. There was evident here. Intranasal CPiV vaccines are also available in no overlap in clinical personnel between the 4 dogs; however, combination with other CIRDC agents, and this approach is it is possible that kennel staff handled both dogs. General preferable because it can have a greater impact on both disease environmental fomites must also be considered, but items that and viral shedding (21). These are not part of the recommended might have been used on multiple dogs were not identified. “core” canine vaccines (20), typically being reserved for dogs at Environmental exposure from sites contaminated by Dog 1 perceived higher risk for exposure (e.g., dogs going to kennels) such as hallways or the dog walking area is also possible but and had not been administered to any of these dogs. unlikely. The authors are unaware of data describing environ- This outbreak of CPiV infection should serve as a reminder of mental persistence of CPiV; however, being an enveloped virus, the ever-present risk of HA-infections, including outbreaks that CPiV would not be expected to persist for a prolonged length of originate from clinically normal individuals. Prompt recognition time and would be readily inactivated by accelerated hydrogen of potential outbreaks, the presence of a good standard infection peroxide, the disinfectant used at this facility. Environmental control program, and the implementation of enhanced infec- infection was therefore considered unlikely given the greater tion control practices may be important to reduce the impact potential of aerosol or personnel-borne transmission and the on patients and the hospital. lack of infections identified in dogs outside of that ward that did not have direct contact with the index case. Acknowledgment While no testing was performed to confirm CPiV infection Canine influenza testing was funded by Merck Animal Health. in Dog 5, it was considered a suspected case based on exposure CVJ

CVJ / VOL 54 / JANUARY 2013 81 FOR PERSONAL USE ONLY

References 11. Englund L, Jacobs AA, Klingeborn B, Chriél M. Seroepidemiological survey of Bordetella bronchiseptica and canine parainfluenza-2 virus in . 1 Walther B, Wieler LH, Friedrich AW, Kohn B, Brunnberg L, Lübke- dogs in Sweden. Vet Rec 2003;152:251–254. Becker A. Staphylococcus aureus and MRSA colonization rates among 12. Buonavoglia C, Martella V. Canine respiratory viruses. Vet Res personnel and dogs in a small animal hospital: Association with nosoco- 2007;38:355–373. mial infections. Berl Munch Tierarztl Wochenschr 2009;122:178–185. 13. Ueland K. Serological, bacteriological and clinical observations on an 2. Weese JS, Faires M, Rousseau J, Bersenas AM, Mathews KA. Cluster of outbreak of canine infectious tracheobronchitis in Norway. Vet Rec methicillin-resistant Staphylococcus aureus colonization in a small animal 1990;126:481–483. intensive care unit. J Am Vet Med Assoc 2007;231:1361–1364. 14. Ellis JA, Krakowka GS. A review of canine parainfluenza virus infection 3. Francey T, Gaschen F, Nicolet J, Burnens AP. The role of Acinetobacter in dogs. J Am Vet Med Assoc 2012;240:273–284. baumannii as a nosocomial pathogen for dogs and cats in an intensive 15. Binn LN, Alford JP, Marchwicki RH, Keefe TJ, Beattie RJ, Wall HG. care unit. J Vet Intern Med 2000;14:177–183. Studies of respiratory disease in random-source laboratory dogs: Viral 4. Sanchez S, McCrackin Stevenson MA, Hudson CR, et al. Character­ infections in unconditioned dogs. Lab Anim Sci 1979;29:48–52. ization of multidrug-resistant Escherichia coli isolates associated with 16. Binn LN, Lazar EC. Comments on epizootiology of parainfluenza SV-5 nosocomial infections in dogs. J Clin Microbiol 2002;40:3586–3595. in dogs. J Am Vet Med Assoc 1970;156:1774–1777. 5. Weese J, Armstrong J. Outbreak of Clostridium difficile-associated disease 17. Teo WY, Rajadurai VS, Sriram B. Morbidity of parainfluenza 3 outbreak

COMMUNICATIONBRÈVE in a small animal veterinary teaching hospital. J Vet Intern Med 2003; in preterm infants in a neonatal unit. Ann Acad Med Singap 2010; 17:813–816. 39:837–836. 6. Cherry B, Burns A, Johnson GS, et al. Salmonella Typhimurium 18. Lee AV, Bibby DF, Oakervee H, et al. Nosocomial transmission of para- outbreak associated with veterinary clinic. Emerg Infect Dis 2004;10: influenza 3 virus in hematological patients characterized by molecular 2249–2251. epidemiology. Transpl Infect Dis 2011;13:433–437. 7. Wright JG, Tengelsen LA, Smith KE, et al. Multidrug-resistant 19. Piralla A, Percivalle E, Di Cesare-Merlone A, Locatelli F, Gerna G. Salmonella Typhimurium in four animal facilities. Emerg Infect Dis Multicluster nosocomial outbreak of parainfluenza virus type 3 2005;11:1235–1241. infection in a pediatric oncohematology unit: A phylogenetic study. 8. Kawakami K, Ogawa H, Maeda K, et al. Nosocomial outbreak of serious Haematologica 2009;94:833–839. canine infectious tracheobronchitis (kennel cough) caused by canine 20. Paul MA, Carmichael LE, Childers H, et al. 2006 AAHA canine vaccine herpesvirus infection. J Clin Microbiol 2010;48:1176–1181. guidelines. J Am Anim Hosp Assoc 2006;42:80–89. 9. Mochizuki M, Yachi A, Ohshima T, Ohuchi A, Ishida T. Etiologic 21. Kontor EJ, Wegrzyn RJ, Goodnow RA. Canine infectious tracheo- study of upper respiratory infections of household dogs. J Vet Med Sci bronchitis: Effects of an intranasal live canine parainfluenza-Bordetella 2008;70:563–569. bronchiseptica vaccine on viral shedding and clinical tracheobronchitis 10. Erles K, Dubovi EJ, Brooks HW, Brownlie J. Longitudinal study of (kennel cough). Am J Vet Res 1981;42:1694–1698. viruses associated with canine infectious respiratory disease. J Clin Microbiol 2004;42:4524–4529.

Books Available for Review Livres disponibles pour compte rendu

The following books are yours to keep free of charge in exchange for a book review that will be published in The CVJ. To order a book and to receive suggestions on how to do a book review, please contact Stella Wheatley, Assistant Managing Editor, Canadian Veterinary Medical Association, at [email protected]

1. Hill P, Warman S, Shawcross G. 100 Top Consultations in 6. Little SE. The Cat — Clinical Medicine and Management. Small Animal General Practice. Wiley-Blackwell, Oxford, Elsevier, St. Louis, Missouri, USA. 2012. 1398 pp. ISBN UK. 2011. 432 pp. ISBN 9781-4051-6949-3. 9781-4377-0660-4. 2. Newman K. The Amazing Treat Diet for Dogs — How I 7. Zachary JF, McGavin MD. Pathologic Basis of Veterinary Saved My Dog from Obesity. Pomp Productions. Sherman Disease, 5th edition. Elsevier, St. Louis, Missouri, USA. Oaks, California, USA. 2011. 164 pp. ISBN 9780-6155- 2012. 1322 pp. ISBN 9780-3230-7533-6. 1051-4. $10.76 US. 8. Quesenberry KE, Carpenter JW. Ferrets, Rabbits, and 3. Auer JA, Stick JA. Equine Surgery, 4th edition. Elsevier. Rodents — Clinical medicine and surgery. 3rd edition. St. Louis, Missouri, USA. 2012. 1536 pp. ISBN 9781- Elsevier, St. Louis, Missouri, USA. 2012. 594 pp. ISBN 4377-0867-7. $253.00. 9781-4160-6621-7. 4. Pugh DG, Baird AN, eds. Sheep and Goat Medicine, 9. Harvey JW. Veterinary Hematology — A Diagnostic 2nd edition. St. Louis, Missouri, USA. 2012. 621 pp. Guide and Color Atlas. Elsevier, St. Louis, Missouri, USA. ISBN 9781-4377-2353-3. $144.00. 2012. 360 pp. ISBN 9781-4377-0173-9. 5. Govaere J, Martens K, de Kruif A. Foal in Mare — 10. Carpenter JW. Exotic Animal Formulary, 4th edition. Insights inside the foaling mare, 2nd edition. Department Elsevier, St. Louis, Missouri, USA. 2013. 724 pp. ISBN of Reproduction, Obstetrics, and Head Health, Faculty of 9781-4377-2264-2. Veterinary Medicine, Ghent University, 2011 CD.

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82 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY Case Report Rapport de cas

Postsurgical segmental mesenteric ischemic thrombosis in a horse

María Martín-Cuervo, Luis A. Gracia, Verónica Vieitez, Joquin Jiménez, Esther Durán, Luis J. Ezquerra

Abstract — A 16-year-old, Lusitanian stallion was admitted to the Veterinary Teaching Hospital with a 12-hour history of signs of abdominal pain. Exploratory celiotomy was performed due to an inguinal hernia, and a second celiotomy was performed in response to the abdominal pain. The horse was euthanized and mesenteric venous thrombosis was diagnosed and considered likely due to peritonitis and systemic inflammatory response syndrome (SIRS).

Résumé — Thrombose ischémique mésentérique segmentaire post-chirurgicale chez un cheval. Un étalon Lusitanien âgé de 16 ans a été admis à l’hôpital d’enseignement vétérinaire avec une anamnèse de 12 heures de douleurs abdominales. Une coeliotomie exploratoire a été réalisée en raison d’une hernie inguinale et une deuxième coeliotomie a été réalisée en réponse à la douleur abdominale. Le cheval a été euthanasié et une thrombose de la veine mésentérique a été diagnostiquée et considérée probablement attribuable à une péritonite et au syndrome de la réaction inflammatoire systémique (SRIS). (Traduit par Isabelle Vallières) Can Vet J 2013;54:83–85 Case description on the bowel. The segment affected was the distal part of the jejunum, about 20 cm cranial to the ileum. A routine castra- A 16-year-old, Lusitanian stallion was admitted to the Veterinary tion of the left testicle was done. The appearance of the bowel Teaching Hospital of the University of Extremadura with a didn’t improve after correction of the strangulation and decom- 12-hour history of signs of abdominal pain. Initial findings on pressing distended small intestine by massaging fluid out of it; physical examination included enlargement of the left testicle, therefore, jejunojejunostomy was performed after resection of heart rate of 58 beats/min (bpm), respiratory rate of 20 breaths/ approximately 73 cm of jejunum. A sterile Penrose drain was min, temperature 36.9°C, and abdominal sounds decreased on applied 20 cm proximal to the anastomosis site. The end-to- both sides. Transabdominal ultrasonography identified distended end anastomosis was closed by a two-layer continuous pattern loops of small intestine in the lower caudal portion of the abdo- with polyglycolic acid SafilTM 3-0 (Braun Aesculap, Barcelona, men and in the left inguinal ring. Spain) for the submucosa and mucosa, followed by a Cushing Results of laboratory tests indicated that the horse had pattern in the seromuscular layer. The vessels were sealed by mild serum hyperlactacidemia (2.1 mmol/L, reference value: the LigaSureTM (Valleylab, Tyco International Healthcare, , 2 mmol/L), hyperbilirubinemia [78.5 mmol/L; reference Boulder, Colorado, USA) vessel sealing system. Before closing interval (RI): 8.6 to 35.9 mmol/L], and hyperfibrinogenemia the abdominal incision, the small intestine was decompressed (24.8 mmol/L; RI: 5.9 to 11.8 mmol/L). Analysis of peritoneal by massaging its contents into the cecum. After the surgery fluid revealed hyperlactacidemia of 3.1 mmol/L (reference value: the entire intestine was normal in color, had peristalsis, and , 2 mmol/L) as the only abnormality detected. was not distended. The linea alba was closed with polyglycolic Exploratory celiotomy revealed a strangulated nonreducible acid, SafilTM 5 suture material (Braun Aesculap) in a continuous inguinal hernia. The hernia was corrected through an inguinal pattern. Subcutaneous tissue was closed with polyglycolic acid incision over the external inguinal ring. A ventral midline Safil® 2/0 (Braun Aesculap) in a continuous pattern and the celiotomy was performed to allow intra-abdominal traction skin was closed with staples. Treatment consisted of Lactated Ringer’s solution adminis- Department of Animal Medicine, Veterinary Teaching Hospital, tered IV with calcium and potassium chloride at a maintenance University of Extremadura, Avenida de la Universidad s/n, rate, flunixin meglumine (FINADYNE; Shering Plough SA, 10071, Cáceres, Spain. Madrid, Spain), 0.5 mg/kg body weight (BW), q12h, poly- Address all correspondence to Dr. María Martín; e-mail: mixin B (Polimixina, Oristá, Barcelona, Spain), 5000 IU/kg BW, [email protected] q12h, lidocaine (Lidocaína Braun, B. Braun Medical SA, Rubí, Use of this article is limited to a single copy for personal study. Spain), 0.05 mg/kg BW per minute, benzyl penicillin sodium Anyone interested in obtaining reprints should contact the (Penilevel; ERN, Barcelona, Spain), 22 000 IU/kg BW, q6h, CVMA office ([email protected]) for additional gentamicin (Ganadexil; INVESA, Esplugues de Llobregat, copies or permission to use this material elsewhere. Spain), 6.6 mg/kg BW, q24h, erythromycin (Pantomicina;

CVJ / VOL 54 / JANUARY 2013 83 FOR PERSONAL USE ONLY RAPPORTCAS DE

Figure 1. The second surgery revealed distension of the small Figure 2. Macroscopic appearance of a large clot inside the intestine, necrotic bowels, and a clear line between healthy and mesenteric vein. injured intestine.

After the results of the tests had been examined, and because of persistent signs of abdominal pain, an exploratory celiotomy was performed (3 days after the first one), which revealed several thrombi in the mesenteric veins. The small intestine had several infarcts and extensive lesions (Figure 1). There were 3 separate affected segments each longer than 1 m. The anastomosis site was not affected and was separated by about 5 m from the first affected segment. It was suspected, however, that there might have been a leak at the anastomosis site, which caused the peri- tonitis. Severe peritonitis and intestinal ischemia were confirmed at surgery. Due to the seriousness of the lesions the horse was euthanized and samples were submitted for histopathological studies (Figures 2 and 3).

Figure 3. Microscopic appearance of a large clot in the Discussion mesenteric vein. Hematoxylin and eosin stain Mesenteric venous thrombosis (also known as visceral venous thrombosis) is a rare but lethal form of mesenteric ischemia in CEVA Salud Animal, Barcelona, Spain), 2.2 mg/kg BW, q6h, humans (1). Warren and Eberhard (2) reported that intestinal and omeprazole (GASTROGARD; Mérial, Lugo, Spain), infarction resulted from ischemia due to venous thrombosis, and 4 mg/kg BW, q24h. The stallion recovered from surgery without they reported a mortality rate of 34% in human patients with reflux and pain but subsequently signs of pain developed and venous thrombosis after resection. The concept of Virchow’s the stallion began refluxing gastric contents 3 d after surgery. triad explains the disease as a secondary complication after At this time, the heart rate was 80 bpm, the respiratory rate endothelial lesions, flow alterations, or hypercoagulation states. 28 breaths/min, and abdominal sounds decreased on both sides. Mesenteric ischemia (MI) can be classified as acute (AMI) or The mucous membranes were congested (dark red). chronic (CMI) depending on the progression of clinical signs (3). Hematologic analyses revealed a peripheral white blood cell As well, there are classifications according to the origin (arterial (WBC) count of 3.5 3 103/mL, (RI: 6 to 12 3 103/mL), hema- or venous) and physiopathology (obstructive or not obstructive) tocrit of 48.4% (RI: 32% to 48%) and total protein of 40 g/L (4). Traditionally, AMI was associated with low output cardiac (reference range: 53 to 73 g/L). Serum biochemical abnor- flow, decreases in blood flow, and/or hypovolemic shock (5). malities included high fibrinogen concentration (25.0 mmol/L), The risk of acute mesenteric venous thrombosis increases in slightly high creatinine concentration (176.8 mmol/L; RI: human patients with hypercoagulable states (e.g., polycythemia 44.2 to 150.3 mmol/L), high total bilirubin concentration vera, protein C and S deficiencies) (6–8), visceral infection (9), (211.0 mmol/L), slightly high lactate concentration (2.4 mmol/L) portal hypertension (10), perforated viscus (11), blunt abdomi- and low potassium concentration (2.3 mEq/L; RI: 3 to 5 mEq/L). nal trauma (12), malignancy (13), and previous abdominal Abdominocentesis yielded peritoneal fluid with a total protein surgery (open or laparoscopic) (14,15). High mortality (20% concentration of 40 g/L (reference value: , 25 g/L), WBC count to 50% in humans) might be due to late diagnosis and pres- of 27 600/mm3 (RI: 500 to 5000/mm3), lactate concentration ence of factors such as disseminated intravascular coagulation of 7.6 mmol/L (reference value: , 2.5 mmol/L), and glucose (DIC) or systemic inflammatory response syndrome (SIRS) (16). concentration 0.89 mmol/L (RI: 4.2 to 7.1 mmol/L). Horses usually develop thrombosis secondary to migration of

84 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY larvae of Strongylus vulgaris (17,18) and rarely thrombosis may bosis. Associated systemic disorders and hypercoagulability status of be a cause of rectal perforation (19). Parker et al (20) reported 21 surgical patients. Hepatogastroenterology 2007;54:1080–1084. 9. Wang LF, Liu M, Zhang SJ, Han W, Gao F, Qi JP. Clinicopathologic 2 cases of infarction of segments of intestine other than at the study of ischemic intestinal disease due to mesenteric venous lesions. site of obstruction of the primary celiotomy in a retrospective Zhonghua Bing Li Xue Za Zhi 2006;35:620–622. evaluation of repeat celiotomies in 53 horses, but they didn’t 10. Hamidi K, Pauwels A, Bingen M, et al. Recent portal and mesen- teric venous thrombosis associated with Fusobacterium bacteremia. specify whether it was as a consequence of venous or arterial Gastroenterol Clin Biol 2008;32:734–739. REPORT CASE thrombosis. Other authors described vascular injury associated 11. Kader HA, Baldassano RN, Harty MP, et al. Ruptured retrocecal appen- with strangulating obstructions of the equine large colon such as dicitis in an adolescent presenting as portal-mesenteric thrombosis and pylephlebitis. J Pediatr Gastroenterol Nutr 1998;27:584–588. thrombosis of the mesenteric colic vessels (21). Intestinal infarc- 12. Fried M, Van Ganse W, Van Avermaet S. Mesenteric vein thrombosis tion has been associated with mesenteric vascular thrombotic triggered by blunt abdominal trauma in a patient with the primary disease in horses, but it was the consequence of cranial mesen- antiphospholipid syndrome. Eur J Gastroenterol Hepato 2002;14: 697–700. teric artery thrombosis (22). No parasites were observed in this 13. Hedayati N, Riha GM, Kougias P, et al. Prognostic factors and treat- horse and the possible causes of AMI were peritonitis and SIRS. ment outcome in mesenteric vein thrombosis. Vasc Endovascular Surg We recommend that postsurgical segmental mesenteric isch- 2008;42:217–224. 14. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. emic thrombosis be included in the differential diagnoses of Portomesenteric venous thrombosis after laparoscopic surgery: A systematic abdominal pain after surgery. Horses with small intestine dis- literature review. Arch Surg 2009;144:520–526. eases or peritonitis might be susceptible to developing secondary 15. Vadalà S, Cinardi N, Li Volti G, Foresta G, Giannone G. Portal vein thrombosis following laparoscopic total mesorectal excision: Case report. thrombosis. CVJ Tech Coloproctol 2008;12:259–261. 16. Rhee RY, Gloviczki P, Mendonca CT, et al. Mesenteric venous throm- References bosis: Still a lethal disease in the 1990s. J Vasc Surg 1994;20:688–697. 17. White NA. Intestinal infarction associated with mesenteric vascular 1. Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg Clin North thrombotic disease in the horse. J Am Vet Med Assoc 1981;178: Am 1997;77:327–338. 259–262. 2. Warren S, Eberhard TP. Mesenteric venous thrombosis. Surg Gynecol 18. DeLay J, Peregrine AS, Parsons DA. Verminous arteritis in a 3-month- Obstet 1935;61:102–121. old thoroughbred foal. Can Vet J 2001;42:289–291. 3. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl 19. Guglick MA, MacAllister CG, Ewing PJ, Confer AW. Thrombosis J Med 2001;345:1683–1688. resulting in rectal perforation in a horse. J Am Vet Med Assoc 1996;209: 4. Kozuch PL, Brandt LJ. Review article: Diagnosis and management of 1125–1127. mesenteric ischaemia with an emphasis on pharmacotherapy. Aliment 20. Parker JE, Fubini SL, Todhunter RJ. Retrospective evaluation of repeat Pharmacol Ther 2005;21:201–215. celiotomy in 53 horses with acute gastrointestinal disease. Vet Surg 5. Eldrup-Jorgensen J, Hawkins RE, Bredenberg CE. Abdominal vascular 1989;18:424–431. catastrophes. Surg Clin North Am 1997;77:1305–1320. 21. Snyder JR, Pascoe JR, Olander HJ, Hinds DM, Young R, Tyler WS. 6. Cardot F, Borg JY, Guédon C, Lerebours E, Colin R. Syndromes Vascular injury associated with naturally occurring strangulating of venous mesenteric ischemia: Infarctation and transient ischemia. obstructions of the equine large colon. Vet Surg 1990;19:446–455. Gastroenterol Clin Biol 1992;16:644–648. 22. White NA 2nd. Intestinal infarction associated with mesenteric vas- 7. Alvi AR, Khan S, Niazi SK, Ghulam M, Bibi S. Acute mesenteric cular thrombotic disease in the horse. J Am Vet Med Assoc 1981;178: venous thrombosis: Improved outcome with early diagnosis and prompt 259–262. anticoagulation therapy. Int J Surg 2009;7:210–213. 8. Acosta-Merida MA, Marchena-Gomez J, Hemmersbach-Miller M, Conde-Martel A, Hernandez-Romero JM. Mesenteric venous throm-

CVJ / VOL 54 / JANUARY 2013 85 FOR PERSONAL USE ONLY Diagnostic Ophthalmology Ophtalmologie diagnostique

Bruce H. Grahn, Bianca Bauer, Tawni Silver

History and clinical signs 7-year-old female boxer dog was examined by the oph- A thalmology service at the Western College of Veterinary Medicine with a history of acute onset blindness of approxi- mately 1 month. Vaccinations for distemper, parvo, and rabies viruses were current. Our neuro-ophthalmic examination revealed that bilateral mydriasis and the pupillary reflexes and menace responses were absent; palpebral and oculocephalic reflexes were present bilaterally. Photopic and scotopic maze testing was completed and the dog was unable to navigate the obstacle course. Schirmer tear tests (Schirmer Tear Test Strips; Alcon Canada, Mississauga, Ontario) values were approximately 20 mm/min bilaterally. The intraocular pressures, estimated with a rebound tonometer (Tonovet; Tiolat Oy, Helsinki, Finland), were 16 and 17 mmHg in the right and left eye, respectively. Biomicroscopic (Osram 64222; Carl Zeiss Canada, Don Mills, Ontario) and indirect ophthalmoscopic (Heine Omega 200; Heine Instruments Canada, Kitchener, Ontario) examinations were completed and no significant abnormalities could be detected. Corneal dystrophy was present; however, it was mild and had been present for several years and was not progressing. Figure 1. A photograph of the fundus of the left eye. The right A routine photopic electroretinogram was completed and the fundus was similar in appearance. a-waves were 35 microvolts and the b-waves were approximately 115 microvolts; these values are within normal reference ranges Discussion for a dog of this age (Figure 1). The CT images reveal a contrast enhancing extra axial tumor What are your clinical diagnoses, in the ventral brain which involves the optic chiasma and optic differential diagnoses, diagnostic plan, nerves (Figure 2). The tumor is creating mechanical obstruction and prognosis? of the third ventricle with secondary third and lateral ventricular Our clinical diagnoses were blindness, and afferent pupillary enlargement. A dural tail sing (meningial enhancement) was not defects which are consistent with optic nerve and optic chias- noted on the CT images. The appearance is most consistent mal disorders including central nervous system neoplasms and with a neoplasm and meningioma, glioma, astrocytomas, and inflammatory conditions including optic neuritis. A physical several metastatic neoplasms may be considered. The prognosis examination, complete blood cell count, serum biochemical for this dog is guarded and external beam radiation was offered profile, and urinalysis were completed; no significant abnor- but declined. The owner declined further therapy and the dog malities were detected. Routine sedation and general anesthesia is being managed conservatively. were advised and contrast enhanced computerized tomography Neoplasms of the optic chiasmal neoplasia are a relatively (CT scan) with iohexol, (Omnipaque; GE Health Care Canada, uncommon cause of blindness in animals. However, its impor- Mississauga, Ontario) of the cranium was done. tance rises quickly in our differential diagnoses list when the electroretinogram and ophthalmoscopic examinations are within Department of Small Animal Clinical Sciences, Western College normal limits. These evaluations rule out intraocular disorders of Veterinary Medicine, University of Saskatchewan, 52 Campus that commonly induce blindness including but not limited Drive, Saskatoon, Saskatchewan S7N 5B4. to cataracts, retinal detachments, and retinal degenerations. Use of this article is limited to a single copy for personal study. Sudden acquired retinal degeneration (SARD) is by far the most Anyone interested in obtaining reprints should contact the common cause of acute blindness in middle-aged dogs without CVMA office ([email protected]) for additional clinically apparent intraocular lesions that could impair vision. copies or permission to use this material elsewhere. SARD is confirmed by electroretinography which reveals no

86 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY DIAGNOSTIC OPHTHALMOLOGYDIAGNOSTIC

Figure 2. Computed tomography post-contrast transverse and saggital images of the cranium of a blind 7-year-old female boxer dog.

­retinal activity. In this dog, the retinal electrical activity was In conclusion, acute blindness in the absence of ophthal- within normal limits, which mandates sectional imaging of the moscopic detectable vision impairing lesions warrant an optic nerves and chiasma to determine an etiologic diagnosis. ­electroretinogram to confirm or negate SARD. When SARD The most common etiologies for these dogs are either optic has been ruled out, contrast enhanced sectional imaging (MRI chiasmal neoplasia or optic neuritis. These disorders can be or CT scans) is required to establish the diagnosis for afferent differentiated by the sectional imaging manifestations. This dog pupillary defects. manifested with a large tumor that was centered on the optic chiasma with extension down the optic nerves. References Unfortunately we were unable to confirm the type of neo- 1. Palmer AC, Malinnowski W, Barnett KC. Clinical signs including pap- illedema associated with brain tumours in twenty-one dogs. J Sm Anim plasm that invaded this optic nerve or attempt therapy such as Pract 1974;15:359–386. external beam radiation. Optic nerve meningioma was consid- 2. Mauldin EA, Deehr AJ, Hertzke D, Dubielzig RR. Canine orbital menin- ered one of the most likely primary neoplasms; however, many giomas: A review of 22 cases. Vet Ophthalmol 2000;3:11–16. other primary and metastatic neoplasms are possible (1,2).

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The participation of advertisers in the CVJ is an indication of their com- Le support des annonceurs démontre leur engagement pour mitment to the advancement of veterinary medicine in Canada. We l’avancement de la médecine vétérinaire au Canada. Nous vous encourage our readers to give their products and services appropriate ­encourageons à prendre ­connaissance de leurs services et ­produits. consideration. — Ed. — NDLR

CVJ / VOL 54 / JANUARY 2013 87 FOR PERSONAL USE ONLY Veterinary Practice Management Gestion d’une clinique vétérinaire

Associate veterinarian salaries continue to rise La hausse des salaires des vétérinaires se poursuit

Darren Osborne, Simon Miller

ssociate veterinarian salaries were up in most provinces n 2012, les salaires des vétérinaires étaient en hausse dans A for 2012 despite lagging veterinary economies last year. E la plupart des provinces, malgré la perte de vitesse des Last year, many practices posted negative client growth and finances vétérinaires de l’an dernier. Au cours de la dernière stagnating revenues, but associate veterinarian salaries seemed année, beaucoup de pratiques ont affiché une croissance négative to have risen above the clamor to come out not only positive de la clientèle et ont connu un chiffre d’affaires stagnant, mais in most provinces, but ahead of inflation. Nationally, salaries les salaires des vétérinaires semblent s’être hissés au-dessus du increased 2%, while inflation rose only 1.2%. brouhaha pour une croissance non seulement positive, mais The response rate to the economic survey was the first give- supérieure au taux d’inflation À l’échelle nationale, les salaires away that good news was on the way. In past years, the response ont augmenté de 2 %, tandis que l’inflation a progressé de to associate veterinarian surveys usually lingered around 20% seulement 1,2 %. with a greater number of responses coming from the least Le taux de réponse au sondage économique était le premier populated provinces. This year, response rates exceeded 50% in indice de l’arrivée de bonnes nouvelles. Au cours des années 3 provinces (Saskatchewan, Nova Scotia, and New Brunswick) précédentes, le taux de réponse aux sondages pour les vétérinaires and the lowest response rate from any province was still a very salariés se situait autour de 20 % avec un nombre supérieur de respectable 29%. The provinces with the fewest responses were réponses provenant des provinces les moins populeuses. Cette Alberta (29%), Quebec (30%), and Newfoundland (31%). The année, les taux de réponse dépassaient 50 % dans trois provinces national response rate was 36% (Table 1). (Saskatchewan, Nouvelle-Écosse et Nouveau-Brunswick) et le In Ontario, allowances were made to calculate response taux de réponse le plus faible d’une province s’établissait à un rates based on CVMA and OVMA memberships, since 98% pourcentage très respectable de 29 %. Les provinces avec les of responses came from members in one of the two groups. taux de réponse les plus bas étaient l’Alberta (29 %), le Québec Information was not available to calculate the response rate from (30 %) et Terre-Neuve (31 %). Le taux de réponse national était associate veterinarians in British Columbia since the survey was de 36 % (tableau 1). only distributed to those associate veterinarians who are CVMA En Ontario, on a effectué le calcul des taux de réponse en members and there were no data available on the total number fonction de l’adhésion à l’ACMV et à l’OVMA, vu que 98 % of associate members in the province. The national figures des réponses provenaient de membres de l’un des deux groupes. assume the response from British Columbia would match the Des données n’étaient pas disponibles pour calculer le taux de national median. réponse des vétérinaires salariés de la Colombie-Britannique vu Information for the survey was submitted anonymously. Since que le sondage a seulement été distribué aux vétérinaires salariés individual responses cannot be cross-referenced, the survey qui sont membres de l’ACMV et qu’il n’y avait pas de données reports the “median” figures. The median is obtained by ranking disponibles sur le nombre total de membres salariés dans la

This article is provided as part of the CVMA Business Management Program, which is co-sponsored by IDEXX Laboratories, Petsecure Insurance, Merck Animal Health, and Scotiabank. Address all correspondence to the CVMA Business Management Committee; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. Le présent article est rédigé dans le cadre du Programme de gestion commerciale de l’ACMV, qui est cocommandité par IDEXX Laboratories, Petsecure Insurance, Merck Santé Animale et la Banque Scotia. Veuillez adresser toute correspondance au Comité de la gestion commerciale de l’ACMV; courriel : [email protected] L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

88 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

Table 1/Tableau 1. Provincial response rates for 2012./Taux de Table 2/Tableau 2. Associate veterinarians income by province

réponse provinciaux en 2012 for 2012/Revenu des vétérinaires salariés par province en 2012 PRACTICE MANAGEMENT VETERINARY Surveys returned Response rate Change Province Sondages retournés Taux de réponse Province 2011 2012 Changement BC/C.-B. 67 n/a BC/C.-B. $83 000 $85 000 2% AB/Alb. 197 29% AB/Alb. $80 000 $83 000 4% SK/Sask. 98 65% SK/Sask. $75 000 $74 500 21% MB/Man. 78 46% MB/Man. $75 000 $77 250 3% ON*/Ont.* 356 43% ON/Ont. $75 000 $77 000 3% QC 194 30% QC $66 276 $68 000 3% NS/N.-É. 83 59% NS/N.-É. $70 000 $70 000 0% NB/N.-B. 34 52% NB/N.-B. $70 000 $70 000 0% PE/Î.-P.-É. 11 46% PE/Î.-P.-É. $60 750 $62 856 3% NL/T.-N.L. 11 31% NL/T.-N.L. $70 000 $85 750 23% Canada 984 36% Canada $79 682 $81 637 2%

* Represents OVMA/CVMA members only./Représente les seulement les membres BC — British Columbia, AB — Alberta, SK — Saskatchewan, MB — Manitoba, de l’OVMA/ACMV. ON — Ontario, QC — Quebec, NS — Nova Scotia, NB — New Brunswick, BC — British Columbia, AB — Alberta, SK — Saskatchewan, MB — Manitoba, PE — Prince Edward Island, NL — Newfoundland and Labrador. ON — Ontario, QC — Quebec, NS — Nova Scotia, NB — New Brunswick, C.-B. — Colombie-Britannique, Alb. — Alberta, Sask. — Saskatchewan, PE — Prince Edward Island, NL — Newfoundland and Labrador. Man. — Manitoba, Ont. — Ontario, QC — Québec, N.-É. — Nouvelle-Écosse, C.-B. — Colombie-Britannique, Alb. — Alberta, Sask. — Saskatchewan, N.-B. — Nouveau-Brunswick, Î.-P.-É. — Île-du-Prince-Édouard, Man. — Manitoba, Ont. — Ontario, QC — Québec, N.-É. — Nouvelle-Écosse, T.-N.L. — Terre-Neuve et Labrador. N.-B. — Nouveau-Brunswick, Î.-P.-É. — Île-Prince-Édouard, T.-N.L. — Terre-Neuve et Labrador.

all responses from smallest to largest and then taking the mid- province. Les données nationales présument que la réponse de point. The advantage of using the median for anonymous sur- la Colombie-Britannique correspondrait à la médiane nationale. veys is that the results are not influenced by extreme responses. Les données du sondage ont été soumises anonymement. Vu To account for the difference in the cost-of-living from one qu’une correspondance ne peut pas être établie entre les réponses province to another, associate veterinarian wages were adjusted individuelles, le rapport présente les données «médianes». La using a multiplier that reflects the cost-of-living in each province médiane est obtenue en classant toutes les réponses, de la plus (1). For example, households spend more in Ontario and Alberta faible à la plus élevée, puis en prenant la donnée du milieu. then they do in Newfoundland or Prince Edward Island so an L’avantage de l’utilisation de la médiane pour les sondages associate veterinarian earning the median Canadian salary of anonymes est que les résultats ne sont pas influencés par des $81 637 would have more spending power in Newfoundland réponses extrêmes. or Prince Edward Island, where household expenses are lower. Pour tenir compte de la différence du coût de la vie d’une The survey was distributed electronically to members using province à l’autre, les salaires des vétérinaires ont été ajustés en e-mails provided by the provincial associations and the CVMA. utilisant un multiplicateur qui reflète le coût de la vie dans chaque Members were sent multiple weekly reminders encouraging par- province (1). Par exemple, les ménages dépensent plus en Ontario ticipation. Respondents were asked to report on current figures et en Alberta qu’à Terre-Neuve ou à l’Île-du-Prince-Édouard, and project incomes for the full calendar year. Associate veteri- et un vétérinaire salarié gagnant le salaire canadien moyen de narians who were paid on production reported on cases over 81 637 $ aurait donc plus de pouvoir d’achat à Terre-Neuve the last 12-month period. The salaries reported in this article ou à l’Île-du-Prince-Édouard, où les dépenses des ménages sont represent salaries for the current year — 2012. Nationally, the inférieures. figures are accurate to 1/2 1.5%, 19 times out of 20. Le sondage a été distribué électroniquement aux membres The 2012 Associate Veterinarian Survey of Compensation and en utilisant les adresses de courriel fournies par les associations Benefits is a member service provided by provincial Veterinary provinciales et l’ACMV. De nombreux rappels hebdomadaires Medical Association and the Canadian Veterinary Medical ont été envoyés aux membres en les encourageant à participer. Association. Each year, the CVMA, in cooperation with the Nous avons demandé aux répondants de déclarer les chiffres provincial VMAs and support from industry sponsors, Petsecure, actuels et de projeter les revenus pour l’année civile complète. Merck, and Scotiabank survey associate veterinarians in each Les vétérinaires salariés qui étaient rémunérés en fonction de la province to determine the level of compensation and benefits production ont présenté des rapports sur les cas examinés au by province. cours des 12 derniers mois. Les salaires présentés dans le présent Seven out of 10 provinces saw associate veterinarian salaries article représentent les salaires de l’année en cours — 2012. increase in 2012 (Table 2). Saskatchewan had a slight decrease À l’échelle nationale, les données sont exactes à 1/2 1,5 %, in salaries from $75 000 to $74 500 and associate veterinarians 19 fois sur 20. in Nova Scotia and New Brunswick experienced zero growth in Le Sondage 2012 sur la rémunération et les avantages sociaux annual salaries. There was a tight cluster of median increases in des vétérinaires salariés est un service aux membres fourni par other provinces ranging from 2% to 4% with the predominant chaque association de médecins vétérinaires (AMV) provinciale increase being just ahead of inflation at 3%. Newfoundland et par l’Association canadienne des médecins vétérinaires. and Labrador reported an extraordinary increase in salaries, Chaque année, en collaboration avec les AMV provinciales et

CVJ / VOL 54 / JANUARY 2013 89 FOR PERSONAL USE ONLY

BC AB SK MB ON QC NS NB PE NL Canada C.-B. Alb. Sask. Man. Ont. N.-É. N.-B. Î.-P.-É. T.-N.L.

Figure 1. Cost-of-living adjusted associate veterinarian salaries for 2012./Salaires des vétérinaires salariés ajustés au coût de la vie en 2012. BC — British Columbia, AB — Alberta, SK — Saskatchewan, MB — Manitoba, ON — Ontario, QC — Quebec,

GESTION D’UNECLINIQUE VÉTÉRINAIRE NS — Nova Scotia, NB — New Brunswick, PE — Prince Edward Island, NL — Newfoundland and Labrador C.-B. — Colombie-Britannique, Alb. — Alberta, Sask. — Saskatchewan, Man. — Manitoba, Ont. — Ontario, QC — Québec, N.-É. — Nouvelle-Écosse, N.-B. — Nouveau-Brunswick, Î.-P.-É. — Île-du-Prince-Édouard, T.-N.L. — Terre-Neuve et Labrador

but this may be attributed to fewer responses and lower overall grâce au soutien des commanditaires de l’industrie, Petsecure, sample size. The median national increase was calculated using Merck et Banque Scotia, l’ACMV procède à un sondage auprès a weighted median based on the response from each province des vétérinaires salariés de chaque province pour déterminer so the figures from Newfoundland and Labrador did little to le niveau de la rémunération et des avantages sociaux selon la affect the national figures. province. The coastal provinces reported the highest median salaries Dans sept provinces sur dix, les salaires des vétérinaires which were within $750 of each other. Newfoundland and ont augmenté en 2012 (tableau 2). La Saskatchewan a Labrador posted a median associate veterinarian salary of affiché une légère baisse des salaires, de 75 000 $ à 74 500 $, $85 750 and British Columbia reported $85 000. Along with et les vétérinaires salariés de la Nouvelle-Écosse et du Alberta at $83 000, these were the only provinces that exceeded Nouveau-Brunswick ont connu une croissance zéro du salaire the national median income. annuel. Il y avait un groupe serré de hausses médianes dans les After adjusting for the cost-of-living in each province, autres provinces s’échelonnant de 2 % à 4 % et l’augmentation Newfoundland and Labrador continued to dominate the land- prédominante se situait à peine au-dessus de l’inflation à scape with the highest salaries in the country, even without the 3 %. Terre-Neuve et Labrador a déclaré une augmentation extraordinary leap in incomes last year. If one used the figures extraordinaire des salaires, mais cela peut être attribué à un from Newfoundland and Labrador last year and adjusted for nombre de réponses inférieur et à un échantillon global réduit. the cost-of-living, it would still hold the podium on provincial La hausse médiane nationale a été calculée en utilisant une incomes. médiane pondérée basée sur le taux de réponse dans chaque The only other provinces that exceeded the national median province et les données de Terre-Neuve et Labrador n’ont donc income after adjusting for the cost-of-living were Manitoba pas affecté les données nationales. and New Brunswick (Figure 1). Both provinces were almost Les provinces côtières ont signalé les salaires médians les $1000 higher than the national median figures. plus élevés, qui présentaient tous un écart de 750 $ entre eux. The “have” provinces, Ontario and Alberta, lagged behind Terre-Neuve et Labrador a affiché un salaire médian de 85 750 $ all other provinces in cost-of-living adjusted salaries. Echoing pour les vétérinaires salariés et la Colombie-Britannique a signalé past years’ results, Alberta associate veterinarian salaries failed to un salaire de 85 000 $. Avec l’Alberta, qui se situe à 83 000 $, il gain ground on the highest cost-of-living in the country. Practice s’agissait des seules provinces qui dépassaient le revenu médian owners made valiant attempts to keep pace offering the highest national. year over year increase outside of Newfoundland and Labrador Après l’ajustement au coût de la vie dans chaque province, and posted the third highest incomes before the cost-of-living Terre-Neuve et Labrador continuait de dominer le paysage avec adjustment. This, however, was not enough to offset the cost-of- les salaires les plus élevés au pays, même sans tenir compte du living differences. Ontario posted higher than average increases bond extraordinaire des revenus l’an dernier. Si l’on utilisait les as well but started out below the national average and as a result, données de Terre-Neuve et Labrador de l’an dernier et qu’on les associate veterinarian salaries hit second from the bottom after ajustait au coût de la vie, la province monterait toujours sur le the cost-of-living adjustment. podium en ce qui concerne les revenus provinciaux. For a complete report on associate veterinarian salaries along Les seules autres provinces qui dépassaient le revenu médian with breakdowns of benefits and vacation time for associate national après l’ajustement au coût de la vie étaient le Manitoba

90 CVJ / VOL 54 / JANUARY 2013 FOR PERSONAL USE ONLY

veterinarians, go to the CVMA Economic Hub and down- Reference VETERINARY PRACTICE MANAGEMENT VETERINARY load the report for your province. If you have any questions 1. Average household expenditures, by province and territory, Statistics regarding the Associate Report on Compensation and Benefits Canada, CANSIM, [page on Internet] Available from http://www5. please contact Darren Osborne at [email protected] or statcan.gc.ca/cansim/search-recherche?lang=eng&searchTypeByValue= 1&pattern=203-0001&p2=37 Last accessed November 14, 2012. ■ 1-800-670-1702, ext. 14.

et le Nouveau-Brunswick (figure 1). Les deux provinces à la moyenne, mais le salaire était déjà inférieur à la moyenne affichaient des salaires près de 1000 $ supérieurs à la médiane et les salaires des vétérinaires se sont classés à l’avant-dernière nationale. place après l’ajustement au coût de la vie. Les provinces «nanties», l’Ontario et l’Alberta, accusaient Pour obtenir un rapport complet sur les salaires des vétérinaires un retard par rapport à toutes les autres provinces pour les de même que des données complètes sur les avantages sociaux salaires ajustés au coût de la vie. Imitant les résultats des et les vacances, aller au Carrefour financier de l’ACMV et années précédentes, les salaires des vétérinaires de l’Alberta téléchargez le rapport de votre province. Si vous avez des questions n’ont pas réussi à gagner du terrain par rapport au coût de concernant le Rapport sur la rémunération et les avantages sociaux la vie le plus élevé au pays. Les propriétaires de pratique ont des salariés, veuillez communiquer avec Darren Osborne au effectué des tentatives vaillantes pour suivre le rythme de [email protected] ou au 1-800-670-1702, poste 14. l’inflation en offrant la hausse annuelle la plus élevée à l’extérieur de Terre-Neuve et Labrador et ils affichaient des salaires se Renvoi situant au troisième rang avant l’ajustement au coût de la vie. 1. Dépenses moyennes des ménages, par province et territoire, Statistique Canada, CANSIM, [page sur Internet] Disponible au http://www5. Cependant, cela n’a pas suffi pour compenser les différences du statcan.gc.ca/cansim/search-recherche?lang=eng&searchTypeByValue= coût de la vie. L’Ontario a aussi affiché des hausses supérieures 1&pattern=203-0001&p2=37 Dernière consultation le 14 novembre 2012. ■

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