October/Octobre 2017October/Octobre The Canadian Veterinary Journal

La Revue vétérinaire canadienne Vol. 58, No. 10 Vol. 58,

October/Octobre 2017 Volume 58, No. 10

Epidemiology of gastrointestinal nematode infections in grazing yearling beef cattle in Saskatchewan

Evaluation of long-acting oxytetracycline and a commercial monovalent vaccine for the control of Campylobacter fetus subsp. venerealis infection in beef bulls

Retrospective evaluation of toceranib (Palladia) treatment for canine metastatic appendicular osteosarcoma

Evaluation of the effect of umbilical hernias on play behaviors in growing pigs

Feline meningoencephalomyelitis of unknown origin: A retrospective analysis of 16 cases

Use of topical healing agents on scrotal wounds after surgical castration in weaned beef calves

Association of unmeasured strong ions with outcome of hospitalized beef and dairy diarrheic calves

Prevalence and clinical features of hypoadrenocorticism in Great Pyrenees dogs in a referred population: 11 cases

Hypocholesterolemia and nonregenerative, suspected immune-mediated, anemia: Report of 3 canine cases

Hemangiosarcoma within an intermuscular lipoma in a golden retriever dog

Accidental selenium toxicosis in lambs FOR PERSONAL USE ONLY

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OCTOBER/OCTOBRE 2017 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

ARTICLES 1086 Association of unmeasured strong ions with 1044 Epidemiology of gastrointestinal nematode outcome of hospitalized beef and dairy infections in grazing yearling beef cattle diarrheic calves in Saskatchewan Diego E. Gomez, Jeanne Lofstedt, Luis G. Arroyo, Maureen Wichtel, Tammy Muirhead, Henri Stämpfli, Murray Jelinski, John Gilleard, Lisa Rocheleau, J. Trenton McClure Grant Royan, Cheryl Waldner 1093 Prevalence and clinical features of 1051 Evaluation of long-acting oxytetracycline and hypoadrenocorticism in Great Pyrenees a commercial monovalent vaccine for the dogs in a referred population: 11 cases control of Campylobacter fetus subsp. venerealis infection in beef bulls Magali Decôme, Marie-Claude Blais Nathan E.N. Erickson, Emily Lanigan, Taryn Waugh, Karen Gesy, Cheryl Waldner CASE REPORTS RAPPORTS DE CAS 1059 Retrospective evaluation of toceranib 1100 Hypocholesterolemia and nonregenerative, (Palladia) treatment for canine metastatic suspected immune-mediated, anemia: appendicular osteosarcoma Report of 3 canine cases Changseok Kim, Arata Matsuyama, Rachel Robbins, Katrina R. Viviano Anthony J. Mutsaers, J. Paul Woods 1105 Hemangiosarcoma within an intermuscular 1065 Evaluation of the effect of umbilical hernias lipoma in a golden retriever dog on play behaviors in growing pigs Claire Leriquier, Marie-Odile Benoit-Biancamano, Melissa Atkinson, Rocio Amezcua, Josepha DeLay, Hugues Lacoste, Gregory D. Herndon Tina Widowski, Robert Friendship 1110 Accidental selenium toxicosis in lambs 1073 Feline meningoencephalomyelitis of unknown origin: A retrospective analysis Christina M. McKenzie, Ahmad N. Al-Dissi of 16 cases 1029 QUIZ CORNER Arianna Negrin, Sarah Spencer, Giunio Bruto Cherubini TEST ÉCLAIR 1081 Use of topical healing agents on scrotal wounds after surgical castration in weaned beef calves Sonia Marti, Karen S. Schwartzkopf-Genswein, Eugene D. Janzen, Daniela M. Meléndez, Désirée Gellatly, Edmond A. Pajor

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OCTOBER/OCTOBRE 2017 Contents Table des matières

FEATURES RUBRIQUES SPÉCIALES

LETTERS TO THE EDITOR THE ART OF PRIVATE COURRIER DES LECTEURS VETERINARY PRACTICE 1017 Cruelty to Animals L’ART DE LA PRATIQUE Robert J. Evenson VÉTÉRINAIRE PRIVÉE 1123 Catastrophic communication 1017 Animal Health Surveillance Myrna Milani Ian Alexander, Harold Kloeze BOOK REVIEWS EDITORIAL COMPTES RENDUS DE LIVRES ÉDITORIAL 1099 Crow & Walshaw’s Manual of Clinical 1021 The medical case report Procedures in Dogs, Cats, Rabbits Le rapport de cas médical & Rodents, 4th edition Carlton Gyles Janeen Junaid

1025 VETERINARY MEDICAL ETHICS 1116 Veterinary Medicine: A Textbook of the DÉONTOLOGIE VÉTÉRINAIRE Diseases of Cattle, Horses, Sheep, Pigs, and Goats, 11th edition, Volumes 1 and 2 WHAT CAN’T BE TAUGHT Cathy Patterson CE QUI NE S’ENSEIGNE PAS 1113 Strategies for fostering resilience as NOTICES ANNONCES veterinary care providers Marie K. Holowaychuk 1121 Index of Advertisers Index des annonceurs COMMENTARY 1125 Classifieds COMMENTAIRE Petites annonces 1117 Comments on the Ethical Question of the Month: July 2017 (CVJ 2017;58:651) Maureen Harper NEWS | NOUVELLES

DIAGNOSTIC DERMATOLOGY 1031 NEWS DERMATOLOGIE DIAGNOSTIQUE NOUVELLES 1119 Canine Malassezia dermatitis Heather Broughton, Isabelle Vallières Jangi Bajwa

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 58 / OCTOBER 2017 1013 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 Website/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 2017 Carlton Gyles, Guelph, Ontario L’Association canadienne des médecins vétérinaires 2017 Associate Editors/Rédacteurs associés Bruce Grahn, Saskatoon, Saskatchewan The Canadian Veterinary Journal is indexed or abstracted in: Wayne McDonell, Guelph, Ontario La Revue vétérinaire canadienne est indexée ou ses articles sont Feature Editors/Rédacteurs des chroniques résumés dans : Jangi Bajwa, Burnaby, British Columbia AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Bruce Grahn, Saskatoon, Saskatchewan Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Myrna Milani, Charlestown, New Hampshire Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Debbie Stoewen, Ayr, Ontario Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Tim Blackwell, Fergus, Ontario Assistant Editors/Rédacteurs adjoints Photo by/Photo de : Shutterstock Robert Friendship, Guelph, Ontario Greg Harasen, Regina, Saskatchewan Typesetting/Typographie Jacob Thundathil, Calgary, Alberta AN Design Communications Ron Johnson, Guelph, Ontario Richard Kennedy, Pincher Creek, Alberta Printed by/Imprimé par Shawn McKenna, Charlottetown, P.E.I. The Lowe-Martin Group Ottawa, Ontario Managing Editor/Directrice de la rédaction Heather Broughton, Ottawa, Ontario ISSN 0008-5286 Assistant Managing Editor/Directrice adjointe de la rédaction Stella Wheatley, Ottawa, Ontario Return undeliverable Canadian addresses to: Editorial Coordinator/Coordonnatrice de la rédaction 339 rue Booth Street Kelly Gray-Sabourin, Ottawa, Ontario Ottawa, Ontario K1R 7K1 e-mail: [email protected] Advertising Manager/Gérante de la publicité Laima Laffitte, Wendover, Ontario Subscriptions (2017). Annual: Canada $205 + applicable GST or HST; foreign $220 US; institutional $275. Express subscriptions available. Single issue/back issue: Published monthly by/ $25 each, institutional single issue = $50.00 + GST or HST, if applic­able. (All prices Publication mensuelle de subject to change.) Missing issues will be replaced if the Subscriptions Office is Canadian Veterinary Medical Association 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) or (1-800-567-2862) and fax (613-236-9681) orders accepted with a valid Visa or MasterCard number. Please advise the publisher of address changes promptly. Abonnements (2017). Annuel : Canada 205 $ + TPS ou TVH en vigueur; pays étranger 220 $ É-U; prix d’une institution 275 $. Abonnement express disponible. Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + 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) ou (1-800-567-2862), 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.

STUDENT SUBSCRIPTIONS/ABONNEMENTS DES ÉTUDIANTS

The editors and staff of The Canadian Veterinary Journal are pleased to have as readers student veterinarians at Canadian veterinary colleges! The production and distribution of student subscriptions is made possible through the generous sponsorship of Scotiabank

Les rédacteurs et le personnel de La Revue vétérinaire canadienne sont heureux de compter les étudiants en médecine vétérinaire des collèges vétérinaires au Canada au nombre de leurs lecteurs. La production et la distribution des abonnements des étudiants ont été rendues possible grâce au généreux soutien de Banque Scotia

1014 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY

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INFLUENCE KNOWLEDGE ADVANCING YOUR ISSUES, YOUR CONCERNS KEEPING YOU CURRENT ON VETERINARY SCIENCE AND YOUR PROFESSIONAL INTERESTS. AND PRACTICE, RESEARCH, INNOVATION AND The CVMA looks at policy matters in terms of their potential impact on TRENDS TO ENHANCE YOUR CAREER DEVELOPMENT the profession. Our role as an advocate for animal welfare and veterinary AND LIFELONG LEARNING. medicine at the national level influences your access to critical drugs, contributes to the development of responsible animal welfare policies, The CVMA provides you with the latest news, information, and clinical and mitigates decisions that could adversely affect your delivery of veterinary non-clinical continuing professional development. Our role as a knowledge care, and fosters a wider appreciation of the role of veterinarians in the provider enables you to broaden your knowledge and skills and maintain One Health concept. your competence to the highest professional standards.

As a CVMA member you benefit from… As a CVMA member you benefit from…

• Engagement with Government and key stakeholders to influence policy • The Canadian Veterinary Journal decisions • Canadian Journal of Veterinary Research • International relations to provide the Canadian veterinary perspective • Clinician’s Brief™ (free global digital edition) • Media and public relations to provide balanced and trustworthy information • CVMA national convention and to promote veterinary professionals • CVMA Veterinary Summit • Position statements on animal welfare and national veterinary issues • CVMA National Issues Forum • Codes of practice for Canadian kennel and cattery operations, and for the • CVMA Emerging Leaders Program care and handling of farm animals • CVMA Canadian Veterinary Reserve • Member consultations and online discussions on key veterinary issues • Member e-newsletter ‘Online from 339’ • Pan-Canadian Framework for Professional Standards in Veterinary Oversight of Antimicrobial Use • CVMA online continuing education portal • VetFolio® online educational resources (subscription discount)

RESOURCES SAVINGS SUPPORTING OUR MEMBERS THROUGH EVERY PUTTING MONEY IN YOUR POCKET AND DELIVERING STAGE OF THEIR CAREER WITH ACCESS TO A RANGE MORE VALUE TO INCREASE YOUR PROFITABILITY. OF EXCLUSIVE PRACTICE TOOLS AND RESOURCES. The CVMA provides members access to professional resources, veterinary The CVMA uses its national purchase power and strategic partnerships economic reports, practice management solutions, client education so that you can benefit from discount rates and money-saving services. resources, and exclusive online content to support you and your practice team in the effective delivery of veterinary services.

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• MyVetStore.caTM - CVMA web store solution for clinics • Hotel discounts worldwide • NEW! MonerisTM preferred payment processing rates • National and Enterprise Rent-a-Car discounts • NEW! CVMA Petcard Program - financing options for your clients • The Personal Insurance home and auto group savings • Practice owner’s economic survey • Scotiabank® business banking and lending solutions • Individual practice diagnostic and valuation report • The CVJ classified ads discount • Provincial suggested fee guide • Staples Advantage™ business products • Associate compensation and benefits report • Adtel® telephone hold service and digital signage • Compensation report for non-DVM staff • Petro-Canada SuperPass™ fuel/diesel/car wash discount • Compensation report for DVMs outside private practice • WSAVA World Congress (registration discount) • Practice management articles and resources • WVA Congress (registration discount) • CVMA group insurance program • Plumb’s Veterinary Drugs™ (subscription discount) • CVMA mentoring program • NEW! GoodLife Fitness Corporate Discount • VetLaw Online™ legal advice column • NEW! HRdownloads™ discounts • CVMA Green Veterinary Practice and self-audit tool • Antimicrobial SmartVet mobile app • Veterinarian health and wellness resources For information about the many benefits and privileges • Early career DVM web resource hub of membership. • Guidelines for the successful employment of new veterinary graduates • Sedative, anaesthetic and pain management protocols posters • Guidelines for the legitimate use of compounded drugs in veterinary practice CANADIAN VETERINARY MEDICAL ASSOCIATION • Antimicrobial prudent use guidelines for beef cattle, dairy cattle, poultry and 339 Booth Street, Ottawa (Ontario) K1R 7K1 swine T • (800) 567-2862 • (613) 236-1162 • Therapeutic decision cascade poster F • (613) 236-9681 • Animal abuse resources for practitioners faced with this issue [email protected] • Preventive healthcare, nutritional assessment and client education tools and canadianveterinarians.net resources • Animal health week annual public awareness campaign

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Cruelty to Animals Dear editor, I would like to see a law requiring commercial livestock This letter is in regard to the ongoing cruelty and abuse that operations to install video cameras to monitor their operation our food-producing animals and birds are undergoing across on a 24-hour daily basis. This would allow owners, managers, Canada on a daily basis. supervisors to see any abuse or cruelty and take appropriate The following are examples of undercover videos showing steps to correct it. The videotapes should also be checked by acts of cruelty and abuse that have been aired over the past 1 to government inspectors to ensure any abuse or cruelty is dealt 2 years on CTV. with appropriately. This system would replace undercover sur- • Horses — abused while being processed at slaughter houses veillance, which is difficult to undertake and is spotty, resulting (no longer slaughtered in Canada); in only a small percentage of abuse cases being identified. • Horses shipped in undersized crates overseas to Japan. Many In summary, our food-producing animals and birds are suf- horses cannot lift their heads and end up going down and fering cruelty and abuse across Canada on a daily basis with dying in transport; only a small percentage of cases being identified. A compulsory • Dairy calves — housed in poor conditions, wooden slatted video system, along with government inspection of recordings, floors, tied to chains, unable to move around, and not treated would identify the majority of cases and would also act as a when sick; strong deterrent to acts of cruelty, as abusers would risk loss of • Dairy cows — Downer cows prodded with electric prods, their jobs and prosecution with fines or a jail term. dragged across floors and beaten; If there was support for such a law, how would one go • Swine — Sows kept in gestation crates approximately 90% about getting it implemented? Perhaps petitions to the federal of their lives, not able to walk or turn around. This results in government by the Canadian Veterinary Medical Association, extreme mental cruelty, stress, and greater susceptibility to Saskatchewan Veterinary Medical Association, Society for the disease; Prevention of Cruelty to Animals, Members of Parliament, at • Chickens — In a large commercial enterprise, a video show- both the federal and provincial levels, veterinarians, and taxpay- ing chickens being thrown against walls, and having their legs ers might be helpful. pulled off while alive to entertain the inhumane workers. Cruelty and abuse can happen at any level of farm produc- Dr. Robert J. Evenson, BSA, DVM tion, but it appears that there is a much higher incidence in Northeast Veterinary Services large commercial operations with large numbers of employees. PO Box 1838 Small owner-operated farms are likely to have a lower incidence Tisdale, Saskatchewan S0E 1T0 of animal abuse.

Animal Health Surveillance Dear Editor, animal health risks and zoonoses are occurring more frequently. We would like to recognize and thank Dr. Wayne Lees and Formulating early advice in order to effectively deal with risks Mr. Cameron Prince for preparing the special report on “Lessons is essential in order to protect the public health of Canadians, learned from the evolution of terrestrial animal health surveil- and to support the animal health status of our country, thereby lance in Canada and options for creating a new collaborative ultimately benefitting our trade negotiations with international national structure,” found in the May issue of The CVJ (Can partners. Vet J 2017;58:459–465). The Canadian Food Inspection Agency (CFIA) is a strong The publishing of this report is very timely as the topics of supporter of the need for this type of collaboration as has been animal health surveillance, how we derive intelligence from demonstrated by its ongoing support of Canadian Animal raw information, and how we collectively share this informa- Health Surveillance Network (CAHSN) over the past decade. I tion are becoming increasingly important as new and emerging would like to highlight that CAHSN has had ongoing progress

Constructive and professional comments made in the spirit of intellectual debate are welcomed by the Editor. Writers are expected to be respectful of others and to ensure that letters are considerate and courteous. The Editor reserves the right to remove comments deemed to be inflammatory or disrespectful.

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over the years towards data sharing and test development col- laboration between animal health laboratories and networks across the country. While the surveillance component has not perhaps progressed to the degree envisioned originally by the federal and provincial partners when the project began over a decade ago, there have been significant accomplishments. How much CAHSN has an Information Sharing Agreement which is cur- rently signed by 10 of 12 partners, has finalized both the privacy tolerance should and data security frameworks and has ongoing data collations. Bovine spongiform encephalopathy (BSE) data are collected by there be for automated daily uploads to the central database, as managed by the Canadian Network for Public Health Intelligence, from all flea bites? 8 laboratories that test for this disease in Canada. Scrapie and Chronic Wasting Disease data are similarly collected. CAHSN has enabled daily uploads of clinical test results from the public sector animal health laboratories in western Canada and is devel- oping and distributing case reports, syndromic surveillance, and other innovative products based upon this data. The combined efforts of CAHSN, the Community for Emerging and Zoonotic Diseases (CEZD) and the Canadian Animal Health Surveillance System (CAHSS) provide Canada with a unique opportunity to further develop this collaborative approach to surveillance and intelligence activities. These surveillance activities align well with objectives of the Plant and Animal Health Strategy, which is bringing federal, provincial, and territorial governments as well as industry together to guide future collaborative work on plant and ani- mal health. Once again we would like to thank the authors for their article and for their work in developing the systems Zero. discussed here.

Dr. Ian Alexander Executive Director, Animal Health Science Canadian Food Inspection Agency

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*Mehlhorn H, Hansen O, Mencke N. (2001). Comparative study on the effects of three insecticides (fipronil, imidacloprid, selamectin) on developmental stages of the cat flea (Ctenocephalides felis Bouché 1835): a light and electron microscopic analysis of in vivo and in vitro experiments. Parasitol Res. 87(3):198-207.

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www.vetoquinol.ca FOR PERSONAL USE ONLY Editorial Éditorial

The medical case report Le rapport de cas médical

he medical case report is a format whose origins have been e rapport de cas médical est un format dont on retrace les T traced to hundreds of years before records on Egyptian L origines à des centaines d’années avant les premiers rapports papyrus around 1600 BCE (1). This format remains an impor- consignés sur du papyrus égyptien vers 1600 av. J.-C. (1). Ce tant part of the array of methods for education and continuing format demeure un élément important de l’éventail de méthodes education of personnel in all medical fields, including veterinary pour l’éducation et la formation continue du personnel dans medicine. The case report is popular because it tells a story (and tous les domaines médicaux, y compris la médecine vétérinaire. people love to read stories), it provides information in a relevant Le rapport de cas est populaire parce qu’il raconte une histoire real-life context, it usually does not require substantial expendi- (et les gens adorent lire des histoires), fournit des renseignements ture on the part of the authors, and the time from beginning of dans un contexte réel et n’exige pas habituellement des dépenses the case to preparation of a manuscript may be relatively short. considérables de la part des auteurs. De plus, le manuscrit peut However, the case report format faces a number of challenges, être rédigé relativement peu de temps après le début du cas. not the least of which is the journal impact factor. Cependant, le format du rapport de cas doit relever plusieurs Case reports are generally cited less frequently than research défis, dont celui du facteur d’impact des revues. papers. One reason for this is that the case report is viewed as Les rapports de cas sont généralement cités moins a less reliable type of evidence compared with research studies. fréquemment que les travaux de recherche, notamment parce In the latter part of the 1900s there was a downgrading of the que le rapport de cas est considéré comme un type de preuve importance of this type of data as evidence-based approaches moins fiable comparativement aux études de recherche. Durant began to be emphasized and the case report was placed at the la deuxième moitié du 20e siècle, il s’est produit un déclassement bottom of the evidence hierarchy in which the weight to be de l’importance de ce type de données, car on a commencé à attached to knowledge is stratified with the randomized clini- insister sur les approches factuelles et le rapport de cas a été cal trial at the top of the pyramid (1). The other reason for low placé au bas de la hiérarchie des preuves où le poids associé frequency of citation is that case reports are often geared toward aux connaissances est stratifié et l’essai clinique randomisé se unusual cases, including rare diseases or rare forms of disease, trouve au haut de la pyramide (1). Une autre raison pour la which are not often the topic of research articles. faible fréquence de citations est que les rapports de cas portent Infrequent citations of articles in a journal result in low souvent sur des cas inusités, notamment les maladies rares ou impact scores that are often translated to mean low quality une forme rare de la maladie qui ne font pas souvent l’objet of the journal. However, the value of the case report can- d’articles de recherche. not be measured by its citation in research publications. Des citations peu fréquentes d’articles dans une revue As an example, The Journal of Medical Case Reports (BMC) produisent de faibles notes d’impact qui se traduisent souvent (https://jmedicalcasereports.biomedcentral.com/) has an impact par une qualité moyenne faible de la revue. Cependant, la valeur factor of 0.69 — which is low; however, the journal reports du rapport de cas ne peut pas être mesurée par ses citations dans that “throughout 2016, articles were accessed from the jour- les publications de recherche. À titre d’exemple, The Journal nal website more than 1.7 million times; an average of over of Medical Case Reports (BMC) (https://jmedicalcasereports. 4600 accesses per day.” Professor Michael Kidd, editor-in-chief biomedcentral.com/) a un facteur d’impact de 0,69 — ce qui of the journal notes that “In the era of evidence-based practice, est faible. Cependant, la revue signale que «au cours de 2016,

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.

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we need practice-based evidence … detailed information from on a accédé aux articles sur le site Web de la revue plus de the case reports of individual people which informs both our 1,7 million de fois, soit une moyenne de plus de 4600 accès clinical research and our daily clinical care.” par jour». Le professeur Michael Kidd, rédacteur en chef de la In the veterinary field, Veterinary Record Case Reports revue fait remarquer que : «En cette ère de pratique basée sur les (http://vetrecordcasereports.bmj.com/pages/authors/) states: preuves, nous avons besoin de preuves basées sur la pratique… “We want to publish cases with clinically valuable lessons… des renseignements détaillés provenant de rapports de cas sur des Articles may be about a single animal, herd, flock or other group personnes individuelles qui informent notre recherche clinique of animals managed together. Common cases that present a et nos soins cliniques quotidiens.» diagnostic, ethical or management challenge, or that highlight Dans le domaine vétérinaire, Veterinary Record Case Reports aspects of mechanisms of injury, pharmacology or histopathol- (http://vetrecordcasereports.bmj.com/pages/authors/) déclare : ÉDITORIAL ogy are deemed of particular educational value. We want to «Nous désirons publier des cas présentant des leçons cliniques publish cases worthy of discussion particularly around aspects utiles… Les articles peuvent porter sur un seul animal ou of differential diagnosis, decision-making, management, clini- troupeau ou sur un autre groupe d’animaux gérés ensemble. cal guidelines and pathology. The advantage is that we learn Les cas communs qui présentent des difficultés diagnostiques from real cases… Cases will be judged on clinical interest and ou éthiques ou des problèmes de gestion ou qui soulignent les educational value NOT novelty or rarity.” This is a departure aspects des mécanismes de la blessure, de la pharmacologie ou de from the usual requirement for novelty and clearly recognizes l’histopathologie sont jugés d’une valeur éducative particulière. the value of the case report as an educational tool not only a Nous désirons publier des cas qui méritent d’être discutés, mechanism for reporting rarity. particulièrement sur les aspects du diagnostic différentiel, de la The case report has its limitations. For example, reports of a prise de décision, de la gestion, des lignes directrices cliniques single case are limited with respect to the conclusions that can et de la pathologie. L’avantage est que nous apprenons de cas be drawn regarding effectiveness of a novel therapy. However, a réels… Les cas seront jugés selon leur intérêt clinique et leur report of a single case may describe a new disease, a new varia- valeur éducative et NON leur nouveauté ou rareté.» Il s’agit tion of a well-known disease, an important rare adverse reaction d’une nouvelle approche par rapport au critère habituel de to a drug, unusual drug interactions, or may alert practitioners nouveauté qui reconnaît clairement la valeur du rapport de to new diagnostic and therapeutic approaches. Furthermore, a cas comme un outil éducatif et non seulement comme un case series or several independent reports of a particular disease mécanisme pour signaler la rareté. may provide valuable information on diagnosis, case manage- Le rapport de cas possède ses limitations. Par exemple, ment, and therapy. These studies may point to successful and les rapports sur un seul cas sont limités en ce qui a trait aux unsuccessful treatments and may be the basis for designing conclusions concernant l’efficacité d’une thérapie nouvelle. prospective studies to test hypotheses. Cependant, le rapport d’un seul cas peut décrire une nouvelle What can be done to improve the effectiveness of the case maladie, une nouvelle variation d’une maladie bien connue, une report as an educational tool? High quality color images can réaction indésirable rare importante face à un médicament, des contribute much to the story that is told and should be used interactions inhabituelles de médicaments ou il peut informer whenever they are needed. Because of costs, authors sometimes les praticiens à l’égard de nouvelles approches diagnostiques et use black and white images or no images where color images thérapeutiques. De plus, une série de cas ou plusieurs rapports would be more effective. Also, tests that could add to the indépendants sur une maladie particulière peuvent fournir de understanding of the disease are sometimes not done because précieux renseignements sur le diagnostic, la gestion des cas et the client is unable or unwilling to pay. There should be funds la thérapie. Ces études peuvent signaler le succès et l’échec de in clinical departments to meet the costs of publication and traitements et elles peuvent servir de fondement à la conception the cost of tests, where such tests are not essential for patient d’études prospectives pour tester des hypothèses. care but could contribute to understanding the disease process. Que peut-on faire pour améliorer l’efficacité du rapport I close with a quotation from the Dutch medical scientist, de cas en tant qu’outil éducatif? Des images en couleur de J.P. Vandenbroucke (2): “Now that medical practitioners all haute qualité peuvent apporter une contribution importante à over the world are firmly convinced that ‘evidence’ should l’histoire racontée et elles devraient être utilisées au besoin. En guide their actions, is there still a role for the age-old corner- raison des coûts, les auteurs utilisent parfois des images en noir stone of the medical literature, the case report? The answer is et blanc là où des images en couleur seraient plus efficaces. De an emphatic yes: The case report is as necessary as ever for the plus, les tests qui pourraient améliorer notre compréhension de progress of medical science and the practice of medicine.” la maladie ne sont parfois pas réalisés parce que le client ne peut pas ou ne veut pas payer. Il devrait y avoir des fonds dans les Carlton Gyles départements cliniques afin de financer les coûts de publication et des tests lorsque ces tests ne sont pas essentiels pour les soins References du patient mais pourraient contribuer à la compréhension du 1. Nissen T, Wynn R. The history of the case report: A selective processus pathogénique. review. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4012665/ JRSM Open. April 2014. Last accessed August 2, 2017. Je termine par une citation du scientifique médical hollandais 2. Vandenbroucke JP. Case reports in an evidence-based world. J Royal Soc J.P. Vandenbroucke (2) : «Maintenant que les praticiens Med 1999;92:159–163. ■ médicaux de toutes les régions du monde sont fermement

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convaincus que les «preuves» devraient guider leurs actions, y Références a-t-il toujours une place pour l’éternel pilier de la littérature 1. NISSEN, T. et R. WYNN. The history of the case report: A selective médicale, le rapport de cas? La réponse est un oui catégorique : review. Disponible au : https://www.ncbi.nlm.nih.gov/pmc/articles/ Le rapport de cas est toujours aussi nécessaire pour les progrès PMC4012665/ JRSM Open. Avril 2014. Dernière consultation le 2 août 2017. de la science médicale et de la pratique de la médecine.» 2. VANDENBROUCKE, J.P. «Case reports in an evidence-based world», J Royal Soc Med, 1999, vol. 92, p. 159–163. ■ Carlton Gyles EDITORIAL

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341 CPD Points FOR PERSONAL USE ONLY Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — October 2017 Stockpeople raise livestock with the intention of producing meat, milk, fiber, and a range of other products. When an animal develops a problem such as lameness, producers wrestle with a sense of failure together with the belief that it is wrong to “waste” the animal’s life, i.e., euthanize an animal that has not fulfilled its purpose. The belief that an animal’s life should have a purpose is one reason that less than perfectly fit animals are sometimes transported to slaughter. When such animals appear at abattoirs or sales barns, producers may be accused of trying to extract the last bit of profit from an animal, or that they didn’t recognize that the animal had a problem. The producer on the other hand feels it is wrong that an animal that he or she has cared for over months or years should be killed and disposed of on the farm because it was not perfectly fit to travel. Is this belief that an animal should fulfill its intended purpose misguided? Is it wrong to “waste” an animal’s life? Question de déontologie du mois — Octobre 2017 Les éleveurs élèvent le bétail dans le but de produire de la viande, du lait, des fibres et un éventail d’autres produits. Lorsqu’un animal développe des problèmes comme la boiterie, les producteurs composent avec un sentiment d’échec ainsi qu’avec la croyance qu’il n’est pas éthique de «gaspiller» la vie d’un animal, c.-à-d., euthanasier un animal qui n’a pas été utilisé aux fins prévues. La croyance que la vie d’un animal devrait avoir un but est l’une des raisons pour laquelle des animaux qui ne sont pas entièrement aptes sont parfois transportés vers l’abattoir. D’une part, lorsque de tels animaux sont présentés aux abattoirs ou aux encans à bestiaux, on pourra accuser les producteurs de tenter d’extraire un dernier profit de l’animal ou de ne pas avoir reconnu que l’animal avait un problème. D’autre part, le producteur estime qu’il n’est pas juste qu’un animal dont il s’est occupé pendant des mois ou des années soit tué et éliminé à la ferme parce qu’il n’était pas parfaitement apte à voyager. La croyance voulant qu’un animal soit utilisé aux fins prévues est-elle erronée? Est-ce une erreur de «gaspiller» la vie d’un animal?

Responses to the case presented are welcome. Please limit your Les réponses au cas présenté sont les bienvenues. Veuillez reply to approximately 50 words and forward along with your limiter votre réponse à environ 50 mots et nous la faire parvenir name and address to: Ethical Choices, c/o Dr. Tim Blackwell, par la poste avec vos nom et adresse à l’adresse suivante : 6486 E. Garafraxa, Townline, Belwood, Ontario N0B 1J0; Choix déontologiques, a/s du Dr Tim Blackwell, 6486, telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: E. Garafraxa, Townline, Belwood (Ontario) N0B 1J0; [email protected] téléphone : (519) 846-3413; télécopieur : (519) 846-8178; Suggested ethical questions of the month are also welcome! All 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 58 / OCTOBER 2017 1025 FOR PERSONAL USE ONLY

Ethical question of the month — July 2017 In modern livestock farming a variety of metrics are used to measure animal productivity. Many of these production metrics are also considered indicators of animal welfare. Mortality rate is one metric used to judge both production efficiency and animal welfare on the farm. By extension, some use mortality rates during transport to judge the welfare of livestock during transport. Whereas livestock on a farm may die from a wide variety of causes including infectious disease, only fit and healthy animals are transported for sale. Therefore the reasons for transport deaths are seldom the same as the reasons for mortalities in the barn. Is transportation mortality an appropriate indicator for judging the welfare of livestock being transported? Question de déontologie du mois — Juillet 2017 Dans l’agriculture d’élevage moderne, divers paramètres sont utilisés pour mesurer la productivité de l’animal. Beaucoup de ces paramètres de production sont aussi considérés des indicateurs du bien-être animal. Le taux DÉONTOLOGIEVÉTÉRINAIRE de mortalité est l’un des paramètres utilisés pour évaluer l’efficacité de la production et le bien-être animal à la ferme. Par extension, certaines personnes utilisent les taux de mortalité durant le transport pour évaluer le bien-être du bétail durant le transport. Tandis que le bétail à la ferme peut mourir en raison d’une diversité de causes, dont les maladies infectieuses, seulement des animaux aptes et en santé sont transportés aux fins de vente. Par conséquent, les causes de décès durant le transport sont rarement les mêmes que celles des mortalités se produisant à la ferme. La mortalité lors du transport représente-t-elle un indicateur approprié pour évaluer le bien-être du bétail qui est transporté?

Is mortality the mark of welfare in transport? — Comments Animal welfare assessment evaluates quality of life and a humane cold or heat stress, type of truck/trailer, and square footage per death. Following death, there are no health or behavioral animal. Time duration of transport without rest, feed, and water parameters to measure. Therefore, transport mortality is not an is regulated depending on the species of animal. Not only is the appropriate welfare indicator of transported livestock. Rather, transport conveyance regulated, and the humane handling of the welfare indicators should be animal-based and reflect conditions animals by personnel, but the loading and unloading facilities of the transport environment. must be safe and humane for the type and size of animal. The CFIA regulations are much more extensive and detailed Lindsay Nakonechny, M.Sc, Edmonton, Alberta than presented here. Don’t be misled to think that mortality is the only parameter in the animal welfare of transported animals, There are some very stringent regulations under the Canadian as your Ethical Question implies. There are severe penalties Food Inspection Agency (CFIA) Transport of Animals. Mortality for the trucker, producer, or handlers for not following Best is one of the parameters but probably not more common or Management Practices for transport of animals. important than downers, lameness, fractures, dehydration, stress or injuries from lacerations, bruising or trauma to the skin. Don Church, DVM, Red Deer, Alberta, [email protected] Overcrowding is regulated by the animal transported, size, sex,

An ethicist’s commentary on is mortality the mark of welfare in transport? There is no question that if an animal dies as a result of trans- I have been told that horses are crated and shipped by air to port, one can confidently assert that during the period of Japan to be killed for food. Again, it is beyond disingenuous ­transport, it did not enjoy good welfare. In other words, not to suggest that if they arrive alive, they enjoyed good welfare dying is a necessary condition for an attribution of good welfare. during the trip. When cattle are crowded into double-decker But in the same sense, so are the presence of oxygen, a tempera- trucks that are poorly ventilated and horrendously hot, and the ture above absolute zero, and myriad other factors. ride is hellishly uncomfortable, it is absurd to suggest that these Asserting that if an animal did not die during transport, it animals are well-off if they do not die. enjoyed good welfare is absurd. In the bad old days when farm- My son was and is an extremely tough guy. When he was ers, particularly dairy farmers, used to routinely ship downer four years old, he crashed a bicycle and broke his arm. He never cows to slaughter so as to realize some minimal profit from cried. When we rushed him to the doctor, the pediatrician con- these miserable animals, no one with an ounce of common sense cluded that the arm could not be broken because the child was would have affirmed that those animals were well off, since the not crying. In fact, I only remember him crying twice when he animals were often sick or seriously injured. Indeed, on some was a small child. On one occasion, we stopped at a railroad occasions, they arrived at the slaughterhouse with broken legs, crossing right next to a cattle truck. After peering at the truck, unable to walk. he began to cry silently and profoundly. I was very upset and

1026 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY asked him what was wrong. He replied, “Those poor cows. It welfare by reference to a simple and patently observable single is very hot outside and even hotter in that two-level truck. And criterion makes a mockery of the concept. The Farm Animal the ones on the top level are peeing and pooping on the others. Welfare Council in Britain was spot on when it affirmed that: ETHICS MEDICAL VETERINARY That is wrong!” “The welfare of an animal includes its physical and mental To assume that animals are well-off in transport because they state and we consider that good animal welfare implies arrive at a destination not dead, but possibly weak, sick, sore, or both fitness and a sense of well-being. Any animal kept dehydrated is a fantasy. On other occasions in this column, we by man, must at least be protected from unnecessary have discussed the amount of time the animals are legally per- suffering.” mitted in a truck without being fed and watered or off-loaded. To use an odious human analogy, one might as well affirm that Shame on anyone who dares to affirm that an animal enjoys people crammed into cattle cars in Nazi Germany for transport good welfare if it is not dead! In fact, a thorough overhaul of all to a concentration camp were well-off when they arrived alive. aspects of animal transportation from stress-promoting loading We have repeatedly stressed in this column that animal wel- to heat and poor ventilation is long overdue. fare is an extremely complex and value-laden notion, predicated on ethical positions articulating what we owe animals. Defining Bernard E. Rollin, PhD

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Quiz Corner Test éclair

1. Cavalier King Charles spaniels are predisposed to which of 1. Les Épagneuls cavalier King Charles sont prédisposés à the following heart diseases? laquelle des maladies cardiaques suivantes? A. Dilated cardiomyopathy A. cardiomyopathie dilatée; B. Subaortic stenosis B. sténose subaortique; C. Mitral valve endocardiosis C. endocardiose de la valve mitrale; D. Hypertrophic cardiomyopathy D. cardiomyopathie hypertrophique; E. Chemodectoma E. chémodectome. 2. Which of the following is most correct concerning uroabdo- 2. Lequel des énoncés suivants est le plus juste à propos de men (uroperitoneum)? l’uroabdomen (uropéritoine)? A. The measurement of abdominal fluid BUN is the definitive A. La mesure du BUN du liquide abdominal est le test biochemical test for confirming the diagnosis. biochimique de référence pour confirmer le diagnostic. B. The measurement of abdominal fluid creatinine is the B. La mesure de la créatinine du liquide abdominal est le test definitive biochemical test for confirming the diagnosis. biochimique de référence pour confirmer le diagnostic. C. The measurement of abdominal fluid sodium and potas- C. La mesure du sodium et du potassium du liquide sium are the definitive biochemical tests for confirming abdominal est le test biochimique de référence pour the diagnosis. confirmer le diagnostic. D. The observation of urination excludes the diagnosis of D. La présence de miction exclut un diagnostic d’uropéritoine. uroperitoneum. E. La récupération de l’urine à la suite du passage d’un E. The retrieval of urine after the passage of a urinary cath- cathéter urinaire exclut un diagnostic d’uropéritoine. eter excludes the diagnosis of uroperitoneum. 3. Lequel des médicaments immunosuppresseurs suivants 3. Which of the following immunosuppressive drugs should ne doit pas être administré aux chats? NOT be administered to cats? A. cyclosporine; A. Cyclosporine B. prednisolone; B. Prednisolone C. chlorambucil; C. Chlorambucil D. azathioprine; D. Azathioprine E. sels d’or. E. Gold salts 4. Un poulain Égyptien de type arabe montre des signes 4. An Egyptian Arabian foal is displaying neurologic signs at neurologiques à la naissance. L’examen révèle de la tétanie, birth. Examination reveals tetany, paddling, and a dilute du pédalage et un pelage de couleur diluée. Lequel des coat color. Which of the following is the most likely diag- diagnostics suivants est le plus probable? nosis for this foal? A. hypopigmentation; A. Hypopigmentation B. albinisme; B. Albinism C. syndrome létal du poulain blanc; C. Lethal white foal syndrome D. syndrome létal du poulain lavande; D. Lethal lavender foal syndrome E. vitiligo. E. Vitiligo

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5. Which of the following options LEAST warrants investiga- 5. Laquelle des options suivantes justifie le moins une tion in an outbreak of papillomatous digital dermatitis in investigation lors d’une flambée de dermatite digitale cattle? papillomateuse chez les bovins? A. Foot bath size A. La grosseur des bains de pieds. B. Alley scraping B. Le grattage des allées. C. Concrete age C. L’âge du béton. D. Copper sulfate invoices D. Le traitement au sulfate de cuivre. E. Stock invoices E. La qualité des animaux.

TESTÉCLAIR (See p. 1122 for answers./Voir les réponses à la page 1122.)

Questions and answers were derived from Review Questions and Answers Les questions et les réponses sont extraites de Review Questions and for Veterinary Boards 2nd ed., a 5-volume series including Basic Sciences, Answers for Veterinary Boards 2nd ed., une série de cinq ­volu­mes qui Clinical Sciences, Small Animal Medicine and Surgery, Large Animal ­comprend Basic Sciences, Clinical Sciences, Small Animal Medicine and Medicine and Surgery, and Ancillary Topics, by kind permission of the Surgery, Large Animal Medicine and Surgery, et Ancillary Topics, avec publisher, Mosby–Year Book, Inc., St. Louis, Missouri. l’aimable permission de ­l’éditeur, Mosby–Year Book, Inc. de St. Louis (Missouri).

Have Another Look at CJVR Avez-vous consulté la RCRV dernièrement? Members of the CVMA are entitled to receive the Canadian Journal Les membres de l’ACMV reçoivent un abonnement gratuit à la of Veterinary Research (CJVR) at no additional charge. The CJVR, Revue canadienne de recherche vétérinaire. On peut consulter la in the form of an interactive (portable document format) pdf, can RCRV, qui est présentée en format pdf interactif, sur le site Web be found on the CVMA member-only website (www.canadian de l’ACMV réservé aux membres (www.veterinairesaucanada.net/ veterinarians.net/publications-research-issue.aspx). publications-research-issue.aspx). Published by the CVMA, this quarterly, peer-reviewed journal is Publiée par l’ACMV, cette revue trimestrielle évaluée par les pairs Canada’s only national veterinary research ­publication. est la seule publication nationale de recherche vétérinaire au Canada.

Articles from the July 2017 issue of CJVR that might be Les articles suivants du numéro de juillet 2017 de of interest to practitioners include: la RCRV pourraient intéresser­ les praticiens : Direct repeat unit (dru) typing and antimicrobial Direct repeat unit (dru) typing and antimicrobial resistance of methicillin-resistant Staphylococcus resistance of methicillin-resistant Staphylococcus pseudintermedius isolated from dogs in Atlantic pseudintermedius isolated from dogs in Atlantic Canada on page 192 Canada à la page 192 The impact of carboplatin and toceranib phosphate The impact of carboplatin and toceranib phosphate on serum vascular endothelial growth factor (VEGF) on serum vascular endothelial growth factor (VEGF) and metalloproteinase-9 (MMP-9) levels and survival and metalloproteinase-9 (MMP-9) levels and survival in canine osteosarcoma on page 199 in canine osteosarcoma à la page 199

The CJVR, along with the monthly Canadian La RCRV, avec La Revue vétérinaire canadienne qui est Veterinary Journal, is also archived on PubMed Central publiée mensuellement, est aussi archivée sur PubMed (www.pubmedcentral.com) 6 months after publication. Central (www.pubmedcentral.com) six mois après la An interactive pdf of The CVJ is also available on the publication. member-only section of the CVMA website. Un pdf interactif de La RVC est aussi disponible dans la section réservée aux membres du site Web de l’ACMV.

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NEWS | NOUVELLES

2017 CVMA Convention and Council Congrès de l’ACMV et réunion Meeting du Conseil de l’ACMV 2017 he Canadian Veterinary Medical Association (CVMA) Association canadienne des médecins vétérinaires (ACMV) Theld its 69th Annual Convention July 13th to 16th in L’ a tenu son 69e congrès annuel du 13 au 16 juillet à Charlottetown, PEI. The program provided 105 concurrent ses- Charlottetown, à l’Île-du-Prince-Édouard. Le programme comportait sions delivered by 42 speakers for the almost 1000 participants. 105 ateliers parallèles présentés par 42 conférenciers pour Once again, the Program was RACE (Registry of Approved les plus de 1000 participants. De nouveau, le programme était Continuing Education) approved. approuvé par RACE (Registry of Approved Continuing Education). The 2017 CVMA Convention enjoyed the valued partnership Le congrès 2017 de l’ACMV a profité du précieux partenariat of the Registered Veterinary Technicians and Technologists of de Technologues et techniciens vétérinaires agréés du Canada Canada (RVTTC) and the Atlantic Veterinary College (AVC). (TTVAC) et de l’Atlantic Veterinary College (AVC). CVMA Convention — Where Canada’s Le congrès de l’ACMV — Le lieu de rencontre veterinarians meet des vétérinaires du Canada In addition to continuing education (CE), the CVMA En plus de la formation continue, le congrès de l’ACMV sert de Convention provides an annual forum for discussion and meet- forum annuel pour les discussions et les réunions des vétérinaires ings of veterinarians from across the country. provenant de toutes les régions du pays. The CVMA Summit, chaired by Dr. Troye McPherson, Le Sommet de l’ACMV, qui a été présidé par la Dre Troye featured the theme of “The Future of Veterinary Medicine: McPherson, présentait le thème «L’avenir de la médecine Embracing Change and Innovation,” followed by the National vétérinaire : Adopter les changements et l’innovation», suivi du Issues Forum, moderated by Dr. Art Ortenburger under the Forum sur les enjeux nationaux, qui a été modéré par le

Back row, lt to rt: R. Carlson (WVA), R. Johnson (AVA), CVMA Council: T. Chotowetz, (SK), C. Bell (MB), L. Kwantes (AB), C. Armstrong (BC), B. Stemshorn (Treasurer), M. Hicks (NB), K. MacMillan (AVC/FMV), L. Ridway (RVTTC), J. am Rhyn (CEO), E. Stiles (QC), J. Donlin (AVMA), M. Brown-Bury (NL), T. Arthur (ON), W. Ingwersen (WSAVA), M. Topper, (AVMA) Front row, lt to rt: J. Glencross-Winslow (PE), E. Hartnett (SCVMA), K. Machin (WCVM/UCVM/OVC), R. Laguens (FVE), T. Bourque (CVMA President), T. Meyer (AVMA), T. McPherson (NS), N. Gallant (CVMA Past-president), K. Moser (In-coming SCVMA President) The above are seated in front of the quay in Charlottetown where the Chilean Navy’s tall ship, Esmeralda, was docked.

Rangée arrière, de gauche à droite : R. Carlson (AMV), R. Johnson (AVA), Conseil de l’ACMV : T. Chotowetz, (Sask.), C. Bell (Man.), L. Kwantes (Alb.), C. Armstrong (C.-B.), B. Stemshorn (trésorier), M. Hicks (N.-B.), K. MacMillan (AVC/FMV), L. Ridway (TTVAC), J. am Rhyn (PDG), E. Stiles (QC), J. Donlin (AVMA), M. Brown-Bury (T.-N.-L.), T. Arthur (Ont.), W. Ingwersen (WSAVA), M. Topper, (AVMA) Rangée avant, de gauche à droite : J. Glencross-Winslow (Î.-P.-É.), E. Hartnett (ÉACMV), K. Machin (WCVM/UCVM/OVC), R. Laguens (FVE), T. Bourque (président de l’ACMV), T. Meyer (AVMA), T. McPherson (N.-É.), N. Gallant (présidente sortante de l’ACMV), K. Moser (présidente désignée des ÉACMV) Les personnes ci-dessus sont assises en face du quai de Charlottetown où était accosté le grand voilier de la marine chilienne, l’Esmeralda.

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N theme “Is Alternative Medicine no Longer Alternative.” The lat- Dr Art Ortenburger sous la rubrique «La médecine parallèle ter presentations and plenary discussions will assist the CVMA est-elle toujours parallèle?». Ces présentations et les discussions in its endeavor to renew its current position. Both initiatives, plénières aideront l’ACMV à tenter d’améliorer sa position actuelle. together with further research, are meant to help explore the Les deux initiatives, conjointement à de nouvelles recherches, “Uber” of veterinary medicine and how the CVMA can assist visent à explorer l’«Uber» de la médecine vétérinaire et comment its members with changes to come in the profession. l’ACMV peut appuyer ses membres à l’égard des changements à The annual CVMA Emerging Leaders Program allowed venir dans la profession. 37 individuals to participate in this highly interactive 8-hour L’édition annuelle du Programme des futurs leaders de workshop facilitated by Dr. Rick DeBowes. Attendees sharpened l’ACMV a permis à 37 personnes de participer à un atelier their skills and knowledge on how to manage various challenges hautement interactif d’une durée de huit heures qui a été animé encountered in professional and personal life. This program is par le Dr Rick DeBowes. Les participants ont perfectionné graciously supported by VIROX Animal Health. leurs compétences et leurs connaissances en vue de gérer les Approximately 260 individuals attended the Annual General divers défis qui doivent être relevés dans la vie professionnelle Meeting. Canada’s Minister of Health, the Honorable Jane et personnelle. Ce programme est généreusement appuyé par Philpott, sent a message to CVMA members. Excerpts of her VIROX Animal Health. address include: “I want to commend the CVMA for the work Environ 260 personnes ont assisté à l’Assemblée générale you are doing to tackle AMR. Your recent work on updating annuelle. La ministre de la Santé du Canada, l’honorable Jane guidelines for the prudent use of veterinary antimicrobial medi- Philpott, a envoyé un message aux membres de l’ACMV. Voici cations and developing a national veterinary prescription-based un extrait de son message : «Je désire féliciter l’ACMV pour antimicrobial use surveillance program are examples of our le travail que vous réalisez afin d’aborder la résistance aux shared commitment to reducing the burden of AMR.” “The antimicrobiens. Votre travail récent en vue de mettre à jour les action that the CVMA is taking shows that you understand lignes directrices sur l’administration judicieuse des antimicrobiens the complex challenges of AMR. The Government of Canada vétérinaires et de créer un programme national de surveillance looks forward to continuing to work with our partners, such as de l’utilisation des antimicrobiens représentent des exemples the CVMA, to find innovative solutions to this global health de notre engagement commun afin de réduire le fardeau de la problem.” The Mayor of Charlottetown, Mr. Clifford Lee, résistance aux antimicrobiens. Les mesures prises par l’ACMV also extended greetings to the CVMA members assembled. montre que vous comprenez les défis complexes de l’utilisation International guests attending the AGM included: Dr. René des antimicrobiens. Le gouvernement du Canada se réjouit à Carlson, president of the World Veterinary Association; l’avance de poursuivre le travail avec nos partenaires, comme Dr. Walter Ingwersen, president of the World Small Veterinary l’ACMV, afin de trouver des solutions innovatrices à ce problème Animal Association; Dr. Rafael Laguens, president of the de santé mondial.» Le maire de Charlottetown, M. Clifford Lee, a Federation of Veterinarians of Europe; Dr. Tom Meyer, president aussi souhaité la bienvenue aux membres de l’ACMV réunis lors

Speakers at the 2017 CVMA Summit: Drs. Caleb Frankel (lt), Adam Little (centre) and Following the Chain of Office and Pinning Ceremony: Dr. Troy Bourque, CVMA out-going Nick Stace (rt) President, Dr. Troye McPherson, CVMA in-coming President Conférenciers au Sommet 2017 de l’ACMV : Drs Caleb Frankel (à gauche), Adam Little Après la cérémonie de la remise de la chaîne de fonction et de l’épingle : Dr Troy Bourque, (au centre) et Nick Stace (à droite) président sortant de l’ACMV, Dre Troye McPherson, présidente désignée de l’ACMV

1032 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY of the American Veterinary Medical Association; and Dr. Robert du congrès. Les invités internationaux présents incluaient N Johnson, president of the Australian Veterinary Association. notamment : Dre René Carlson, présidente de l’Association The new president and Executive of the CVMA were intro- mondiale vétérinaire; Dr Walter Ingwersen, président de la duced: Dr. Troye McPherson, president; Dr. Terri Chotowetz, World Small Animal Veterinary Association; Dr Rafael Laguens, president-elect; Dr. Melanie Hicks, vice-president; Dr. Enid président de la Fédération des vétérinaires d’Europe; Dr Tom Stiles, executive member; Dr. Troy Bourque, immediate past- Meyer, président de l’American Veterinary Medical Association; et president; Dr. Barry Stemshorn, treasurer; and Mr. Jost am Dr Robert Johnson, président de l’Australian Veterinary Association. Rhyn, chief executive officer. The CVMA would like to extend La nouvelle présidente et le nouvel exécutif de l’ACMV ont sincere thanks to Dr. Nicole Gallant for her leadership and été présentés : Dre Troye McPherson, présidente; Dre Terri dedication through many years to the CVMA’s governing bod- Chotowetz, présidente désignée; Dre Melanie Hicks, vice- ies as a Council member, Executive member, president, and présidente; Dre Enid Stiles, membre de l’exécutif; Dr Troy immediate past-president. Bourque, président sortant; Dr Barry Stemshorn, trésorier; et A number of veterinary professionals were honored at the M. Jost am Rhyn, président-directeur général. L’ACMV aimerait Annual Awards Ceremony held during the Convention: sincèrement remercier la Dre Nicole Gallant de son leadership et • Small Animal Practitioner Award: Dr. David Condon (PEI), dévouement pendant de nombreuses années passées au sein des for his compassion towards the animals in his care and his instances dirigeantes de l’ACMV en tant que membre du Conseil, dedication to the student veterinarians he mentors and membre de l’exécutif, présidente et présidente sortante. supervises. Plusieurs professionnels vétérinaires ont été honorés lors de • Merck Veterinary Award: Dr. Stephen LeBlanc (ON), for la Cérémonie annuelle de remise des prix qui s’est déroulée his production of high quality applied clinical research in durant le congrès : the diagnosis and control of metabolic, inflammatory, and • Prix du praticien des petits animaux : Dr David Condon reproductive diseases of dairy cattle. (Î.-P.-É.), pour sa compassion envers les animaux confiés à ses • CVMA Humane Award: Dr. Anne McDonald (BC), for her soins et son dévouement envers les étudiants en médecine role in the removing of, caring for, and re-homing of almost vétérinaire qu’il supervise et appuie en tant que mentor. 600 parrots from the World Parrot Refuge on Vancouver • Prix vétérinaire Merck : Dr Stephen LeBlanc (Ontario), pour sa Island. production de recherche clinique appliquée de grande qualité • CVMA Practice of the Year Award: Mona Campbell Centre pour le diagnostic et le contrôle des maladies métaboliques, for Animal Cancer (ON), for creating a comprehensive inflammatoires et reproductrices des bovins laitiers. veterinary cancer centre serving central Canada and beyond, • Prix humanitaire de l’ACMV : Dre Anne McDonald (C.-B.), while offering unique clinical trial research opportuni- pour son rôle dans le retrait, les soins et l’adoption de près de ties, facilitated by the University of Guelph’s Institute for 600 perroquets du World Parrot Refuge dans l’île de Vancouver. Comparative Cancer Investigation. • Prix de la pratique de l’année de l’ACMV : Mona Campbell • CVMA Life Membership: Dr. Jeanne Lofstedt (PEI), for Centre for Animal Cancer (Ontario), pour la création d’un her significant contributions to the veterinary profession centre vétérinaire complet pour le traitement du cancer worldwide. desservant le centre du Canada et d’autres régions, tout en • CVMA President’s Award: Dr. Bob Bellamy (SK), for his offrant des occasions uniques pour la recherche et les essais innovative approach to veterinary medicine communication cliniques, facilitées par l’Institute for Comparative Cancer and his dedication to the profession. Investigation de l’Université de Guelph. The president of the Students of the CVMA, Ms. Elizabeth • Titre de membre à vie de l’ACMV : Dre Jeanne Lofstedt (Î.-P.-É.), Hartnett, was recognized for her work in promoting stu- pour ses contributions importantes à la profession vétérinaire dent interests in the Association. The Registered Veterinary à l’échelle mondiale. Technologists and Technicians of Canada (RVTTC) also • Prix du président de l’ACMV : Dr Bob Bellamy (Saskatchewan), joined the Awards Ceremony to present one of its mem- pour son approche innovatrice face à la communication en bers, Ms. Elise Wickett, with the 2017 Canadian Registered médecine vétérinaire et son dévouement envers la profession. Veterinary Technologists/Technicians of the Year Award. Finally, La présidente des Étudiants de l’ACMV, Mme Elizabeth Hartnett, Veterinarians without Borders presented its Canada Volunteer of a été reconnue pour son travail en vue de promouvoir l’intérêt the Year Award to Dr. Joseph Ansong-Danquah. des étudiants envers l’Association. L’organisme Technologues Numerous business meetings and collegial and social events et techniciens vétérinaires agréés du Canada (TTVAC) a aussi took place during the Convention such as the Presidents’ participé à la Cérémonie de remise des prix afin de présenter à Meeting (regulatory body, self-interest, species and special- l’une de ses membres, Mme Elise Wickett, le Prix du technologue/ ties associations presidents), the Provincial Forum (registrars/ technicien vétérinaire agréé 2017 pour le Canada. Enfin, executive directors, communications directors), the Canadian Vétérinaires sans frontières a présenté son Prix du bénévole Council of Veterinary Registrars (CCVR), deans; the CVMA canadien de l’année au Dr Joseph Ansong-Danquah. Past-Presidents’ Forum Luncheon meeting, and OVC and AVC Plusieurs réunions d’affaires, réunions d’anciens et activités alumni receptions. sociales se sont déroulées durant le congrès, comme la Réunion Thank you to the Professional Development Committee, des présidents (présidents des organismes de réglementation, des its chair, Dr. Natalie Reid; the 2017 local chair, Dr. Kathleen groupes d’intérêt, des groupes d’espèces et des associations de

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N MacMillan; Dr. Jeanne Lofstedt (CE Coordinator); the spécialistes), le Forum provincial (registraires, directeurs généraux, numerous volunteers and CVMA staff, both onsite and in the directeurs des communications), la réunion du Conseil canadien office, who made this Convention and the many corporate des registraires vétérinaires (CCRV), la réunion des doyens, la meetings happen. Thank you to all participants, exhibitors, rencontre du midi du Forum des anciens présidents de l’ACMV and sponsors for choosing to be part of the 2017 CVMA ainsi que les réceptions d’anciens de l’OVC et l’AVC. Convention. Merci au Comité de perfectionnement professionnel et à sa Strategic Planning: Under the theme “A Successful Career, a présidente, la Dre Natalie Reid; à la présidente locale 2017, la Balanced Life,” the CVMA has developed and delivered a num- Dre Kathleen MacMillan; à la Dre Jeanne Lofstedt (coordonnatrice ber of member programs over the years, including its Business de la formation continue); aux nombreux bénévoles et au personnel Management Program with the Suggested Provincial Fee Guides, de l’ACMV, sur place et dans le bureau, qui ont permis la tenue de a Mentorship Program, an Emerging Leaders Program, Member ce congrès et des nombreuses réunions d’affaires. Merci à tous les Wellness web content, Continuing Education and more. As a participants, exposants et commanditaires qui ont choisi d’assister whole, career success and life balance is increasingly important au congrès 2017 de l’ACMV. as is the need for providing service. In this regard, Council has Planification stratégique : Sous le thème «Une carrière approved a Strategic Plan, developed during the March meeting, prospère, une vie équilibrée», l’ACMV a élaboré et présenté au with input from about 140 selected veterinarians. The CVMA’s fil des ans plusieurs programmes pour les membres, dont le goal is to foster the personal and professional well-being of its Programme de gestion commerciale avec ses Guides tarifaires members. Some examples of the strategic actions are to provide suggérés provinciaux, un programme de mentorat, le Programme pertinent wellness resources; establish and promote mentorship des futurs leaders, le contenu Web pour le bien-être des animaux, services; promote and adapt Emerging Leaders Program; main- de la formation continue et plus encore. Une carrière prospère et tain and adapt career and financial tools; and provide pertinent une vie équilibrée semble acquérir tout autant d’importance que le practice management tools. besoin de fournir des services. À cet égard, le Conseil a approuvé Antimicrobial Resistance (AMR): As part of the un Plan stratégique, qui a été élaboré durant la réunion de mars Government of Canada’s Federal Action Plan on Antimicrobial avec de la rétroaction de plus 140 vétérinaires. Le but de l’ACMV Resistance and Use, the final version of the Regulations consiste à favoriser le bien-être personnel et professionnel de ses Amending the Food and Drug Regulations (Veterinary Drugs — membres. Voici quelques exemples d’actions stratégiques : fournir Antimicrobial Resistance) was published in the Canada Gazette, des ressources pertinentes pour le bien-être; établir et promouvoir Part II. The new rules come into force between November les services de mentorat; promouvoir et adapter le Programme des 2017 and July 2019. Regulatory changes include 1) Increased futurs leaders; mettre à jour et adapter les outils pour la carrière oversight on importation of veterinary drugs (OUI) and APIs; et les finances; et fournir des outils pertinents pour la gestion 2) The facilitation of access to low-risk veterinary health prod- d’une pratique. ucts as additional tools for the maintenance of animal health and Antibiorésistance : Dans le cadre du Plan d’action fédéral welfare; and 3) Mandatory reporting of sales volume from manu- sur la résistance et le recours aux antimicrobiens au Canada, facturers and importers to support antimicrobial use surveillance. la version finale du Règlement modifiant le Règlement sur Policy changes include 1) Removing growth promotion claims les aliments et drogues (drogues d’application vétérinaire — from pre-2004 approved medically important antimicrobials résistance aux antimicrobiens) a été publiée dans la Gazette du (MIAs); and 2) Increasing veterinary oversight over all MIAs Canada, Partie II. Les nouvelles règles entreront en vigueur entre (pre-2004 approved). novembre 2017 et juillet 2019. Les modifications réglementaires • In conjunction with the CCVR and with broad stake- incluent : 1) Surveillance accrue de l’importation des médicaments holder input, the CVMA developed the “Veterinary vétérinaires (importation pour utilisation personnelle) et des Oversight of Antimicrobial Use-Professional Standards ingrédients pharmaceutiques actifs (IPA); 2) Facilitation de l’accès for Veterinarians,” which serves veterinary regulatory bodies à des produits de santé vétérinaire à faible risque en tant qu’outils as a template for developing their own regulations addressing additionnels pour le maintien de la santé et du bien-être animal; the upcoming policy and regulatory changes. et 3) Déclaration obligatoire des volumes de ventes de la part • On behalf of the Veterinary Pharmaceutical Stewardship des fabricants et des importateurs afin d’appuyer la surveillance Advisory Group (VPSAG), Dr. Duane Landals is develop- de l’utilisation des antimicrobiens. Les modifications politiques ing preliminary guidelines for veterinary care of bees and will incluent : 1) Élimination des allégations liées à la stimulation de present this to the CCVR. la croissance des antimicrobiens importants sur le plan médical • With funding from Agriculture and Agri-Food Canada, the (AIM); et 2) Accroissement de la surveillance vétérinaire pour tous CVMA held its first workshop, chaired by Dr. Phil Buote, les AIM (approuvés avant 2004). with approximately 40 stakeholders, to initiate the renewal • Conjointement avec le CCRV et avec une vaste rétroaction des of CVMA’s Antimicrobial Prudent Use Guidelines. The intervenants, l’ACMV a élaboré le document «Surveillance de purpose of this project is to develop ready-for-delivery, l’utilisation des antimicrobiens — Normes professionnelles practical tools to assist veterinarians in the prudent use of pour les médecins vétérinaires» qui sert de modèle aux antimicrobials for 6 defined species groups (including food organismes de réglementation de la médecine vétérinaire afin and companion animals). The purpose of the workshop was d’élaborer leurs propres règlements abordant les changements to engage stakeholders and obtain input into defining the à venir en matière de politiques et de réglementation.

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needs for future tools to assist veterinarians in the prudent use • Au nom du Groupe consultatif sur la gouvernance des produits N of antimicrobials. New Prudent Use Guidelines are scheduled pharmaceutiques vétérinaires (VPSAG), le Dr Duane Landals to be available by April 2018. travaille à la préparation de lignes directrices préliminaires pour • With funding from the CFIA, the CVMA initiated an les soins vétérinaires des abeilles et il présentera ce document Antimicrobial Use (AMU) Surveillance project for large and au CCRV. small animals and, in March, hosted a workshop chaired by • Grâce à du financement d’Agriculture et Agroalimentaire Dr. Duane Landals including approximately 40 stakehold- Canada, l’ACMV a tenu son premier atelier, qui a été présidé par ers. Directed by CFIA needs, the object of this workshop le Dr Phil Buote, auquel ont participé environ 40 intervenants, was to build buy-in from stakeholders and identify the most afin d’entamer le renouvellement des Lignes directrices de relevant type and level of data that should be collected as part l’ACMV sur l’administration judicieuse des antimicrobiens. of a prescription-based AMU surveillance program in sup- Le but de ce projet consiste à élaborer des outils prêts à utiliser port of Canadian commitments to the World Organisation pour la pratique afin d’assister les vétérinaires dans l’utilisation for Animal Health (OIE) and the international community. prudente des antimicrobiens pour les six groupes d’espèces Some of the outcomes included in a comprehensive report définis (y compris les animaux destinés à l’alimentation et les identified different means and needs for surveillance in dif- animaux de compagnie). Cet atelier avait pour but d’engager ferent species groups. Questions also arose on the subject of les intervenants et d’obtenir de la rétroaction afin de définir data collection at the prescription versus dispensing level and les besoins d’outils futurs pour assister les vétérinaires whether different approaches should be chosen for different en lien avec l’utilisation prudente des antimicrobiens. La species groups. The CVMA is in discussions with the CFIA nouvelle version des Lignes directrices sur l’administration on a 2-year follow-up project to, first, put this AMU surveil- judicieuse des antimicrobiens devrait être disponible en lance project into context with AM Stewardship and educate avril 2018. stakeholders on the need for this activity, and second, develop • Grâce à du financement de l’ACIA, l’ACMV a entamé son a surveillance concept that includes a dataset and options for projet de Surveillance de l’utilisation des antimicrobiens the actual data-gathering. pour les grands et les petits animaux et elle a organisé en • All veterinarians will be kept abreast of a communications mars un atelier présidé par le Dr Duane Landals auquel campaign for the implementation of new regulations and ont participé environ 40 intervenants. Axé sur les besoins policies that will be developed by the CVMA in conjunction de l’ACIA, cet atelier avait pour but solliciter l’adhésion with Veterinary Drugs Directorate (VDD). des intervenants et d’identifier les types et les niveaux de • Since March, the CVMA has engaged in meetings on antimi- données les plus pertinents qui devraient être recueillis dans crobial resistance and the implementation of the new regula- le cadre du programme de surveillance des antimicrobiens tions and policies with VDD, the Canadian Animal Health sur ordonnance afin d’appuyer les engagements canadiens Products Regulatory Advisory Committee (CAHPRAC), envers l’Organisation mondiale de la santé animale (OIE) et la and the new CAHPRAC Communications Sub-committee, collectivité internationale. Certains des résultats présentés dans Antimicrobial Stewardship Canada (AMS is a working group un rapport complet identifiaient les différentes méthodes et les of approximately 25 human health NGOs) and as part of the besoins de surveillance chez les divers groupes d’espèces. Des Canadian Global Food Animal Residue Avoidance Databank questions ont aussi été soulevées à propos de la collecte de (CgFarad) Advisory Board. données au niveau de la prescription par rapport à la distribution Engagement of early career DVMs: Helping early career et si des approches différentes devraient être choisies pour DVMs is one of the CVMA’s focal points. Some of the programs les divers groupes d’espèces. L’ACMV tient actuellement des and resources being worked on include: raising awareness of discussions avec l’ACIA pour un projet de suivi de deux ans the existing CVMA mentorship guidelines and mentor roster; afin de situer ce projet de surveillance de l’utilisation des adding resources to the early career DVM online Resource antimicrobiens dans le contexte de l’antibiogouvernance et Hub; constantly adding online Wellness Resources; sharing d’éduquer les intervenants à l’égard du besoin de cette activité of early career experience through The CVJ articles on “What et, ensuite, d’élaborer un concept de surveillance qui comprend Can’t Be Taught;” implementation of reduced recent graduates des groupes de données et des options pour la collecte membership dues (complimentary membership during year of concrète des données. graduation; 75% reduction during year 1 after graduation, 50% • Tous les vétérinaires seront tenus au courant de la campagne reduction during year 2; 25% reduction during year 3). de communication sur la mise en œuvre des nouveaux Student Leadership Workshop: The second annual règlements et politiques qui sera élaborée par l’ACMV de SCVMA Student Leadership Workshop (SLW) will be held concert avec la Direction des médicaments vétérinaires (DMV). at the Ontario Veterinary College (OVC) on November 18, • Depuis mars, l’ACMV a participé à des réunions sur 2017. This Workshop is designed to complement the CVMA’s l’antibiorésistance et la mise en œuvre des nouveaux Emerging Leaders program. Future rotations for the SLW are règlements et politiques avec la DMV, le Comité consultatif foreseen for 2019 at WCVM; 2020 at UCVM; 2021 at AVC; canadien sur la réglementation des produits de santé animale and 2022 at FMV. (CCRPSA) et le nouveau sous-comité des communications Animal Health Technology/Veterinary Technician Program du CCRPSA, Antimicrobial Stewardship Canada (AMS est Accreditation: Council approved accreditation of the Ridgetown un groupe de travail composé d’environ 25 ONG de la santé

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N Veterinary Technology program and the Vanier College Animal humaine) et dans le cadre du Conseil consultatif de la Canadian Health Technology Program. Global Food Animal Residue Avoidance Databank (CgFarad). Housing systems for laying hens: Council agreed to the Engagement des vétérinaires en début de carrière : L’appui Animal Welfare Committee’s proposal to draft a position state- des vétérinaires en début de carrière est l’un des objectifs de ment on housing systems for laying hens. l’ACMV. Voici quelques-uns des programmes et des ressources Humane Transportation: On April 4, the CVMA appeared en voie de réalisation : rehausser la sensibilisation à l’égard des before the House of Commons Standing Committee on lignes directrices de mentorat actuelles de l’ACMV et de la liste Agriculture and Agri-Food regarding the Amendment to the de mentors; ajouter des ressources au Carrefour des ressources Health of Animals Regulations (Humane Transportation). As en ligne pour les vétérinaires en début de carrière; continuer a follow-up, the CVMA was invited to a more informal meet- d’ajouter à la page Web sur les ressources de bien-être; partager ing with the Liberal caucus working group on animal welfare, de l’expérience de début de carrière par l’entremise des articles chaired by Alexandra Mendes, MP (Brossard-Saint-Lambert, de La RVC sur «Ce qui ne s’enseigne pas»; et instaurer des QC). We plan to interact with this Liberal caucus working group cotisations réduites pour les diplômés récents (cotisation gratuite more frequently to identify their needs and have them consider durant l’année d’obtention du diplôme; réduction de 75 % durant which of the CVMA’s animal welfare positions may be pertinent la première année après l’obtention du diplôme, réduction de to them as legislators. 50 % durant la deuxième année après l’obtention du diplôme; Kennel Code: The newest edition of the CVMA’s Kennel réduction de 25 % durant la troisième année après l’obtention Code has been circulated among stakeholders for feedback and is du diplôme). scheduled to be presented for approval to Council in November Atelier de leadership étudiant : La deuxième édition annuelle 2017. In order to be aligned more closely with the National de l’Atelier de leadership étudiant (ALÉ) des ÉACMV se tiendra Farm Animal Care Council (NFACC) Codes of Practice, this le 18 novembre 2017 à l’Ontario Veterinary College (OVC). Cet Code varies greatly from the previous one. The Code is designed atelier est conçu afin de servir de complément au Programme to assist breeders and kennel operators and to serve as a resource des futurs leaders de l’ACMV. Les rotations futures de l’ALÉ sont for the public, including prospective dog owners. prévues au WCVM en 2019; à l’UCVM en 2020; à l’AVC en 2021; Vaccination: CVMA Council approved the joint position et à la FMV en 2022. statement with the American Veterinary Medical Association Agrément des programmes de technologie en santé and the Federation of Veterinarians of Europe on the ben- animale et de techniques vétérinaires : Le Conseil a approuvé efits of animal vaccination programs in advancing animal and l’agrément du Programme de technologie vétérinaire du Ridgetown human health (see https://www.canadianveterinarians.net/policy-­ Campus et le Programme de technologie en santé animale de advocacy/international-relations). The 3 organizations intend Vanier College. to use this new position statement to advocate for federal and Système de logement pour les poules pondeuses : Le regional support for vaccine development and distribution and as Conseil a accepté la proposition du Comité sur le bien-être animal a resource to educate the animal-owning public and other audi- de rédiger un énoncé de position sur les systèmes de logement ences on the benefits of animal vaccination programs as a means pour les poules pondeuses. to counter anti-vaccination arguments. At the World Veterinary Transport sans cruauté : Le 4 avril, l’ACMV a comparu Association (WVA) General Assembly 2017, the 3 organizations devant le Comité permanent de la Chambre des communes sur will propose that the WVA develop a similar statement that l’agriculture et l’agroalimentaire concernant la modification du would address this issue from a global perspective. Règlement modifiant le Règlement sur la santé des animaux OIE: In March, the OIE’s site visit team evaluated Canada’s (transport sans cruauté). Comme suivi, l’ACMV a été invitée à une performance of veterinary services (PVS). The CVMA took réunion plus informelle avec le groupe de travail du caucus libéral part in the preparation of the PVS evaluation that was led by sur le bien-être animal qui est présidé par Alexandra Mendes, the CFIA and made a presentation to the site visit team on its députée fédérale (Brossard-Saint-Lambert, QC). Nous planifions involvement in the national exams, vet college accreditations, une interaction plus fréquente avec ce groupe de travail du caucus veterinary technician program accreditation, animal welfare, libéral afin d’identifier ses besoins et de l’interroger sur les énoncés antimicrobial resistance, and more. de position de l’ACMV sur le bien-être animal qui pourraient être In May, the CVMA president, Dr. Troy Bourque, attended pertinents pour les membres en tant que législateurs. the OIE General Assembly as part of the Federal Government’s Code de pratiques recommandées aux chenils : La plus delegation led by Canada’s Chief Veterinary Officer, Dr. Harpreet récente édition du Code de pratiques recommandées aux chenils Kochhar. du Canada de l’ACMV a été distribuée aux intervenants aux fins de WSAVA: The CVMA continues supporting the WSAVA rétroaction et on prévoit qu’elle sera présentée pour approbation campaign on the use of Ketamine and provided an update on au Conseil en novembre 2017. Afin de s’aligner plus étroitement the subject in its June e-newsletter. The CVMA continues its sur les Codes de pratiques du Conseil national pour les soins aux work in the planning of the WSAVA-CVMA joint Conference animaux d’élevage (CNSAE), ce code présente des modifications in Toronto in 2019. importantes par rapport à la version antérieure. Ce code est conçu FVE-AVMA-CVMA: As a member of this collaborative afin d’assister les éleveurs et les exploitants de chenils et de servir group, the CVMA currently provides input into joint state- de ressource pour le public, y compris les futurs propriétaires de ments on “Responsible and Judicious Use of Antimicrobials,” chiens.

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“Continuous Monitoring of Antimicrobial Use and Vaccination : Le Conseil de l’ACMV a approuvé un énoncé de N Antimicrobial Resistance,” and “Vaccination.” This position position conjoint avec l’American Veterinary Medical Association statement can be found at: https://www.canadianveterinarians. et la Fédération des vétérinaires d’Europe sur les bienfaits des net/documents/benefits-of-animal-vaccination-programs-advanc programmes de vaccination des animaux pour l’avancement de la ing-animal-human-health-avma-fedmvz-cvma santé animale et humaine (voir https://www.veterinairesaucanada. International Veterinary Officers Coalition (IVOC): This net/policy-advocacy/international-relations). Les trois organisations year, the CVMA is organizing the IVOC meeting, which includes ont l’intention d’utiliser ce nouvel énoncé de position pour exercer VMA presidents and CEOs from the veterinary organizations des pressions en vue d’obtenir un soutien fédéral et régional of the USA, Great Britain, Australia, New Zealand and South pour le développement et la distribution de vaccins et en tant Africa, and Canada. Themes of the preliminary agenda include que ressource d’éducation pour le public propriétaire d’animaux the future of the profession, the future of organized veterinary et d’autres publics à l’égard des bienfaits des programmes de medicine, animal welfare, antimicrobial use, member wellness, vaccination animale comme contrepoids aux arguments anti- and further leveraging IVOC. The objective of the Coalition is to vaccination. À l’Assemblée générale 2017 de l’Association mondiale learn from each other (we benchmark our associations annually) vétérinaire (AMV), les trois organisations proposeront que l’AMV and to consider joint actions, if and where appropriate. élabore un énoncé semblable qui aborderait cette question d’un Business Management: Annually, the CVMA, in collabora- point de vue international. tion with provincial veterinary medical associations, conducts a OIE : En mars, l’équipe d’inspection de l’OIE a évalué la practice owners’ economic survey. The purpose of the survey is to performance des services vétérinaires du Canada. L’ACMV a gather data on revenue, expenses, income, number of current and participé à la préparation de cette évaluation qui a été dirigée par new clients, fees, and DVM and non-DVM staff compensation. l’ACIA et elle a fait une présentation devant l’équipe d’inspection In addition to the CVMA’s investment, this survey is graciously sur sa participation aux examens nationaux, l’antibiorésistance et supported by IDEXX Laboratories, Petsecure, Merck Animal plus encore. Health, and Scotiabank. The 2016 report on the CVMA national En mai, le président de l’ACMV, le Dr Troy Bourque, a assisté à Practice Owner survey can be found on www.canadianveterinar l’Assemblée générale de l’OIE en tant que membre de la délégation ians.net/practice-economics/reports du gouvernement fédéral dirigée par le vétérinaire en chef du The overall 2016 findings were that, on average, it was a good Canada, le Dr Harpreet Kochhar. year for veterinarians in Canada. Net incomes were climbing for WSAVA : L’ACMV continue d’appuyer la campagne de la both small animal and mixed/large animal hospitals. Companion WSAVA sur l’utilisation de la kétamine et elle a fourni une mise à animal hospitals leaned on increasing revenues to outweigh jour sur ce sujet dans son cyberbulletin de juin. L’ACMV poursuit climbing expenses, allowing net income to increase. The growth son travail pour la planification de la Conférence conjointe de la in revenue was likely partially driven by a return of current WSAVA-ACMV à Toronto en 2019. and new clients. In contrast, mixed and large animal hospitals FVE-AVMA-ACMV : À titre de membre de ce groupe de employed prudent cost cutting measures to trim expenses in the collaboration, l’ACMV fournit actuellement de la rétroaction sur face of declining revenues in order to grow net income. des énoncés conjoints sur «L’utilisation responsable et judicieuse WebStore: The CVMA WebStore provides member veterinar- des antimicrobiens», «La surveillance continue de l’utilisation des ians with an easy to use online presence. A new initiative aims at antimicrobiens et de l’antibiorésistance», et «La vaccination». improving compliance with diets by using a subscription model, On peut consulter cet énoncé de position au : https://www. whereby the food will be delivered either at home or available veterinairesaucanada.net/documents/benefits-of-animal- for pick-up at the clinic at certain intervals. vaccination-programs-advancing-animal-human-health-avma- Communications: The 2017 Animal Health Week is fedmvz-cvma scheduled for October 1–7. The theme is “Animal Welfare: International Veterinary Officers Coalition (IVOC) : Cette Safeguarding the Five Animal Freedoms.” The monthly année, l’ACMV organise la réunion de l’IVOC qui inclura les #VetCareEverywhere Social Media Awareness Campaign is présidents et les PDG des AMV provenant d’organisations now in its third year and targets public audiences on Facebook vétérinaires des États-Unis, de Grande-Bretagne, d’Australie, de and Twitter. The National Tick Awareness campaign is in its Nouvelle-Zélande, d’Afrique du Sud et du Canada. Les thèmes second year. In partnership with Merck Animal Health, the de l’ordre du jour préliminaire incluent l’avenir de la profession, CVMA declared March as National Tick Awareness Month. The l’avenir de la médecine vétérinaire organisée, le bien-être animal, 2017 National Tick Awareness materials included a webinar, Tick l’utilisation des antimicrobiens, le bien-être des membres et la Talk poster, social media messages, and waiting and examina- façon dont on peut mettre l’IVOC à contribution pour d’autres tion room posters. The CVMA deployed a Forward Booking projets. L’objectif de la Coalition est d’apprendre l’un de l’autre Campaign. Forward booking simply means scheduling next (nous réalisons des évaluations comparatives annuelles de nos appointments for patients during their current visit, before they associations) et de considérer des actions communes, lorsque leave the practice. The goals of forward booking are to advance cela est approprié. patient care and strengthen the health of veterinary practice. Gestion commerciale : L’ACMV, en collaboration avec les Canadian Veterinary Reserve: Through a recruitment cam- associations provinciales de médecins vétérinaires, réalise un paign, we added 70 reservists, bringing the total to 288 reserv- sondage économique annuel auprès des propriétaires de pratique. ists (minimum target number is 200). In late March, the CVR Le but de ce sondage consiste à recueillir des données sur les

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N conducted its annual call-up drill, this revenus, les dépenses, les bénéfices, le nombre de clients actuels et nouveaux, les time as a multi-wave and multi- scenario tarifs ainsi que la rémunération des vétérinaires et des employés non-vétérinaires. En exercise. This call-up involved the CFIA plus de l’investissement de l’ACMV, ce sondage est gracieusement appuyé par IDEXX and Emergency Management BC as first Laboratories, Petsecure, Merck Santé animale et la Banque Scotia. On peut consulter le responders. rapport 2016 sur le sondage national de l’ACMV auprès des propriétaires de pratique au Veterinary services for Indigenous veterinairesaucanada.net/practice-economics/reports communities: The CVMA discussed the Les résultats 2016 ont constaté que, en général, l’année a été bonne pour les issue of availability of veterinary services, vétérinaires du Canada. Les bénéfices nets ont connu une hausse pour les pratiques pour animal health, welfare, and public health petits animaux ainsi que pour les pratiques mixtes et pour grands animaux. Les cliniques and safety with the PHAC president and pour animaux de compagnie ont compté sur la hausse des revenus afin de compenser subsequently with Veterinarians without une augmentation des dépenses, ce qui a permis au bénéfice net de croître. La croissance Borders (VwB). As a result, the CVMA des revenus est probablement partiellement attribuable à un retour des clients actuels et provided VwB with a location to host à l’arrivée de nouveaux clients. Par contraste, les cliniques mixtes et pour grands animaux a workshop during the 2017 CVMA ont employé des mesures de réduction des coûts pour sabrer dans les dépenses en raison Convention. The workshop, in which d’une chute des recettes, ce qui leur permis d’accroître leur bénéfice net. the CVMA participated, provided a MaVitrineVétérinaire : MaVitrineVétérinaire de l’ACMV procure aux vétérinaires forum to discuss animal and public health membres une présence en ligne facile d’utilisation. Une nouvelle initiative vise à améliorer and safety issues within First Nations l’observance des diètes en utilisant un modèle d’abonnement en vertu duquel les aliments ­communities. sont livrés soit au domicile ou sont disponibles pour cueillette à la clinique à certains Future CVMA Conventions: The intervalles. CVMA is looking forward to greeting all Communications : La Semaine de la vie animale 2017 se tiendra du 1er au Canadian — and international — veteri- 7 octobre. Le thème de la campagne est «Protéger les cinq libertés afin d’assurer le narians and veterinary technicians at its bien-être animal». La campagne mensuelle de sensibilisation dans les médias sociaux future Conventions: #Vétérinairespartenaires en est maintenant à sa troisième année et elle vise des publics • 2018 Vancouver, BC: 5–8 July. cibles sur Facebook et Twitter. La campagne de sensibilisation nationale aux tiques en • 2019 Toronto, ON: July (exact days est maintenant à sa deuxième année. En partenariat avec Merck Santé animale, l’ACMV a to be determined). This will be a déclaré le mois de mars comme le Mois national de sensibilisation aux tiques. Le matériel unique opportunity for the CVMA de l’édition 2017 du Mois national de sensibilisation aux tiques comprenait un webinaire, to co-host the World Small Animal une affiche, des messages dans les médias sociaux ainsi que des affiches pour la salle Veterinary Convention on Canadian d’attente et la salle d’examen. L’ACMV a mis en œuvre une Campagne de prise de rendez- soil. vous à l’avance. La prise de rendez-vous à l’avance signifie simplement la prise du prochain • 2020 Quebec City, QC: June 11–14 rendez-vous des patients pendant leur visite à la clinique, avant qu’ils ne quittent les lieux. 2020. La prise de rendez-vous à l’avance a pour objectifs d’améliorer les soins aux patients et la santé de la pratique vétérinaire. Réserve vétérinaire canadienne : Dans le cadre d’une campagne de recrutement, nous avons ajouté 70 réservistes, pour un total de 288 réservistes (le nombre cible minimum est de 200). À la fin mars, la RVC a effectué son exercice de mobilisation annuel et il s’agissait cette fois d’un exercice à plusieurs vagues qui comportait des scénarios multiples. L’ACIA et Emergency Management BC ont participé à l’exercice à titre de premiers répondants. Services vétérinaires pour les collectivités autochtones : L’ACMV a discuté l’enjeu de la disponibilité des services vétérinaires, de la santé et du bien-être des animaux ainsi que de la santé et de la sécurité publiques avec la présidente de l’ASPC et subséquemment avec Vétérinaires sans frontières (VSF). À la suite de cette réunion, l’ACMV a fourni un local à VSF pour la tenue d’un atelier durant le congrès 2017 de l’ACMV. L’atelier, auquel l’ACMV a participé, a servi de forum pour discuter les enjeux liés à la santé animale et à la santé et sécurité du public au sein des collectivités des Premières nations. Futurs congrès de l’ACMV : L’ACMV se réjouit à la penser d’accueillir tous les vétérinaires et techniciens vétérinaires canadiens et internationaux à ses futurs congrès : • 2018 Vancouver (Colombie-Britannique) : du 5 au 8 juillet. • 2019 Toronto (Ontario) : juillet (les dates exactes restent à déterminer). Il s’agira d’une occasion unique pour l’ACMV d’être co-organisateur du congrès de la World Small Animal Veterinary Association en sol canadien. • 2020 Québec (Québec) : Du 11 au 14 juin 2020.

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Animal Welfare: Safeguarding the Protéger les cinq libertés afin N Five Animal Freedoms d’assurer le bien-être animal Happy Animal Health Week! Joyeuse Semaine de la vie animale!

his month, we celebrate Animal Health Week from e mois-ci, nous célébrons la Semaine de la vie animale TOctober 1 to 7, 2017. The Canadian Veterinary Medical Cdu 1er au 7 octobre 2017. L’Association canadienne des Association (CVMA) is highlighting the importance of ani- médecins vétérinaires (ACMV) souligne l’importance du bien-être mal welfare through the campaign slogan, “Animal Welfare: animal sous le thème du slogan de la campagne, «Protéger les Safeguarding the Five Animal Freedoms.” cinq libertés afin d’assurer le bien-être animal». The Five Freedoms include: adequate shelter, proper nutri- Les cinq libertés comprennent : un hébergement adéquat, tion, appropriate veterinary care, proper socialization, and the une alimentation appropriée, des soins vétérinaires appropriés, ability to exhibit normal behaviors. This year’s theme provides us une socialisation appropriée et la capacité de manifester un with an opportunity to remind animal owners of the fundamen- comportement normal. Le thème de cette année nous fournit tal elements they are required to provide the animals in their care l’occasion de rappeler aux propriétaires d’animaux les éléments to ensure them healthy and happy lives. It is our responsibility fondamentaux qui sont requis pour que les animaux confiés à to ensure the animals we care for not only survive, but thrive. leurs soins mènent une vie heureuse et en santé. C’est notre We’re reminding animal owners they can protect the Five responsabilité de veiller à ce que les animaux ne fassent pas Animal Freedoms by: seulement survivre, mais qu’ils s’épanouissent. • Providing proper nutrition Nous rappelons aux propriétaires d’animaux qu’ils peuvent – F reedom from hunger and thirst by ready access to fresh protéger les cinq libertés animales en : water and a diet to maintain full health and vigor. • Fournissant une alimentation appropriée • Ensuring proper socialization – Prévenir la faim et la soif en fournissant de l’eau fraîche et – F reedom to spend time with or away from members of their des aliments afin d’assurer une santé vigoureuse. • Offrant une socialisation appropriée species as appropriate. – D onner la possibilité de passer du temps avec ou sans les • Providing adequate shelter membres de leur espèce en fonction de leurs besoins. – Freedom from discomfort by providing an appropriate envi- • Procurant un hébergement adéquat ronment including shelter and a comfortable resting area. – Fournir un environnement approprié qui comprend un abri et • Providing appropriate veterinary care une aire de repos confortables afin d’éviter l’inconfort. – F reedom from pain, injury or disease by prevention or rapid • Fournissant des soins vétérinaires appropriés diagnosis and treatment. – F avoriser l’absence de douleur, de blessures ou de maladies • Allowing animals to exhibit normal behavior par la prévention ou un diagnostic et un traitement rapides. – F reedom to express normal behavior by providing suffi- • Permettant aux animaux de manifester un comportement cient space, proper facilities, and tools/accessories and not normal punishing animals for carrying out undesired behaviors. – Promouvoir la possibilité d’exprimer un comportement normal Social media en fournissant suffisamment d’espace, des installations The CVMA has promoted Animal Health Week for over adéquates ainsi que les outils et les accessoires nécessaires 30 years. We invite you to share your celebrations on Facebook et en ne punissant pas les animaux lorsqu’ils manifestent des or tweet using the hashtag #AnimalHealthWeek. comportements indésirables.

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N Our sponsors Médias sociaux Generous support of the 2017 Animal Health Week campaign L’ACMV fait la promotion de la Semaine de la vie animale depuis is provided by Principal Plus Sponsor, Boehringer Ingelheim, plus de 30 ans. Nous vous invitons à partager vos célébrations sur Principal Sponsor, Petsecure, and Program Sponsors, Elanco Facebook ou à gazouiller en utilisant le mot-clic #célébronslasva. and iFinance Canada (Petcard). Nos commanditaires The CVMA would not be able to carry out the important Le commanditaire principal Plus, Boehringer Ingelheim, le educational campaign that Animal Health Week is without the commanditaire principal, Petsecure, et les commanditaires de generous support of our sponsors and the dedication of veteri- programme, Elanco et iFinance Canada (Petcard), ont fourni un nary teams throughout the country. Thank you. généreux soutien à la Semaine de la vie animale 2017. During this week-long campaign many veterinary clinics and L’ACMV ne pourrait pas mettre en œuvre l’importante campagne hospitals host open houses, plan dog washes, organize pet poetry éducative de la Semaine de la vie animale sans le généreux soutien or photo contests, and clinic tours. Some veterinarians visit school de nos commanditaires et le dévouement des équipes vétérinaires children or appear on television to talk about animal health care. partout au pays. Merci. Durant cette campagne d’une semaine, beaucoup de pratiques et de cliniques vétérinaires organiseront des journées portes ouvertes, planifieront des lave-chien, organiseront des concours de poésie sur les animaux de compagnie ou des concours de photos ainsi que des visites de la clinique. Certains vétérinaires visiteront des enfants dans les écoles ou se présenteront à la télévision pour parler à propos de la santé animale.

VetFolio® and CVMA Offer Members an Exclusive Price Advantage VetFolioMD et l’ACMV offrent aux membres un prix avantageux exclusif

he Canadian Veterinary Medical Association (CVMA) and Association canadienne des médecins vétérinaires (ACMV) Tpartner VetFolio®, LLC, offer CVMA members a 30-day L’ et son partenaire VetFolioMD, LLC, offrent aux membres de free trial of VetFolio® and a 20% discount on an individual or l’ACMV un essai gratuit de 30 jours de VetFolioMD ainsi qu’un practice annual subscription. In addition, the Students of CVMA rabais de 20 % sur un abonnement annuel individuel ou pour can sign-up for a free subscription. la pratique. De plus, les Étudiants de l’ACMV peuvent obtenir un VetFolio®, LLC, is a one-stop online education platform for abonnement gratuit. veterinary professionals. VetFolio® is jointly owned and managed VetFolioMD, LLC, est une plate-forme en ligne d’éducation à by the North American Veterinary Community (NAVC) and the guichet unique pour les professionnels vétérinaires. VetFolioMD American Animal Hospital Association (AAHA). appartient à la North American Veterinary Community (NAVC) et VetFolio® brings together educational material and valuable à l’American Animal Hospital Association (AAHA) et il est géré information through the combined efforts and resources of conjointement par les deux organismes. AAHA and NAVC, such as online CE courses, Web conferences, VetFolioMD réunit du matériel éducatif et des renseignements topics and proceedings, podcasts and much more that your utiles dans le cadre des efforts et des ressources concertées de practice teams can put to work every day. l’AAHA et de la NAVC, dont des cours de formation continue en The CVMA and VetFolio® are pleased to offer CVMA ligne, des conférences Web, des sujets et des comptes rendus, members this exclusive value-added benefit by providing access des baladodiffusions et autres, qui pourront être utiles au quotidien to relevant continuing education and practice resources at an pour le travail de vos équipes de la pratique. affordable price to help you achieve professional, personal and L’ACMV et VetFolioMD ont le plaisir d’offrir aux membres de financial success. l’ACMV cet avantage exclusif à valeur ajoutée en fournissant To learn more about VetFolio® and to obtain your CVMA l’accès à de la formation continue et à des ressources pertinentes member promo code, visit the CVMA Member Benefits and pour la pratique à un prix abordable afin de vous aider à assurer Services web page (www. votre succès professionnel, personnel et financier. canadianveterinarians. Pour en apprendre davantage à propos de VetFolioMD et net/membership/ben obtenir votre code promotionnel de membre de l’ACMV, visitez efits-services) and click la page Web des Avantages et services aux membres de l’ACMV on VetFolio®. You can (www.veterinairesaucanada.net/membership/benefits-services) et also contact the CVMA cliquez sur VetFolioMD. Vous pouvez aussi contacter directement les Member Services directly Services aux membres de l’ACMV au 1-800-567-2862. at 1-800-567-2862.

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Move Over National Vet Tech Week, it’s Time to Celebrate RVT Month! N La Semaine nationale des techniciens vétérinaires est terminée, célébrons le Mois des TVA!

t is with great pleasure that the Registered Veterinary est avec grand plaisir que Technologues et techniciens ITechnologists and Technicians of Canada (RVTTC) will be C’vétérinaires agréés du Canada (TTVAC) célébrera la celebrating the first annual “RVT Month” this October. The première édition annuelle du «Mois des TVA» en octobre. L’Ontario Ontario Association of Veterinary Technicians, with the sup- Association of Veterinary Technicians, avec le soutien de l’ensemble port of all our provincial associations, has been instrumental de nos associations provinciales, a joué un rôle crucial dans la in developing this national campaign. Because one week just mise sur pied de cette campagne nationale. Parce qu’une semaine wasn’t enough, RVT Month will feature professional recogni- n’était simplement pas suffisante, le Mois des TVA sera axé sur la tion for registered veterinary technologists and technicians. reconnaissance professionnelle des technologues et techniciens Emphasis will be placed on the value and importance of RVTs vétérinaires agréés. On insistera sur la valeur et l’importance within veterinary healthcare. Two teaser videos and one feature des TVA pour les soins vétérinaires. Deux vidéos amorces et video were launched in August and September that highlight the une vidéo reportage ont été lancées en août et en septembre many roles that RVTs play towards animal healthcare. See them afin de souligner les nombreux rôles tenus par les TVA pour at (http://rvttcanada.ca/october2017/). les soins prodigués aux animaux. Vous pouvez les visualiser au RVT Month kits are available on our website for workplaces (http://rvttcanada.ca/october2017/). to highlight their RVT team members and educate colleagues Des trousses du Mois des TVA à utiliser dans les pratiques and members of the public on these skilled members of the team. sont disponibles sur notre site Web en vue de souligner les Each veterinary team is encouraged to utilize the kit materials to TVA qui sont membres de l’équipe et d’éduquer les collègues launch their own activities and join in on social media with the et les membres du public sur ces membres professionnels de hashtags #HugAnRVT #RVTMonth, #oneweekjustwasntenough. l’équipe. On encourage toutes les équipes vétérinaires à utiliser Check out our website (http://rvttcanada.ca/october2017/) or les documents de la trousse afin d’organiser leurs propres activités social media @RVTTC for more activities and ideas to share. et de partager dans les médias sociaux avec les mots-clics Join together to celebrate RVT Month! #HugAnRVT #RVTMonth, #oneweekjustwasntenough. Consultez The RVTTC would like to thank the Ontario Association notre site Web (http://rvttcanada.ca/october2017/) ou nos médias of Veterinary Technicians, British Columbia Veterinary sociaux @RVTTC pour découvrir d’autres activités et idées à Technologists Association, Alberta Association of Animal partager. Rassemblez-vous pour célébrer le Mois des TVA! Health Technologists, Saskatchewan Association of Veterinary TTVAC aimerait remercier l’Ontario Association of Veterinary Technologists, Manitoba Veterinary Technologists Association Technicians, la British Columbia Veterinary Technologists and Eastern Veterinary Technicians Association in working Association, l’Alberta Association of Animal Health Technologists, la together for this truly national campaign in support of our Saskatchewan Association of Veterinary Technologists, la Manitoba members. It is a testament that we accomplish great things when Veterinary Technologists Association et l’Eastern Veterinary we work toward a common goal. Technicians Association pour leur travail concerté en vue de la mise en œuvre de cette campagne nationale dans le but d’appuyer (by Heather Quilty, RVT) nos membres. Cette réalisation témoigne de ce que nous pouvons accomplir lorsque nous travaillons ensemble pour l’atteinte d’un but commun. (par Heather Quilty, RVT)

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N 16th Annual CAHLN-RCTLSA Succès de la 16e réunion annuelle Meeting in Guelph a Success! du RCTLSA-CAHLN à Guelph! ver 160 delegates attended the annual scientific meeting of lus de 160 délégués ont assisté à la réunion scientifique Othe Canadian Animal Health Laboratorians Network — Pannuelle du Réseau canadien des travailleurs des laboratoires Réseau canadien des travailleurs des laboratoires de santé animale de santé animale-Canadian Animal Health Laboratorians Network — (CAHLN-RCTLSA), June 4–7, 2017, hosted by the Animal (RCTLSA-CAHLN), du 4 au 7 juin, qui a été organisée par Health Laboratory, University of Guelph, in Guelph, Ontario. le Laboratoire de santé animale de l’Université de Guelph, à The theme was “Laboratory based disease intelligence in 2017: Guelph, en Ontario. Le thème était «Données de laboratoire pour New and practical approaches,” and attendees were informed le renseignement sur les maladies en 2017 : approches nouvelles through 76 oral and 13 poster presentations of the opportunities et pratiques» et les participants ont été informés dans le cadre in deriving disease surveillance information from a variety of de 76 présentations orales et de 13 présentations d’affiches sources, including social media and multi-stakeholder networks, sur les possibilités de puiser des données de surveillance des coupled with enhanced sharing of laboratory data. The program maladies d’une diversité de sources, dont les médias sociaux et les also included updates on technology advances and research find- réseaux d’intervenants multiples, jumelées à un partage amélioré ings in veterinary diagnostics. des données de laboratoire. Le programme incluait aussi des The CAHLN-RCTLSA meeting was followed on June 7 by mises à jour sur les avancées technologiques et des résultats de the annual meeting of the Canadian Association of Veterinary recherches sur les diagnostics vétérinaires. Pathologists — L’Association Canadienne des Pathologistes La réunion du CAHLN-RCTLSA été suivie le 7 juin Vétérinaries (CAVP-ACPV), which included presentations on par l’assemblée annuelle de L’Association canadienne des lymphoproliferative and histiocytic disorders, mucosal immunity, pathologistes vétérinaires — Canadian Association of Veterinary and swine diagnostic pathology, followed by case reports and Pathologists — (ACPV-CAVP), qui incluait des présentations sur provincial updates. les troubles lymphoprolifératifs et histiocytaires, l’immunité des Selected for the 2017 Laboratorian of the Year Award for muqueuses et la pathologie diagnostique chez les porcs, suivie de his meritorious service to veterinary laboratory medicine was rapports de cas et de mises à jour provinciales. Dr. Doug Campbell, who has worked as a wildlife pathologist Le Dr Doug Campbell a été choisi comme récipiendaire du for the Canadian Wildlife Health Cooperative (CWHC) since Prix du travailleur de laboratoire de l’année 2017 pour son service 1993. During this period, Doug has made substantial contribu- méritoire en médecine vétérinaire de laboratoire et il travaille en tions, not only to wildlife health and disease diagnostics and tant que pathologiste de la faune pour le Réseau canadien de surveillance, but also to human and production animal health. la santé de la faune (RCSF) depuis 1993. Durant cette période,

The Graduate Student Oral Presentation Award was presented by Dr. Jim Goltz, Past-president Dr. Doug Campbell (centre) was presented with the 2017 CAHLN-RCTLSA Laboratorian of of CAHLN-RCTLSA (centre) to co-winners Ellie Milnes (left) and Jamie Rothenburger (right). the Year Award by Dr. Melanie Barham, President of CAHLN-RCTLSA (left). Also present was Le Prix pour la présentation orale de l’étudiant diplômé a été présenté par le Dr Jim Goltz, Dr. Ian Barker, former CWHC Ontario/Nunavut Regional Director (right). ancien président du RCTLSA-CAHLN (au centre), aux colauréates Ellie Milnes (à gauche) et La Dre Melanie Barham, présidente du RCTLSA-CAHLN (à gauche), a remis au Dr Doug Campbell Jamie Rothenburger (à droite). (au centre) le Prix du travailleur de l’année 2017 du RCTLSA-CAHLN. Le Dr Ian Barker, ancien directeur régional du RCSF pour l’Ontario/Nunavut (à droite).

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Doug was involved in the initial detection and diagnosis of new Doug a apporté des contributions considérables, non seulement N wildlife diseases in Ontario, including white-nose syndrome of pour la santé de la faune ainsi que le diagnostic et la surveillance bats, snake fungal disease, and West Nile virus, and has contrib- des maladies, mais aussi pour la santé humaine et la santé des uted to the development of the case definitions used throughout animaux de production. Doug a participé au dépistage initial et au North America for tracking disease and pathogen spread. One of diagnostic de nouvelles maladies de la faune en Ontario, dont le Doug’s many strengths is his ability to communicate complicated syndrome du museau blanc chez les chauves-souris, les maladies information, both orally and in writing, in a way that is acces- fongiques des serpents et le virus du Nil occidental, et il a contribué sible to a wide audience ranging from scientists to students to the à l’élaboration de définitions de cas utilisées en Amérique du Nord public. Dr. Campbell’s extensive knowledge is often sought out pour le suivi des maladies et la propagation des pathogènes. L’une for unusual diagnostic cases in both wild and domestic species des nombreuses forces de Doug est sa capacité à communiquer and he is also in high demand for his knowledge of wildlife dis- des renseignements compliqués, oralement et par écrit, d’une ease in Canada. He is generous with his time and expertise and is manière qui est accessible à un vaste public, dont les scientifiques, always willing to share his extensive knowledge with colleagues. les étudiants et le public. Les vastes connaissances du Dr Campbell Graduate Student Presentation Awards also were presented. sont souvent sollicitées pour les cas de diagnostic inusités chez les The best oral presentation award was a tie, going to Jamie espèces sauvages et domestiques et il est aussi très en demande Rothenburger, from the Department of Pathobiology, University pour ses connaissances sur les maladies de la faune au Canada. of Guelph and Ellie Milnes from the Toronto Zoo, for their Il donne généreusement de son temps et de son expertise et il respective presentations, “Pathology of wild urban rats” and est toujours disposé à partager ses vastes connaissances avec “Mycobacterium epizootic in a zoo population of Chinese gliding ses collègues. frogs (Rhacophorus dennysi): Investigation, management, and Des prix ont aussi été décernés pour les présentations des public health response.” The best poster presentation award went étudiants diplômés. Le prix de la meilleure présentation orale a été to Corrine Schut, for her poster “Salmonella shedding and anti- jugé à égalité et décerné à Jamie Rothenburger, du Département body response to Salmonella in pigs from weaning to marketing.” de pathobiologie de l’Université de Guelph, et à Ellie Milnes du The 2018 meeting will be held in Winnipeg, Manitoba, with Zoo de Toronto, pour leurs présentations respectives, «Pathologie the 2019 meeting to be held in Sainte Hyacinthe, Quebec, and des rats urbains sauvages» et «Épizootie à Mycobacterium dans une the 2020 meeting in Calgary, Alberta. Updates will be posted population de zoo de grenouilles arboricoles de Dennys tachetées on the website (www.cahln-rctlsa.com). (Rhacophorus dennysi) : enquête, gestion et réponse de santé publique». La présentation du prix de la meilleure affiche a été décernée à Corrine Schut pour son affiche «Excrétion de Salmonella et réponse anticorps à l’égard de Salmonella chez les porcs du sevrage à la commercialisation». La réunion de 2018 se tiendra à Winnipeg, au Manitoba, la réunion de 2019 aura lieu à Saint-Hyacinthe, au Québec, et la réunion de 2020 se déroulera à Calgary, en Alberta. Des mises à jour seront affichées sur le site Web (www.cahln-rctlsa.com).

CVJ / VOL 58 / OCTOBER 2017 1043 FOR PERSONAL USE ONLY Article

Epidemiology of gastrointestinal nematode infections in grazing yearling beef cattle in Saskatchewan

Murray Jelinski, John Gilleard, Lisa Rocheleau, Grant Royan, Cheryl Waldner

Abstract —The objective of this study was to provide contemporary data on the epidemiology of gastrointestinal nematode parasite infections of grazing yearling beef cattle in the province of Saskatchewan. Fecal samples (n = 1290) were collected over 4 time periods during the summer grazing season from 21 separately managed groups of cattle. Fecal egg counts (FEC) were estimated using generalized estimating equations with a negative binomial distribution with log link function, adjusting for clustering of samples within each herd for each time period. Nematodirus spp. and Trichuris spp. eggs were enumerated separately and were detected in 5.7% (73/1290) and 1.7% (22/1290) of samples, respectively. One or more strongyle-type eggs were detected in 79.5% (1025/1290) of the samples and FEC increased by 2.8 times over the summer grazing season. Interestingly, FEC were 3.4 times higher on pastures located in dark brown versus brown soil zones, a finding that warrants further investigation.

Résumé — Épidémiologie des infections aux nématodes gastro-intestinaux chez les bovins d’un an en pâturage en Saskatchewan. L’objectif de cette étude consistait à fournir des données contemporaines sur l’épidémiologie des infections aux parasites nématodes gastro-intestinaux des bovins de boucherie âgés d’un an en pâturage dans la province de la Saskatchewan. Des échantillons fécaux (n = 1290) ont été prélevés pendant quatre périodes durant la saison de pâturage estival auprès de 21 groupes de bovins gérés séparément. Les comptes d’œufs dans les fèces (CŒF) ont été estimés en utilisant des équations d’estimation généralisées ayant une distribution binomiale négative en lien avec la fonction log, en ajustant pour le regroupement des échantillons au sein de chaque troupeau pour chaque période. Les œufs de Nematodirus spp. et de Trichuris spp. ont été énumérés séparément et ont été détectés dans 5,7 % (73/1290) et 1,7 % (22/1290) des échantillons, respectivement. Un ou plusieurs œufs de type strongyle ont été détectés dans 79,5 % (1025/1290) des échantillons et les CŒF ont augmenté de 2,8 fois pendant la saison de pâturage estival. Fait intéressant, les CŒF étaient de 3,4 fois supérieurs dans les pâturages situés dans des zones de sol brun foncé comparativement à du sol brun, une constatation qui justifie de nouvelles investigations. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1044–1050

Introduction parasite control programs in western Canadian beef cattle has been extrapolated from American data. This extrapolation is he most economically important gastrointestinal problematic because infection intensities and strongyle species T nematodes (GIN) of cattle belong to the superfamily vary dramatically among regions and by climatic zones. Trichostrongyloidea, colloquially known as strongyles (1). Based on studies in Quebec (6) and the United States (7), While studies on GIN have been conducted on beef cattle in infective trichostrongylid nematode larvae can survive severe western Canada, most were conducted decades ago and only a winter conditions; however, survivability is often low, resulting small number involved pastured yearling beef (2–4) or dairy in a dramatic decline in the population of free-living larvae on (5) cattle. Therefore, much of the information used to design pasture (6,7). Therefore, most pastures are relatively free of

Department of Large Animal Clinical Sciences (Jelinski, Waldner), Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5B4; Comparative Biology and Experimental Medicine, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta T2N 1N4 (Gilleard); 10-502 Rempel Manor, Saskatoon, Saskatchewan S7T 0L7 (Rocheleau); 3618 Wetmore Crescent, Regina, Saskatchewan S4V 2B3 (Royan). Address all correspondence to Dr. Murray Jelinski; e-mail: [email protected] Reprints are not available from the authors. Funding for this project was provided by Merck Animal Health (Canada). 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.

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Table 1. Percentage of individual samples having at least 1 Trichostrongyloidea egg and the percentage of management groups (herds) having at least 1 or at least 2 samples test positive for Trichostrongyloidea eggs (n = 1290 samples, N = 21 management groups) Period in 2015 1 2 3 4 (22 May (June 16 (July 16 (September 9 Strongyle-like to 15 June) to July 15) to August 19) to October 7)

Individual samples 74.4% (293/394) 74.6% (282/378) 87.8% (244/278) 85.8% (206/240) ARTICLE Herds $ 1 positive sample 100% (21/21) 90.5% (19/21) 66.7% (14/21) 57.1% (12/21) Herds $ 2 positive samples 90.5% (19/21) 90.5% (19/21) 66.7% (14/21) 57.1% (12/21)

Nematodirus spp. Individual samples 6.6% (26/394) 5.0% (19/378) 3.6% (10/278) 7.5% (18/240) Herds $ 1 positive sample 52.4% (11/21) 47.6% (10/21) 33.3% (7/21) 33.3% (7/21) Herds $ 2 positive samples 38.1% (8/21) 28.6% (6/21) 9.5% (2/21) 28.6% (6/21)

Trichuris spp. Individual samples 2.5% (10/394) 1.3% (5/378) 0.0% (0/278) 2.9% (7/240) Herds $ 1 positive sample 1.9% (4/21) 19.1% (4/21) 0.0% (0/21) 19.1% (4/21) Herds $ 2 positive samples 9.5% (2/21) 9.5% (2/21) 0.0% (0/21) 14.3% (3/21)

infective larvae when cattle are placed on pasture. These low grazing season, and ii) to assess how environmental conditions infection pressures may explain, in part, why overt clinical para- (temperature and rainfall) and soil zone types in the province sitism occurs infrequently in the northern temperate regions. of Saskatchewan influence fecal egg counts. Although overt parasitism is uncommon, sub-clinical parasitism has been shown to impact production performance in western Materials and methods Canadian beef cattle on pasture (2,3). Sample collection and processing There are several excellent reviews relating to the myriad Sixteen beef cattle producers, managing 21 separate cohorts of factors that determine the prevalence and transmission of (herds) of commercial yearling steers (n = 9) and heifers GIN within cattle populations (1,7–9), with the main determi- (n = 12), located in southern and central Saskatchewan were nants of transmission being ambient temperature and moisture purposively chosen for this study. The cattle were distributed (1,7,10,11). A recent study involving pastured beef cattle in the over a geographical area of 230 km (East–West) by 460 km province of Alberta confirmed that parasite transmission was (North–South). The inclusion criteria for the study included reduced in the hot dry southeastern and cool dry northwest- geographical location, number of animals, producers’ willingness ern regions of the province (12). While environmental factors to participate in the study, and the producers’ ability to provide are important, host factors such as host genetics and acquired information relating to both anthelmintic usage and when their immunity also influence parasite transmission. A recent study of cattle were placed on pasture (‘turnout’). The number of cattle beef cow-calf pairs on pasture in the province of Saskatchewan per management group ranged from 30 to 200. found the cows’ fecal egg counts (FEC) were very low at the The objective was to collect 20 samples from each group of time of pasture turnout and remained low throughout the graz- animals at 4 time points, 1 month apart, over the 2015 sum- ing period, whereas the calves’ FEC increased 9-fold over the mer grazing season. Sample collection involved monitoring the same grazing period (13). These differences in FEC were likely cattle until they defecated at which time a golf ball sized fecal related, at least in part, to acquired host immunity (9,14,15). sample was collected using a plastic palpation sleeve. Samples The most common method of monitoring GIN parasitism at were labeled (herd ID), placed on ice, and transported to the the herd level is to perform fecal egg counts (16). However, FEC laboratory where they were refrigerated at 4°C until shipped are only a proxy for infection intensity and must be interpreted on ice by overnight courier to a commercial testing laboratory with some caution, particularly when performed in the fall and (BioCheck Veterinary Diagnostics and Technologies, Lethbridge, winter months (17). Extrapolating FEC from an individual Alberta). The laboratory processed 3 g aliquots of fecal mate- animal to the herd level can also be problematic because shed- rial as per the Modified Wisconsin Sugar Flotation Technique ding of GIN eggs is not normally distributed within a group of (21). All results were reported as the numbers of eggs per 1 g animals; 15% to 25% of animals are generally responsible for of fecal material (EPG). Most parasites from the superfamily shedding the majority of eggs (18,19). It is generally recom- Trichostrongyloidea shed smooth oval-shaped eggs, which mended to obtain 15 to 20 fecal samples from each group of are morphologically indistinguishable from each other. The animals, which provides a 95% probability that one or more exceptions are Nematodirus spp. and Trichuris spp., both of samples will have come from a high shedding animal (20). which have unique appearances. Therefore, these latter parasites The purpose of this study was two-fold: i) to monitor fecal were enumerated separately, while all other eggs were grouped egg counts in pastured yearling beef cattle over the summer together and classified as strongyle-type eggs.

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a. 1 b. 1 c. 1 1 2 8 2 15 2 3 3 3 4 4 4 1 1 1 2 2 9 2 16 2 3 3 3 4 4 4 1 1 1 3 2 10 2 17 2 3 3 3 4 4 4 1 1 1 4 2 11 2 18 2 3 3 3 4 4 4

Group identifier Group 1 identifier Group 1 identifier Group 1 2 2 2 ARTICLE 5 12 19 3 3 3 4 4 4 1 1 1 6 2 13 2 20 2 3 3 3 4 4 4 1 1 1 7 2 14 2 21 2 3 3 3 4 4 4

0 50 100 150 200 0 50 100 150 200 0 50 100 150 200 Number of Trichostrongyloidea eggs per gram Number of Trichostrongyloidea eggs per gram Number of Trichostrongyloidea eggs per gram

Figures 1 a–c. The 3 figures show the variation in fecal egg counts of strongyle-like eggs taken from each of the 21 groups of yearlings at 4 different time periods. Time periods with no data indicate that a sample was not obtained from that group of cattle at that time period.

Soil types, precipitation, growing degree days Texas, USA). Population-average differences in observed FEC and ecoregion across sampling periods were estimated using generalized esti- The 2015 precipitation, growing degree days (GDD) and soil mating equations (GEE) with a negative binomial distribution zone maps were all obtained from Agriculture and Agri-Food with log link function adjusting for clustering of samples within Canada (22). Accumulated precipitation maps were obtained each cohort for each time period. The only workable option for for May to June, May to July, May to August, and June to the correlation matrix was exchangeable as the same animals September. Similarly, maps summarizing GDD above a base were not sampled over time; therefore, estimating the time temperature of 0°C were obtained for April to June, April to ordered correlation of individual observations was not feasible. July, April to August, and April to September. Growing degree Adjustment for clustering of time period within herd was cho- days (GDD) were calculated by subtracting the base tempera- sen based on QIC as the best fit when compared to adjustment ture from the daily mean temperature (with any negative values for clustering within herd only. For all final models, variance set to 0) and then summing the resulting daily values for each estimation was completed using bootstrapping with a minimum interval. The herd locations were plotted and the corresponding of 5000 completed repetitions based on previously published values of GDD and precipitation were extracted for each inter- recommendations for analysis of egg counts (25). This approach val. The total precipitation for the May to September interval was used for the strongyle-type eggs, Nematodirus spp., and the was estimated for each herd by summing the extracted values total of all observed eggs regardless of species. The same GEE for May to June and June to September. model would not run for Trichuris spp. because the number of The soil zone for each herd was categorized as gray, dark gray, positive samples was too small. Therefore, the best fitting nega- black, dark brown, or brown. Briefly, Saskatchewan soils can be tive binomial regression model with a log link function that categorized into 1 of the 4 Great Groups of the Chernozemic converged included a robust variance option with adjustment Order (brown, dark brown, black, and gray), with color reflecting for clustering within cohort. the amount of soil organic matter (23,24). Brown soils are pri- Differences in the total observed FEC counts across soil marily located in the semi-arid mixed grassland ecoregion; dark types, levels of precipitation, GDD, and ecoregions, adjusted for brown soils are generally cooler and wetter than the brown soils; sample period, were then estimated using GEE with a negative black soils are associated with the Aspen parkland ecoregion; binomial distribution, log link function, adjusting for cluster- and dark gray soils are found in the boreal transition ecoregion. ing within each herd for each time period, and using bootstrap The Universal Transverse Mercator (UTM) coordinates variance estimation with a minimum of 5000 completed repeti- equivalent to the latitude and longitude of the participating tions. All variables were screened using unconditional or bivari- herds were used for the analyses. The Cartesian coordinates, or ate analysis and only those with P , 0.20 were considered in easting and northing, were used to check for north to south and building the final model. A final multivariable model was built east to west trends in total egg counts. using manual stepwise backwards removal and variables with P , 0.05 were retained. Variables removed from the model Statistical analysis were checked to see if they confounded other effect estimates Data analyses were completed in a statistical software program of interest and were considered a confounder if adding the vari- (Stata/SE 14.0 for Windows; StataCorp LP, College Station, able back into the model changed other effect estimates by more

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20

15 ARTICLE

10 Eggs per gram

5

0 May–Jun Jun–Jul Jul–Aug Sept–Oct Sample collection period

Figure 2. Predicted mean (6 standard error) of strongyle-like egg counts for fecal samples collected from May 22 to October 7, 2015 (n = 1290, 21 management groups). a,b — Different superscripts indicate significant differences between sample periods (P , 0.05). than 20%. Effect estimates were reported as relative differences FEC for a single sample period was 48 EPG for herd #1 and in counts with 95% confidence interval (CI). the lowest was 0.02 EPG for herd #6. Furthermore, herds #1 and #2 had individual animals with FEC of 180 EPG, while Results none of the animals in herds #3 and #14 had a FEC above All cattle were placed on pasture between April 18 and June 9, 15 EPG. Extreme intra-herd FEC variability is evident in the 2015, and no sampling was performed at this time. There were 1st collection in herd #1, which had a mean FEC of 19 EPG 66 separate herd samplings out of a potential 84; wet weather and a range of 0 to 181 EPG. Herd #1 consistently had the conditions and a shortage of personnel precluded all the herds highest FEC of all groups; these animals had not received an from being sampled at all time points. Table 1 provides the date anthelmintic treatment since being administered ivermectin ranges of the 4 collection time periods. The 66 sample collec- the previous fall. tions yielded 1290 individual fecal samples. The number of The strongyle-type FEC were significantly higher (P = 0.021) samples collected/group ranged from 10 to 20 (median = 20). in the last (September–October) sampling period compared Most (59/66; 89.3%) collections met the target of 20 samples/ to the first (May–June) (Figure 2). Nematodirus spp. fecal egg group, while 2 herd level collections yielded 10 samples, 1 counts were steady for the first 2 sampling periods, but signifi- yielded 16, 2 yielded 18, and 2 yielded 19 samples. cantly lower (P , 0.05) in the July–August versus September– Fifteen (71.4%) groups of cattle were treated with an iver- October collection periods (Figure 3). A similar trend occurred mectin product, at or prior to, the time of turnout, 1 (4.8%) with Trichuris spp. (not shown), with the FEC for the 3rd col- group was treated with fenbendazole at or before turnout, lection period being significantly lower (P , 0.05) compared and 4 (19.0%) had received ivermectin the previous fall. Of to the other 3 collection periods. the 20 (95.2%) producers who administered an anthelmintic, Total predicted mean strongyle-type FEC varied from 6 (30%) administered both ivermectin and fenbendazole prod- 4.4 EPG (95% CI: 1.6 to 7.1) in the May–June period to 11.6 ucts the previous fall and at turnout. (95% CI: 4.6 to 18.7) in the September–October period, after At least 1 strongyle-type egg was detected in 79.5% accounting for clustering. Risk factors screened using uncon- (1025/1290) of the samples (Table 1). Nematodirus spp. and ditional or bivariate analysis and considered to be potentially Trichuris spp. eggs were detected in 5.7% (73/1290) and associated (P , 0.20) with total FEC included: total accu- 1.7% (22/1290) of samples, respectively. All groups had at mulated precipitation from May to August (P = 0.008), total least 1 strongyle-type egg in the first sample period; however, accumulated precipitation from June to September (P = 0.01), only 52% of groups had at least 1 Nematodirus egg and only total GDD from April to July (P = 0.009), and soil type 1.9% (4/21) groups had at least 1 Trichuris egg (Table 1). (P = 0.06). These simple associations were adjusted only for dif- The box-and-whisker plots in Figure 1 (a–c) show the dis- ferences across sample collection periods and clustering within persion of FEC by herd and sampling period. Overall, there management group and sample collection period. was a wide variation of FEC between herds, within herds, and There was no association between FEC and the following between collection periods. The highest mean strongyle-type factors adjusted only for differences across sample collection

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Table 2. Final multivariable model describing the differences in total strongyle-like fecal egg counts among soil types, growing degree days (GDD), and sampling period adjusted for precipitation and clustering within management group for each sample collection (n = 1290, N = 66 sample collections from 21 management groups) Relative increase in egg count Lower 95% CI Upper 95% CI P-value Sample period 0.06 May to June Reference category June to July 1.77 0.87 3.59 0.11 July to August 2.71 1.09 6.68 0.031 September to October 2.82 1.17 6.79 0.021 ARTICLE Soil type 0.047 Black and dark gray 2.14 0.41 11.3 0.37 Brown Reference category Dark brown 3.36 1.22 9.29 0.019

GDD (Base 0°C) 0.0003

April to July 713° to # 879° days Reference category 880° to # 1045° days 0.10 0.02 0.42 0.002 1046° to # 1211° days 0.44 0.07 2.79 0.38

Total accumulated 0.19 precipitation (mm) June to September 175 to # 200 mm Reference category 201 to # 225 mm 0.65 0.29 1.44 0.29 226 to # 250 mm 2.12 0.85 5.32 0.11 251 to # 275 mm 1.44 0.27 7.77 0.67 276 to # 300 mm 3.18 0.96 10.5 0.06

periods and clustering within management group: total accu- with previous studies involving pastured beef cattle in western mulated precipitation from May to June (P = 0.30), total accu- Canada (4,13). In the case of Nematodirus spp., the low preva- mulated precipitation from May to July (P = 0.96), ecoregion lence is consistent with the view that these parasites are mainly (P = 0.78), and total GDD from April to June (P = 0.79), April a problem of younger calves. to August (P = 0.47), and April to September (P = 0.47). All herds had cattle shedding strongyle-like eggs; however, The final multivariable model for total FEC included sample of greater interest was the marked intra- and inter-herd vari- period (P = 0.06), total GDD from April to July (P = 0.0003), ability in FEC. This finding is salient because most beef herds and soil type (P = 0.047) (Table 2). Total accumulated pre- in western Canada currently use a standard “one size fits all” cipitation from May to August (P = 0.19) was included as it approach to parasite control. The findings, however, underscore confounded the associations between both soil type and total that some herds will have very low levels of parasitism, even at GDD and total egg counts. the end of the grazing season and hence may not benefit from Total FEC were 2.8 times higher in September–October anthelmintic therapy. The extreme variability also extended to than in May–June after accounting for other risk factors in the within the managed groups of cattle, in which some animals final multivariable model (Table 2). Total strongyle-like FEC had very low levels of internal parasites and as such, anthel- were also 3.4 times higher on pastures located on dark brown mintic treatment would be unwarranted. The challenge of versus brown soil types (Table 2). Total FEC were significantly course is coming up with a parasite testing method that is lower in the cattle in areas of mid-range GDD for the period inexpensive, rapid, accurate, and logistically practicable for April to July compared to areas with lower GDD (Table 2). cattle producers. And while this may seem incomprehensible After accounting for other risk factors there was no south to at this time, targeted anthelmintic treatment strategies have north (P = 0.85) or east to west (P = 0.89) trend in total egg been introduced in recent years into the sheep sector (26). counts and therefore northing and easting were not included Not only can targeted approaches be cost-effective, but this in the final model. strategy should mitigate the development of anthelmintic resistance. Discussion The epidemiological pattern of rising FEC over the summer Overall, there was a relatively high prevalence of strongyle grazing season is typical of cattle raised in temperate zones; this nematode infections, with 80% of samples having 1 or more finding was expected. However, the last peer-reviewed studies strongyle-like eggs. However, only a small number of samples involving GIN infections of pastured yearling cattle in western had Nematodirus spp. and Trichuris spp. eggs, which is consistent Canada were published over 25 years ago (2,3). Given that most

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1.0

0.8 ARTICLE 0.6

0.4 Eggs per gram

0.2

0.0 May–Jun Jun–Jul Jul–Aug Sept–Oct Sample collection period

Figure 3. Predicted mean (6 standard error) of Nematodirus spp. egg counts for fecal samples collected from May 22 to October 7, 2015 (n = 1290, 21 management groups). a,b — Different superscripts indicate significant differences between sample periods (P , 0.05).

of Canada’s beef cattle are located in the provinces of Alberta the association between FEC and soil type may have been and Saskatchewan, it is important to have data that are both confounded by cattle management practices. Saskatchewan contemporary and unique to the environmental conditions of cow-calf producers located in brown versus gray or dark brown the Prairie Provinces. The need for these data is highlighted soil zones are more likely to have larger herds, to pregnancy when comparing the results of the current study to those con- check, semen test, and to test their feedstuffs for nutritional ducted years earlier. Specifically, FEC increased nearly 3-fold content (32). Therefore, the higher FEC may be related to some in the current study, whereas in the earlier studies FEC only uncharacterized management practices that influence FEC. increased marginally from 10 to 13 EPG and 16.3 to 24.1 EPG Lastly, dark brown soils tend to be associated with wetter and over a 90 or 120 d grazing period, respectively (2,3). Multiple cooler environmental conditions, which may have confounded factors may account for the differences in the epidemiological the relationship between soil type and FEC. patterns of these earlier studies compared to the current study. There were several limitations to this study. An untreated The species composition of the parasite communities may have control group would have provided insight into how anthel- been different; the climatic conditions between the studies may mintics administered the previous fall and at turnout influenced have influenced parasite transmission rates; and differences in FEC. It would have also been useful to have determined the the type and amount of anthelmintic usage may also explain the species composition of the eggs either by larval culture and differences in the FEC patterns. Paradoxically, most anthelmin- morphology or molecular genotyping (33); the fecundity of tics are very efficacious in reducing parasite burdens; however, Cooperia spp. is much higher than that of Ostertagia spp. Only prolonged exposure to a threshold level of parasites is required 8 groups of cattle were sampled at all 4 time points and precipi- for the host to mount a protective immunological response tation data were obtained from the closest Environment Canada (27). Therefore, anthelmintic usage may in some instances reporting station as opposed to being collected at the level of result in suboptimal immunity, leaving the animals prone to the pasture. GIN infections when placed on pasture for the second grazing Despite the limitations, this is the first study of a cross- season (28,29). Regardless of the reason for the differences in section of cattle spanning a broad geographical area within the the past and current studies, the current study provides a con- province of Saskatchewan in over 25 y. The rise in FEC over the temporary view of what is occurring in grazing yearling cattle summer grazing period appears to be quite different from what in Saskatchewan. was reported decades ago. The extreme variability in FEC both There was nearly a 3.5-fold increase in FEC in cattle grazing within and between groups of cattle underscores the need to take pastures located in the dark brown versus brown soil zones. The a representative number of samples when assessing GIN burdens association between FEC and soil types is unclear but may be at the herd level. There is also a need for research into a targeted related to the soil being a reservoir for larvae or the influence approach for anthelmintic use in pastured beef cattle. Lastly, the of the herbages being grown on the soils, both of which can association between FEC and soil type was an interesting finding indirectly affected GIN transmission (30,31). Alternatively, and deserves more attention.

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Acknowledgments 18. Anderson RM, May RM. Herd immunity to helminth infection and implications for parasite control. Nature 1985;315:493–496. We acknowledge Dr. Janice Berg and Glen Cartwright of Merck 19. Genchi C, Madonna M, Traldi G. Epidemiology of Ostertagia oster- tagi Animal Health (Canada) for their support of this project. CVJ in dairy cows from different breeding systems. Parasitologia 1989;31:123–132. 20. Gasbarre LC, Leighton EA, Bryant D. Reliability of a single fecal egg References per gram determination as a measure of individual and herd values for 1. Yazwinski TA, Tucker CA. A sampling of factors relative to the epide- trichostrongyle nematodes of cattle. Am J Vet Res 1996;57:168–171. miology of gastrointestinal nematode parasites of cattle in the United 21. Bliss DH, Kvasnicka V. The fecal examination: A missing link in food States. Vet Clin Food Anim Pract 2006;22:501–527. animal practice. Compend Contin Educ Pract Vet 1997;19:S104–S109. 2. Kennedy MJ, ZoBell DR. Evaluation of ivermectin on performance of 22. Agriculture and Agri-Food Canada, Map archive. Available beef cattle on pasture in Alberta. Can Vet J 1988;29:566–568. from: http://www5.agr.gc.ca/DW-GS/historical-historiques.

ARTICLE 3. Kennedy MJ, ZoBell DR, Goonewardene L. Effect of invermectin on jspx?lang=eng&jsEnabled=true Last accessed July 25, 2017. weight gains in yearling steers on pasture in central Alberta. Can Vet 23. Agriculture and Agri-Food Canada, Map archive. Available from: J 1989;30:346–347. http://sis.agr.gc.ca/cansis/publications/webmaps.html Last accessed 4. Polley L, Bickis MG. Gastrointestinal nematode parasites in July 25, 2017. Saskatchewan cattle: Egg count distributions in beef animals. Can 24. Soils of Saskatchewan, University of Saskatchewan, College of J Vet Res 19987;51:465–469. Agriculture and Bioresources, Chernozemic Soils. Available from: 5. Cox WR, Lemiski D. Prevalence of gastrointestinal nematodes in dairy http://www.soilsofsask.ca/soil-classification/chernozemic Last accessed heifers in western Canada. Can Vet J 1989;30:666–668. July 25, 2017. 6. Ranjan S, Trudeau C, Prichard RK, Piché C, Bauck S. Epidemiological 25. Alexander N. Review: Analysis of parasite and other skewed counts. study of parasite infection in a cow-calf herd in Quebec. Vet Parasitol Trop Med Int Health 2012;17:684–693. 1992;42:281–293. 26. McBean D, Nath M, Lambe N, Morgan-Davies C, Kenyon F. Viability 7. Stromberg BE. Environmental factors influencing transmission. Vet of the Happy FactorTM targeted selective treatment approach on several Parasitol 1997;72:247–264. sheep farms in Scotland. Vet Parasitol 2016;218:22–30. 8. Fox MT. Pathophysiology of infection with gastrointestinal nema- 27. Kanobana K, Ploeger HW, Eysker M, Vervelde L. Individual varia- todes in domestic ruminants: Recent developments. Vet Parasitol tion and effect of priming dose level on establishment, growth and 1997;72:285–308. fecundity of Cooperia oncophora in re-infected calves. Parasitology 9. González JF, Molina JM, Ruiz A, Conde de Felipe MM, Rodriguez- 2004;128:99–109. Ponce E. The innate response against gastrointestinal nematodes in 28. Claerebout E, Dorny P, Vercruysse J, Agneessens J, Demeulenaere D. ruminants: A review. Rev Iber Parasitol 2003;63:97–115. Effects of preventive anthelmintic treatment on acquired resistance to 10. Zimmerman GL, Worley DE, Rickard LG. Epidemiology of Ostertagia gastrointestinal nematodes in naturally infected cattle. Vet Parasitol in northwestern USA. Vet Parasitol 1993;46:303–311. 1998;76:287–303. 11. Stromberg BE, Averbeck GA. The role of parasite epidemiology in the 29. Michel JF. The epidemiology and control of some nematode infections management of grazing cattle. Int J Parasitol 1999;29:33–39. in grazing animals. Adv Parasitol 1976;14:355–397. 12. Beck MA, Colwell DD, Goater CP, Kienzle SW. Where’s the risk? 30. Stromberg BE, Gasbarre LC. Gastrointestinal nematode control Landscape epidemiology of gastrointestinal parasitism in Alberta beef programs with an emphasis in cattle. Vet Clin Food Anim Pract cattle. Parasit Vectors 2015;8:434. 2006;22:543–565. 13. Jelinski M, Lanigan E, Gilleard J, Waldner C, Royan G. Survey of 31. Waghorn TS, Reynecke DP, Oliver AM, et al. Dynamics of the free- gastrointestinal nematode parasites in Saskatchewan beef herds. Can living stages of sheep intestinal parasites on pasture in the North Vet J 2016;57:160–163. Island of New Zealand. 1. Patterns of seasonal development. N Z Vet 14. Vercruysse J, Claerebout E. Immunity development against Ostertagia J 2011;59:279–286. ostertagi and other gastrointestinal nematodes in cattle. Vet Parasitol 32. Jelinski MD, Campbell J, Hendrick S, Waldner C. Survey of 1997;72:309–326. Saskatchewan beef cattle producers regarding management practices 15. Gasbarre LC. Effects of gastrointestinal nematode infection on the and veterinary service usage. Can Vet J 2015;56:66–72. ruminant immune system. Vet Parasitol 1997;72:327–343. 33. Avramenko RW, Redman EM, Lewis R, Yazwinski 16. Eysker M, Ploeger HW. Value of present diagnostic methods for TA, Wasmuth JD, Gilleard JS. Exploring the gastrointesti- gastrointestinal nematode infections in ruminants. Parasitology nal “Nemabiome:” Deep amplicon sequencing to quantify the spe- 2000;120:S109–S119. cies composition of parasitic nematode communities. PLoS One 17. Malczewski A, Jolley WR, Woodard LF. Prevalence and epidemiology of 2015;10:e0143559. trichostrongylids in Wyoming cattle with consideration of the inhibited development of Ostertagia ostertagi. Vet Parasitol 1996;64:28–297.

1050 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Evaluation of long-acting oxytetracycline and a commercial monovalent vaccine for the control of Campylobacter fetus subsp. venerealis infection in beef bulls

Nathan E.N. Erickson, Emily Lanigan, Taryn Waugh, Karen Gesy, Cheryl Waldner

Abstract — A blinded randomized controlled trial was used to evaluate a multi-modal therapeutic regime for treatment of beef bulls infected with Campylobacter fetus subsp. venerealis (Cfv). Treatment included 2 doses of a commercially available monovalent vaccine and long-acting oxytetracycline applied twice at a 2-week interval with treatment completed 2 weeks before post-treatment observation. Fifteen confirmed Cfv infected bulls were randomly allocated to control (n = 8) or treatment groups (n = 7). Preputial scrapings were collected each week from before infection to 11 weeks following the last treatment. When the polymerase chain reaction (PCR) results for both culture and preputial scrapings were interpreted in parallel, there were no significant differences between treated and untreated bulls. Regardless of the type of diagnostic testing considered, treatment with 2 label doses of this regime did not stop shedding of Cfv in all treated bulls and is, therefore, not recommended as an effective management strategy.

Résumé — Évaluation de l’oxytétracycline d’action prolongée et d’un vaccin monovalent commercial pour maîtriser l’infection par Campylobacter fetus ssp. venerealis chez les taureaux de boucherie. Un essai clinique randomisé à l’insu a été utilisé pour évaluer un régime thérapeutique multimodal pour le traitement des taureaux de boucherie infectés par Campylobacter fetus ssp. venerealis (Cfv). Le traitement a inclus deux doses d’un vaccin monovalent disponible dans le commerce et de l’oxytétracycline d’action prolongée appliquée deux fois à un intervalle de 2 semaines et le traitement a été complété deux semaines avant l’observation post-traitement. Quinze taureaux présentant une infection confirmée par Cfv ont été assignés au hasard au groupe témoin (n = 8) ou au groupe de traitement (n = 7). Des grattages de la surface du prépuce ont été prélevés à chaque semaine à partir du moment avant l’infection jusqu’à 11 semaines suite au dernier traitement. Lorsque les résultats de l’amplification en chaîne par polymérase (ACP) pour les cultures et les biopsies de surface du prépuce ont été interprétés en parallèle, il n’y avait aucune différence significative entre les taureaux traités et les taureaux non traités. Sans égard au type de test diagnostique considéré, le traitement à l’aide de deux doses recommandées sur l’étiquette n’a pas freiné l’excrétion de Cfv chez tous les taureaux traités et n’est donc pas recommandé comme une stratégie de gestion efficace. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1051–1058

Introduction ern Canadian cow-calf herds was thought to be limited; however, recent studies suggest that BGC is present and an important mbryonic deaths and abortions in the North American cause of reproductive failure (3,4). cow-calf herd result in substantial production losses and E The causative agent of BGC, Campylobacter fetus subsp. economic hardship for producers (1). Venereal pathogens, such venerealis (Cfv), also referred to as “vibrio” stemming from as bovine genital campylobacterosis (BGC), are an important previous nomenclature (2,5–9), has been conclusively linked to cause of reproductive loss (2). The impact of BGC among west- fetal losses. The economic losses are often compounded since the full extent of the problem is not recognized until the herd Department of Large Animal Clinical Sciences, Western is pregnancy checked in the fall or until the subsequent calving College of Veterinary Medicine, 52 Campus Drive, Saskatoon, season (10–13). Campylobacter fetus subsp. venerealis is primarily Saskatchewan S7N 5B4. maintained and transmitted by chronically infected bulls that Address all correspondence to Dr. Nathan Erickson; e-mail: serve as asymptomatic carriers which harbor the bacteria within [email protected] folds or crypts in the prepuce (11,13,14). Use of this article is limited to a single copy for personal study. The 2 most common options for control of BGC in infected Anyone interested in obtaining reprints should contact the herds include vaccination and test and removal of infected CVMA office ([email protected]) for additional bulls (14). While commercial vaccines for BGC are available copies or permission to use this material elsewhere. to producers in Canada there is limited information on their

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Table 1. Outline of the timeline for infection, treatment and post-treatment monitoring of Campylobacter fetus subsp. venerealis in beef bulls Week 20 — Negative naïve bulls and 3 — Infected bulls 22 Infection period Preputial scraping and infection protocol Baseline testing and inoculation of naïve bulls 21 Preputial scraping and infection protocol 15 — Infected bulls (8 — Bulls culled) 8 — Treatment bulls 7 — Control bulls Random allocation to groups 0 Treatment period Vaccine, antibiotic, Preputial scraping Treatment 1 Preputial scraping

ARTICLE 1 Preputial scraping Preputial scraping 2 Vaccine, antibiotic, Preputial scraping Treatment 2 Preputial scraping 3 Preputial scraping Preputial scraping 8 — Treatment Bulls 7 — Control Bulls Start of observation period 4 Post-treatment Preputial scraping Preputial scraping Day 1 5 monitoring period Preputial scraping Preputial scraping Day 7 (equivalent to Period 1 6 3 estrous cycles or Preputial scraping Preputial scraping Day 14 7 63 day breeding Preputial scraping Preputial scraping Day 21 Day 1 period) Preputial scraping Preputial scraping Day 7 Period 2 9 Preputial scraping Preputial scraping Day 14 10 Preputial scraping Preputial scraping Day 1 Day 21 11 Preputial scraping Preputial scraping Day 7 Period 3 12 Preputial scraping Preputial scraping Day 14 13 Preputial scraping Preputial scraping Day 21

effectiveness (15). As vaccination alone is often not considered oxytetracycline was used because of its wide availability in sufficient to manage an outbreak, testing and culling of infected Canada and the USA, its limited use in human health care, and bulls is routinely recommended. Test and cull procedures, a report from research in Argentina (23). The authors hypoth- however, have a substantial cost associated with premature esize that the combination of antimicrobial treatment and vac- loss of high value animals; especially, considering the price cination will not result in the clearance of Campylobacter fetus of breeding bulls. The effectiveness of testing and removal subsp. venerealis from the prepuce of carrier bulls. of infected bulls is also limited by the clinical sensitivity and specificity of the diagnostic tests suitable for use under field Materials and methods conditions (16). Experimental infection Some researchers have reported the potential for treating car- All animal procedures were performed in accordance with rier bulls using either vaccination with a monovalent oil-based the Canadian Council on Animal Care and approved by the vaccine or repeated antibiotic therapy (17–22). To date, many University of Saskatchewan Animal Research Ethics Board of the published antimicrobial treatment protocols use antimi- (Protocol # 20150025). Twenty (n = 20) cull beef bulls were crobial products that are not commercially available in Canada obtained either by purchase from a local auction or from a local (17,21). Furthermore, many of the previous studies either community pasture bull battery (Table 1). Preputial scrapings lacked an appropriate control group or used autogenous vac- were collected from all bulls before the start of the experiment cines (18–20,22). None of the published studies have provided and tested by culture and direct real-time polymerase chain strong evidence supporting a treatment option that eliminates reaction (RT-PCR) to confirm that the bulls were test negative shedding in infected bulls. for Cfv. The objective of this study was to use a randomized con- Three previously infected (PI) bulls, owned by the Western trolled trial to determine whether treatment with a combination College of Veterinary Medicine (Saskatoon, Canada), were used of a long-acting antimicrobial and a commercially available as a source of organisms to infect the naïve bulls (16). Preputial Campylobacter fetus vaccine would induce bacterial clearance in scrapings were collected from the 3 PI bulls followed by isola- carrier bulls for the duration of a breeding season lasting three tion and recovery of Cfv isolates. Pure cultures of Cfv from 21-day cycles. The authors chose a combination therapy regime, the 3 previously infected bulls were expanded on Skirrow agar vaccination and treatment with long-acting oxytetracycline, in plates to generate sufficient inoculum to infect the naïve bulls. order to minimize the number of treatment groups given the Pure Cfv cultures grown from the PI bulls were harvested into limited number of study subjects available. If a favorable out- warmed phosphate buffered saline (PBS; 20 mM phosphate,

come is found for the combined treatment, further study would 150 mM NaCl) and diluted to an optical density (OD600) be indicated to determine whether vaccination or antimicrobial of 0.4. Immediately before transfer, 2.5 mL of this inoculum therapy alone is sufficient for bacterial clearance. Long-acting was loaded into a series of 10-mL sterile plastic syringes with

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1 syringe for each bull. Each of the 20 naïve bulls were infected Skirrow (Campylobacter-selective) agar plates (Oxoid, Nepean, by placing the inoculum directly into the prepuce using an Ontario). After incubation of the plates for 30 min at 37°C, AI pipette, then 6 mL of air was used to flush the remaining filter-side up, the membranes were removed and the plates inoculum through the AI pipette. This technique was modified were incubated for 48 h in microaerophilic conditions using from Bier et al (24). The procedure was repeated 1 wk later, GasPak EZ Campy Pouch System (BO Diagnostics, Mississauga, so each of the 20 naïve bulls was inoculated twice (Table 1). Ontario). Colonies with the morphology consistent with

At the end of the infection protocol, 12 of the 20 bulls were Campylobacter spp. were Gram-stained for verification then sub- ARTICLE determined by culture and PCR to be positive for Cfv. Together cultured for 48 h under the same conditions to produce pure with the 3 PI bulls, a cohort of 15 infected bulls was available Campylobacter colonies for DNA extraction and PCR analysis. at the start of treatment. Real-time PCR was completed weekly on both direct pre- The 15 infected bulls were randomized into either the con- putial DNA samples and DNA from pure Cfv colonies. The trol (n = 8) or treatment (n = 7) group within blocks based on DNA was released from 200 mL prepuce scraping in PBS source (auction, community pasture, or previously infected). solution using direct heat lysis with minor alterations (4). The The bulls were confirmed positive based on laboratory testing preputial samples were centrifuged for 5 min at 12 000 3 g and immediately before their second infective dose of Cfv at week -1 the supernatant discarded (26). The preputial pellet was then and their positive status was re-evaluated with a sample collected re-suspended in 100 mL sterile water before heat lysis at 95°C immediately before treatment at week 0. The treatment group for 10 min. Finally, samples were diluted 1:10 in sterile water was vaccinated with a monovalent oil-based Cfv commercial before analysis using both conventional and real-time quantita- vaccine (Vibrin; Zoetis Canada, Kirkland, Quebec), 2 mL and tive PCR (27). injected with long-acting oxytetracycline (Liquamycin LA-200; The RT-PCR mixture was created using SYBR green (iQ Zoetis Canada), 1 mL/10 kg body weight (BW), after collec- SYBR green supermix; Bio-Rad, Mississauga, Ontario), 400 nM tion of a preputial sample. Both the vaccine and antibiotic were of each primer, and 2 mL of dilute lysate in a final volume of administered subcutaneously twice at a 2-wk interval (Table 1). 25 mL. All samples were run in duplicate on a thermocycler (iCy- The vaccine and antibiotic were placed on contralateral sides of cler/MyIQ; Bio-Rad) as previously described (4) with a primer each bull’s neck at each treatment. set targeting Cfv (VenSF and VenSR) (4). Each test included The person who collected the preputial scrapings and the 1 template and positive controls, also in duplicate. Melt-curve laboratory personnel were blinded to the treatment status of analysis was used to indicate infection status; the lower detection the bulls. Vaccination and injection with long-acting oxytetra- limit was 103 copies. The resulting data were analyzed using cycline were administered by other researchers and veterinarians commercial software (iQ5 Optical System Software, Bio-Rad). from the WCVM teaching hospital. All treatment records were Samples with a melt curvature signature comparable to the posi- maintained by a research assistant. tive control, peak signal of 78.5°C 6 0.5°C [mean 6 standard Preputial samples were collected from all bulls each week deviation (SD)], and threshold cycle (Ct) value , 35 were of the study both before and during treatment and for 11 wk considered positive. following the last treatment (Table 1). One aliquot from the Identification of the Cfv organisms and pure Cfv colonies sample was designated for culture and a second was tested using at both the species and subspecies levels was confirmed with a direct RT-PCR. series of conventional PCR tests of pure sub-cultured colony DNA lysate. In the first step, the highly conserved insertion Preputial sample collection gene, ISCfe1, was used for subspecies identification (28). A The procedure for collecting preputial scrapings was adapted second multiplex PCR was used to confirm the species (i.e. from Guerra et al (16). The sample was obtained from the Campylobacter fetus) and provide additional evidence to dif- prepuce of each bull using a 63.5-cm plastic uterine infusion ferentiate between subspecies (i.e., C. fetus fetus versus C. fetus pipette attached to a 20-mL syringe. The pipette was repeatedly venerealis) as per Hum et al. (29). The carbon starvation gene inserted its full length into the prepuce in a back and forth fash- (cstA) identifies the species level, while the plasmid stabiliza- ion such that the preputial lining was scraped at least 10 times tion protein gene (parA) provides additional information to while at the same time approximately 15 mL of suction was differentiate the subspecies. The PCR products were resolved applied by the syringe. The resulting sample was immediately by gel electrophoresis (110 V, 40 min) on a 1.5% agarose gel transferred into a screw top vial containing 2 mL of PBS. The stained with ethidium bromide (Fisher Scientific, Ottawa, sample was maintained at 20°C for transport to the laboratory Ontario) and visualised under UV light. Positively identified (25). A new sterile syringe and pipette and new latex gloves were PCR products were purified using QIAquick PCR Purification used for each sample (Table 1). Kit (Qiagen, Valencia, California, USA), and sequenced through Macrogen Inc. (Seoul, Korea). Sequence results Culture and PCR diagnostics were aligned using the Staden Software Package 2-1.0.0b9. A The culture protocol was adapted from Chaban et al (25). BLAST search was completed for consensus sequences on the Fresh preputial scrapings were transported to the laboratory National Center for Biotechnology Information (NCBI) website: within 2 h of collection. Upon arrival, 300 mL aliquots were (http://www.ncbi.nlm.nih.gov) for verification of identity. spread onto a sterile 0.65 mm mixed cellulose ester membrane Conventional PCR and PCR product sequence analysis was filter (Millipore; Billerica, Massachusetts, USA) and placed on performed 4 times throughout the trial.

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Whole genome sequencing and untreated groups were estimated for each period using Due to some controversy in the literature regarding the specific- exact logistic regression. Odds ratios and exact 95% confidence ity of the available PCR primers (14), we definitively verified intervals (CI) were calculated to compare the odds of control the identity of the isolates used in the infection trial by submit- bulls being positive for Cfv compared with the treated bulls. ting DNA from the Cfv isolates for whole genome sequencing A P-value , 0.05 was considered statistically significant. The (WGS) through Macrogen (South Korea) at the conclusion of differences for control versus treated bulls were determined for the study. Isolates were selected and expanded in triplicate on 21-day cycle results summarized from weekly culture results Skirrow plates as described. Each plate was washed with 1.5 mL confirmed with PCR, direct RT-PCR of preputial aspirates, and PBS then pelleted by centrifugation for 10 min at 21 000 3 g. combined results for culture and prepuce RT-PCR. The joint ARTICLE The DNA was extracted using a modified salting out procedure interpretation of both culture and direct RT-PCR represented (30) then combined in various quantities until the desired parallel interpretation of the 2 tests and was evaluated to opti- concentration of 1 mg per sample was achieved. Quality and mize the sensitivity of the analysis. quantity were rechecked using a Nanodrop 2000 and a Qubit Fluorometer 3.0 (Thermofisher Scientific). Additional quality Results tests included running 10 mL DNA on 1% agarose gel at 90 V Of the 15 Cfv infected bulls used in the project, 5 were 3 y for 1 h to monitor for shearing and assure high quality samples old and 2 were 5 y old. Age records were not available for the were submitted. remaining 8 bulls, but physical appearance and size suggested Campybacter fetus DNA of adequate quality was sequenced they were at least 3 y of age. The bulls ranged in weight from from isolates from 4 of the artificially infected bulls. The FASTA 827 kg to 1102 kg with an average weight of 953 kg and a sequences resulting from the analysis were uploaded to the median weight of 939 kg. There was no difference in weights NCBI nucleotide site and a BLAST search was undertaken for (P = 0.5) between the bulls assigned to the treatment and con- highly similar sequences (megablast) using default settings to trol groups. The 15 bulls included 8 Black Angus, 3 Simmental, confirm the identity of isolates as Cfv (Appendix 1 — available 2 Red Angus, and 2 Charolais. None of the bulls required anti- on request from the corresponding author). biotic treatment for other reasons during the study. All 15 bulls were culture and PCR-positive on at least Statistical analysis 2 weekly samples after inoculation of the naïve bulls with Cfv All data were entered into a spreadsheet and analyzed using Stata and before the 2 treatment sets were complete. Whole genome 13 for Windows (StataCorp LP, College Station, Texas, USA). sequences of Campylobacter isolates from 4 of the artificially Criteria for whether bulls were positive or negative were adapted infected bulls provided definitive confirmation that the organ- from Guerra et al (16). All bulls were considered positive before isms used for artificial infections were Cfv (Appendix 1). The treatment if they had at least 2 positive weekly tests at the time best match was to Cfv str. 84-112, complete genome GenBank: of treatment. A bull was considered negative if it had 4 consecu- HG004426.1 (29,30). tive negative tests (16). Individual bull test results during the post-treatment obser- Sampling times and results in the observation period fol- vation period (OP) differed between the preputial scrapings lowing treatment were summarized into three 21-day periods cultured and verified with PCR (Figure 1) compared with scrap- representative of three 21-day estrous cycle periods which ings analyzed by direct RT-PCR (Figure 2). The results of the constitute an industry recommended 63-day breeding season 2 tests were then combined to facilitate parallel interpretation (Table 1). The first 21-day cycle, which was also the first obser- (Figure 3) and optimize sensitivity. vation period, began on Week 4 or 2 wk after the final treatment One control bull was negative based on preputial scraping (Week 2). The start of the post-treatment observation period culture PCR throughout the three 21-day post-treatment OP (OP) was set assuming the final treatment would require at least (Figure 1); however, the bull did test positive once in the final of 2 wk to be effective and, therefore, if recommended for field use the three 21-day periods with the direct RT-PCR test (Figure 2). the series of treatments would be completed at least 2 wk before Only 2 of the 7 treated bulls had at least 1 culture positive commencement of a breeding season. preputial scraping confirmed by PCR during the OP (Figure 1). The sample collected on Day 21 of Period 1 (or Week 7) One bull’s preputial scraping culture tested PCR positive once represented the status of the bull at the end of Period 1. The on Day 14 of the first 21-day period and then never tested sample collected on Day 21 of Period 1 was also considered to positive again. The second bull’s preputial scraping culture represent the bull’s status for Day 1 of Period 2. An outline of tested PCR positive on Day 14 of the second 21-day period and the treatment and subsequent sampling periods is shown in Day 21 of the third 21-day period. Table 1. For a bull to have been considered test negative at the For the direct RT-PCR on the preputial scraping only 2 of end of a complete 21-day OP, it needed to have a negative test the 7 treated bulls remained negative throughout the three on all 4 test days linked to the period (Days 1, 7, 14, and 21). 21-day post-treatment observation periods (Figure 2). In the If the bull was positive on any 1 test day during the respective first 21-day period there was only 1 direct RT-PCR test posi- period, it was considered test positive for that period. tive bull; however, it was not the same bull that had a positive A Wilcoxon rank-sum test was used to evaluate the differ- culture result. Three bulls had a positive direct RT-PCR result ences in weight between the bulls in the treatment and control during the second 21-day period and 4 of 7 bulls had a positive groups. The differences in Cfv infection between the treated RT-PCR result during the third 21-day OP.

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Culture PCR results

Control Treatment ARTICLE First period

Second period

Third period

Figure 1. Culture PCR results summarized for individual bulls beginning 2 wk after the second of 2 treatments with injectable oxytetracycline and 2 doses of monovalent Campylobacter fetus vaccine. Bulls were reported as positive if they had at least 1 positive test result on day 1, 7, 14, or 21 for each of the subsequent three 21-day observation periods. A bull was reported as negative for a period if he was test negative on all 4 samples considered part of that period. * Results were negative for direct prepuce PCR for 2 of 4 samples and 2 samples were undetermined due to fungal overgrowth.

Direct prepuce PCR results

Control Treatment

First period

Second period

Third period

Figure 2. Direct prepuce PCR results summarized for individual bulls beginning 2 wk after the second of 2 treatments with injectable oxytetracycline and 2 doses of monovalent Campylobacter fetus vaccine. Bulls were reported as positive if they had at least 1 positive test result on day 1, 7, 14, or 21 for each of the subsequent three 21-day observation periods. A bull was reported as negative for a period if he was test negative on all 4 samples considered part of that period.

When the results of both culture and direct preputial more likely to be positive for Cfv (P = 0.02), but only in the RT-PCR were considered in parallel [i.e., the bulls that were first 21-day period (Table 2). positive in either of the 2 tests were considered test-positive When the results of both culture and the direct PCR test were (Figure 3)] all untreated, control bulls were positive at least considered in parallel, there was no significant difference in the once during the OP and all but 1 of the treated bulls were also odds of a positive test result for any of the 21-day post-treatment positive at least once. OP, although the difference between treated and untreated bulls If only the preputial cultures confirmed with PCR were in the first 21-day period (P = 0.07) (Table 2). considered (Figure 1), the odds that control bulls would test No serious side effects were observed in any of the 7 treated positive for Cfv were 27.2 times higher than for the treated bulls. However, 5 bulls developed injection site swellings from bulls (P = 0.02) in all three 21-day post-treatment observation either the vaccine (2 bulls) or long-acting oxytetracycline periods (Table 2). When only the results of the direct RT-PCR (3 bulls). The swellings were small and resolved with no long- test were evaluated (Figure 2), control bulls were 27.2 times term complications.

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Culture and prepuce PCR results

Control Treatment

ARTICLE First period

Second period

Third period

Figure 3. Combination of culture and direct prepuce PCR results summarized for individual bulls beginning 2 wk after the second of 2 treatments with injectable oxytetracycline and 2 doses of monovalent Campylobacter fetus vaccine. Bulls were reported as positive if they had at least 1 positive test result on day 1, 7, 14, or 21 for each of the subsequent three 21-day observation periods. A bull was reported as negative for a period if he was test negative on all 4 samples considered part of that period. * Results were negative for direct prepuce PCR for 2 of 4 samples and 2 samples were undetermined due to fungal overgrowth.

Discussion Canada (16), suggesting the potential for false positive RT-PCR tests. However, recent field data suggest that the difference in the The main objective of this study was to determine if a multi- risk of false positives might not be as large as previously reported modal treatment approach, using a combination of vaccination especially in situations with high pretest probability of infection and long-acting antimicrobial therapy, would reduce or elimi- (31). Previous studies reported similar sensitivities for bacterial nate shedding of Cfv in chronically infected carrier bulls. Two culture using the methods described herein and RT-PCR (82.3% treatments with long-acting oxytetracycline at label doses and a commercial monovalent bacterin did not eliminate BGC in and 85.4%, respectively) (16). The published estimates of clinical all study bulls. There was also no significant difference between sensitivity for culture, however, were based on samples delivered the proportion of treated and untreated bulls that tested posi- to the laboratory substantially faster than in the present study , tive when the results of both culture and direct RT-PCR were ( 30 min). Also, all samples for that study were collected in considered. The 2 test results were combined to optimize the June and July in an insulated barn, potentially leading to higher sensitivity of the testing protocol detection of BGC post- culture sensitivity than that in the present study. Previous studies treatment because of the severe consequences of false negatives. have shown that the sensitivity of the RT-PCR is resilient to the When the results of each diagnostic test were observed sepa- time delays and transport conditions seen herein (32). rately, there was a significant reduction in the likelihood that a Another argument for considering the treatment as poten- treated bull would test positive based on culture for all 3 post- tially successful would be the tendency for a difference between treatment 21-day observation periods and for direct RT-PCR treatments in the first 21-day post-treatment OP when the of the preputial samples for the first 21-day OP (Table 2). One results of both culture and RT-PCR were considered. The fail- potential argument for considering the results of culture alone ure to detect a significant result was very likely a reflection of would be that culture definitively identifies bulls shedding live limited study power. The precision of the estimates of effect for organisms; whereas direct RT-PCR could potentially identify all testing methods was affected by the small number of bulls DNA from nonviable organisms that would not be a risk for in this study. However, regardless of the statistical significance transmission. However, in the current study the observed fre- and precision of effect estimates, treatment success was not quency of RT-PCR positive bulls increased throughout the trial considered adequate in the present study given that 29% (first which is consistent with what we would expect with increasing cycle), 43% (second cycle), and 71% (third cycle) of treated time after treatment. If the RT-PCR results are correct and the bulls were positive on either culture or direct PCR during post- preputial cultures were less sensitive than RT-PCR during the treatment OP designed to simulate a typical breeding season. post-treatment monitoring phase, the lower sensitivity may have There was no complete cycle when all of the treated bulls were been due to death of Cfv during transport to the laboratory negative by culture or direct RT-PCR. The high potential cost and decreasing environmental temperature during collection of having even 1 bull remain infectious warrants a conservative in September and October. interpretation of the findings. The clinical specificity of bacterial culture (100%) is higher There is relatively little good published evidence against which than that of RT-PCR (85%) under field conditions in western to compare the results of the present study; despite h­ istorical

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Table 2. Exact logistic regression results summarizing the odds that a bull would test positive at least once by culture, direct PCR, or either culture or direct PCR for Campylobacter fetus subsp. venerealis for the control group compared to the treated group. Odds ratios were estimated for each of the three 21-day observation periods following treatment. The first observation cycle started 2 weeks after the second of 2 treatments with a monovalent Campylobacter fetus vaccine and injectable oxytetracycline (n = 7 treated bulls and 8 untreated bulls) % Untreated % Treated bulls bulls Cfv Odds ARTICLE 21-day period Cfv positive positive ratio 95% CI P-value 1st period: Culture and PCR 14% (1/7) 88% (7/8) 27.2 (1.50–2194) 0.02 Direct preputial PCR 14% (1/7) 88% (7/8) 27.2 (1.50–2194) 0.02 Combined culture and 29% (2/7) 88% (7/8) 13.6 (0.86–942) 0.07 direct preputial PCR 2nd period: Culture and PCR 14% (1/7) 88% (7/8) 27.2 (1.50–2194) 0.02 Direct preputial PCR 43% (3/7) 88% (7/8) 7.9 (0.50–523) 0.20 Combined culture and 43% (3/7) 100% (8/8) 7.9 (0.50–523) 0.20 direct preputial PCR 3rd period: Culture and PCR 14% (1/7) 88% (7/8) 27.2 (1.50–2194) 0.02 Direct preputial PCR 71% (5/7) 88% (7/8) 3.1 (0.22–Inf) 0.40 Combined culture and 71% (5/7) 100% (8/8) 3.1 (0.22–Inf) 0.40 direct preputial PCR

use of topical streptomycin ointments for the treatment of azole chlorhydrate (DCL) (21). Ten naturally infected bulls were vibrio-infected cattle (33). Vasquez et al (18) reported on the confirmed positive by fluorescent antibody technique (FAT) and therapeutic efficacy of the Cfv bacterin used in the present study. culture. Of the 10 bulls, 4 were infected by Cfv alone, 3 were Of the 10 bulls used in their 1983 study, 6 were initially vacci- infected by Cfv and Campylobacter fetus subsp. fetus (Cff), and 3 nated twice at a 4-week interval and 4 were kept as controls. The were infected by Cff alone. All 10 bulls were negative for Cfv and 6 original vaccinates tested negative by week 8 post-vaccination Cff by FAT and culture at each of 4 bi-weekly samplings after and the 4 controls were positive. The 4 controls were then vac- treatment. However, the authors acknowledged that the negative cinated and 2 of these bulls infected heifers with Cfv. The authors test results could be biased by sporadic resolution as no control determined that 2 of 10 vaccinated bulls remained chronically animals were used. This previous study also used DCL, which infected with Cfv and therefore did not recommend vaccination is not allowed for use in food producing animals in Canada. alone for treatment of Cfv. Based on this finding, we chose com- In addition to DCL, treatment with long-acting oxytetracy- bination therapy with both vaccination and antimicrobials for cline and fluoroquinolone has been reported for bulls naturally the current study. The bulls in the present study were followed infected with Cff in Argentina (23). While this paper did not for 11 wk after vaccination compared with 8 wk in the earlier directly address Cfv infection, it was the motivation for the study. Other limitations of the Vasquez et al (18) study were the choice of antibiotic in the present study. The Argentinian study smaller sample size and lack of blinding. reported 5 of 5 of bulls were negative for Cff by culture and FAT The remaining identified published studies of vaccine trials in 30 d after 2 treatments 72 h apart with long-acting oxytetra- bulls used autogenous or experimental rather than commercial cycline (0.10 mL/kg, ½ IM and ½ SC) (23). Only 1 of 7 bulls vaccines (18,19,22,34,35). Most previous studies did not use a treated with fluoroquinolone was negative at 30 d. There was no negative control, and therefore the infections may have resolved negative control group. The preferred antibiotic for the present spontaneously. Anecdotally, spontaneous recovery occurs in study was long-acting oxytetracycline because of its cost relative young bulls infected with Cfv (17). One bull in the control to other options, limited use in human health, wide availability group for the present study tested positive twice before treat- in Canada, and due to its performance in the previous study. ment but only once by PCR after treatment at the very end of The previous studies that observed treatment response of Cfv the OP. Either this bull failed to completely spontaneously clear infected bulls relied on culture or fluorescent antibody screen- the experimental infection (likely) or the experimental infection ing for their diagnostic testing. While culture has been the gold did not establish in this bull and it was re-exposed later through standard for many years, its sensitivity is problematic especially bull-to-bull contact (less likely) (13). when lag times exist between sampling and arrival at the labora- Although a recent review reported that antimicrobial treat- tory (25). Our study used PCR techniques directly on preputial ments for Cfv are impractical and of limited efficacy (14), scrapings in addition to culture. Use of techniques such as direct 2 previous studies suggested some potential for antimicrobial prepuce PCR is important in western Canada because access to use in management of positive bulls. The first study observed laboratory facilities is limited by distance and transport time. bulls that were infected by both Cfv and Tritrichomonas foetus The development of direct prepuce PCR could improve test and were treated with subcutaneous and intramuscular dimetrid- sensitivity as it is not impacted by transport times up to 96 h

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or to moderate temperature changes (32). The sensitivity of the 13. Hoffer MA. Bovine campylobacteriosis: A review. Can Vet J 1981;22: 327–330. direct PCR also improves with repeated sampling employed in 14. Michi AN, Favetto PH, Kastelic J, Cobo ER. A review of sexually this study (16). The specificity of diagnosis for the agent used in transmitted bovine trichomoniasis and campylobacteriosis affecting the experimental infection and the isolates recovered during the cattle reproductive health. Theriogenology 2016;85:781–791. 15. Schurig GG, Duncan JR, Winter AJ. Elimination of genital vibriosis trial was assured with conventional PCR using multiple primers in female cattle by systemic immunization with killed cells or cell-free followed by whole genome sequencing for a subset of isolates. extracts. J Infect Dis 1978;188:463–472. The differences in results between the RT-PCR of the direct 16. Guerra AG, Chaban B, Hill JE, Waldner CL, Hendrick SH. Clinical sensitivity and specificity of a real-time PCR assay for Campylobacter prepuce samples and culture results observed in this study fetus subsp venerealis in preputial samples from bulls. Am J Vet Res might be attributed to the limited sensitivity of culture under 2014;75:851–560.

ARTICLE field conditions (14,25) or the limited sensitivity and specific- 17. Truyers I, Luke T, Wilson D, Sargison N. Diagnosis and management of venereal campylobacteriosis in beef cattle. BMC Vet Res 2014; ity of the direct RT-PCR (16). While samples were collected as Nov 27;10:280. doi: 10.1186/s12917-014-0280-x. quickly as possible and efforts were made to hold the samples 18. Vasquez LA, Ball L, Bennett BW, et al. Bovine genital campylobacteriosis (vibriosis): Vaccination of experimentally infected bulls. Am J Vet Res at a constant temperature and then deliver them directly to the 1983;44:1553–1537. laboratory, there is the potential for loss of viability due to the 19. Clark BL, Dufty JH, Monsbourgh MJ. Vaccination of bulls against time lag and temperature fluctuations between collection and bovine vibriosis. Aust Vet J 1968;44:530. 20. Allan PJ. A field evaluation of vaccination of bulls against vibriosis. Aust plating for culture, given the susceptibility of Cfv to adverse Vet J 1972;48:72–73. environmental conditions (25). 21. Campero CM, Ballabene NC, Cipolla AC, Zamora AS. Dual infection While this study does provide the first randomized, con- of bulls with campylobacteriosis and trichomoniasis: Treatment with dimetridazole chlorhydrate. Aust Vet J 1987;64:320–321. trolled, and blinded trial on combined therapy with commer- 22. Foscolo CB, Pellegrin AO, Leite RC, Stynen APR, Lage AP. Vaccination cially licensed products, increasing the number of animals in of bulls against genital campylobacteriosis: A therapeutic approach. this study would have resulted in more precise estimates of the Anim Reprod 2005;2:122–127. 23. Campero CM, Cipolla AC, Odriozola E, Medina D, Morsella CG, effect of combined vaccination and treatment on Cfv status in Saubidet M. Tratamientos sistemicos en toros con infeccion genital mature beef bulls. Subsequent studies should consider other a Campylobacter fetus subsp. fetus. Veterinaria Argentina 1993;10: commercially licensed long-acting antimicrobials or emerging 303–309. 24. Bier PJ, Hall CE, Duncan JR, Winter AJ. Experimental infections alternatives to antimicrobial therapy. with Campylobacter fetus in bulls of different ages. Vet Microbiol 1977;2:13–27. Acknowledgments 25. Chaban B, Garcia Guerra A, Hendrick SH, Waldner CL, Hill JE. Isolation rates of Campylobacter fetus subsp venerealis from bovine The authors acknowledge support from the Saskatchewan preputial samples via passive filtration on nonselective medium versus Agricultural Development Fund, Zoetis Canada, and the Prairie selective medium, with and without transport medium. Am J Vet Res 2013;74:1066–1069. Farm Rehabilitation Administration. CVJ 26. McMillen L, Fordyce G, Doogan VJ, Lew AE. Comparison of culture and a novel 59 Taq nuclease assay for direct detection of Campylobacter References fetus subsp. venerealis in clinical specimens from cattle. J Clin Microbiol 1. Bellows DS, Ott SL, Bellows RA. Review: Cost of reproductive diseases 2006;44:938–945. and conditions in cattle. Prof Anim Sci 2002;18:26–32. 27. Chaban B, Musil KM, Himsworth CG, Hill JE. Development of 2. McCool CJ, Townsend MP, Wolfe SG, et al. Prevalence of bovine cpn60-based real-time quantitative PCR assays for the detection of venereal disease in the Victoria River District of the Northern Territory: 14 Campylobacter species and application to screening of canine fecal Likely economic effects and practicable control measures. Aust Vet J samples. Appl Environ Microbiol 2009;75:3055–3061. 1988;65:153–156. 28. Abril C, Vilei EM, Brodard I, Burnens A, Frey J, Miserez R. Discovery 3. Waldner C, Hendrick S, Chaban B, et al. Application of a new diag- of insertion element ISCfe1: A new tool for Campylobacter fetus subspe- nostic approach to a bovine genital campylobacteriosis outbreak in a cies differentiation. Clin Microbiol Infect 2007;13:993–1000. Saskatchewan beef herd. Can Vet J 2013;54:373–376. 29. Hum S, Quinn K, Brunner J, On SL. Evaluation of a PCR assay for 4. Chaban B, Chu S, Hendrick S, Waldner C, Hill JE. Evaluation of a identification and differentiation of Campylobacter fetus subspecies. Aust Campylobacter fetus subspecies venerealis real-time quantitative poly- Vet J 1997;75:827–831. merase chain reaction for direct analysis of bovine preputial samples. 30. Martin-Platero AM, Valdivia E, Maqueda M, Martinez-Bueno M. Fast, Can J Vet Res 2012;76:166–173. convenient and economical method of isolating genomic DNA for lactic 5. Givens MD. A clinical, evidence-based approach to infectious causes of acid bacteria using a modification of the protein “salting-out” procedure. infertility in beef cattle. Theriogenology 2006;66:648–654. Anal Biochem 2007;366:102–104. 6. Finlay RC, Ruckerbauer GM, Stovell PL. Campylobacter fetus in artificial 31. Waldner C, Parker S, Gesy K, Waugh T, Lanigan E, Campbell J. insemination unit and slaughterhouse bulls in Ontario. Can J Comp Med Application of direst polymerase chain reaction assays for Campylobacter 1985;49:231–232. fetus subsp. venerealis and Tritrichomonas foetus to screen preputial 7. Bawa E, Adekeye J, Oyedipe E, Umoh J. Prevalence of bovine campy- samples from breeding bulls in cow-calf herds in western Canada. Can lobacteriosis in indigenous cattle of three states in Nigeria. Trop Anim J Vet Res 2017;81:91–99. Health Prod 1991;23:157–160. 32. Garcia-Guerra A, Waldner C, Pellegrin A, et al. Effect of sample pool- 8. Hum S. Bovine abortion due to Campylobacter fetus. Aust Vet J 1987;64: ing and transport conditions on the clinical sensitivity of a real-time 319–320. polymerase chain reaction assay for Campylobacter fetus subsp. venerealis 9. van Bergen MAP, Linnane S, van Putten JPM, Wagenaar JA. Global in preputial samples from bulls. Can J Vet Res 2016;80:32–39. detection and identification of Campylobacter fetus subsp. venerealis. Rev 33. McEntee K. Bovine vibriosis. Iowa State University Vet 1958;20:14–15. Sci Tech OIE 2005;24:1017–1026. 34. Bouters R, De Keyser J, Vandeplasshe M, Van Aert A, Brone E, Bonte 10. BonDurant RH. Venereal diseases of cattle: Natural history, diagnosis, P. Vibrio fetus infection in bulls: Curative and preventive vaccination. and the role of vaccines in their control. Vet Clin N Am Food Anim Br Vet J 1973;129:52–57. Pract 2005;21:383–408. 35. Yarokhno Y. Diagnosis and vaccination for bovine genital campylobac- 11. Bondurant RH. Inflammation in the bovine female reproductive tract. teriosis in beef heifers [MSc dissertation]. Saskatoon, Saskatchewan: J Anim Sci 1999;77:101–110. University of Saskatchewan, 2015. 12. Campero CM, Moore DP, Odeón AC, Cipolla AL, Odriozola E. Aetiology of bovine abortion in Argentina. Vet Res Commun 2003;27: 359–369.

1058 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Retrospective evaluation of toceranib (Palladia) treatment for canine metastatic appendicular osteosarcoma

Changseok Kim, Arata Matsuyama, Anthony J. Mutsaers, J. Paul Woods

Abstract — This retrospective study evaluated the outcomes of dogs with macroscopic pulmonary metastasis of appendicular osteosarcoma (OSA) treated with toceranib. Medical records of 20 dogs with macroscopic pulmonary metastasis of OSA that received toceranib were reviewed. The median dose and duration of toceranib administration were 2.52 mg/kg (range: 2.12 to 2.72 mg/kg) and 60 days (range: 17 to 231 days). The median progression free survival (PFS) and overall survival (OS) were 36 days (range: 17 to 231 days) and 90 days (range: 17 to 433 days), respectively. The clinical benefit rate was 10% (2/20; 1 partial response and 1 stable disease). The longest length of initial pulmonary nodules had significant impact on both PFS (P = 0.01) and OS (P = 0.02). The prognosis for dogs with metastatic OSA was poor with only 10% of dogs showing clinical benefit from toceranib. These results suggest that toceranib may not improve outcome in dogs with macroscopic pulmonary metastasis of OSA.

Résumé — Évaluation rétrospective du traitement avec tocéranib (Palladia) pour l’ostéosarcome appendiculaire métastatique canin. Cette étude rétrospective a évalué les résultats des chiens souffrant de métastase pulmonaire macroscopique de l’ostéosarcome appendiculaire (OSE) traité avec tocéranib. Les dossiers médicaux de 20 chiens atteints de métastase pulmonaire macroscopique d’OSE qui ont reçu tocéranib ont été évalués. La dose médiane et la durée de l’administration de tocéranib étaient de 2,52 mg/kg (étendue de 2,12 à 2,72 mg/kg) et de 60 jours (étendue de 17 à 231 jours). La progression de survie libre (PSL) médiane et la survie totale (ST) étaient de 36 jours (étendue de 17 à 231 jours) et de 90 jours (étendue de 17 à 433 jours), respectivement. Le taux de bienfaits cliniques étaient de 10 % (2/20; 1 réponse partielle et 1 maladie stable). Le plus long intervalle avant l’apparition des nodules pulmonaires initiaux avait un impact important sur la PSL (P = 0,01) et la ST (P = 0,02). Le pronostic pour les chiens atteints d’OSE métastatique était mauvais et seulement 10 % des chiens ont manifesté des bienfaits cliniques lors de l’usage de tocéranib. Ces résultats suggèrent que le tocéranib pourraient ne pas améliorer les résultats cliniques chez les chiens souffrant de métastase pulmonaire macroscopique causée par OSE. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1059–1064

Introduction response to conventional chemotherapy has not been observed in dogs with macroscopic pulmonary metastasis of OSA (3–5). steosarcoma (OSA), the most common primary bone Therefore, a new focus of treatment is shifting from standard tumor in dogs, can occur at various locations on the body. O cytotoxic approaches to targeted therapeutics in an attempt to Appendicular OSA is the most prevalent type, however, com- suppress the growth of metastatic tumor cells (6–13). Among prising up to 85% of cases (1). The reported median survival the various mechanisms associated with the process of tumor time for dogs with appendicular OSA is 4 to 5 mo with ampu- metastasis, tumor angiogenesis is known to play an important tation alone; the addition of adjuvant chemotherapy improves role in the metastatic process and has been a validated thera- median survival times to 8 to 12 mo (2). Despite the improved peutic target for various tumors (14). overall outcome of this disease with chemotherapy, a positive The involvement of vascular endothelial growth factor (VEGF) and its receptor (VEGFR) in tumor angiogenesis has Department of Clinical Studies (Kim, Mutsaers, Woods), been reported in many studies (15–17). Tumor cells can drive Department of Biomedical Sciences (Matsuyama, Mutsaers), the migration of VEGFR2 expressing circulating endothelial Ontario Veterinary College, University of Guelph, 36 College precursors (CEPs) from the bone marrow to the tumor micro- Avenue West, Guelph, Ontario N1G 2W1. environment through the production of VEGF (18–20). Anti- Address all correspondence to Dr. J. Paul Woods; e-mail: VEGF/VEGFR therapy has been shown to decrease survival [email protected] signaling and mobilization of CEPs to the site of tumor growth Use of this article is limited to a single copy for personal study. (21). These findings led to further studies with small molecule Anyone interested in obtaining reprints should contact the receptor tyrosine kinase (RTK) inhibitors such as sunitinib CVMA office ([email protected]) for additional and sorafenib in preclinical settings. Both drugs were found to copies or permission to use this material elsewhere. inhibit the proliferation of OSA cell lines in vitro and sunitinib

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treatment significantly reduced tumor burden, microvessel Table 1. Variables used for Cox regression analysis of progression density, and pulmonary metastasis in a human xenograft OSA free survival (PFS) and overall survival (OS) mouse model. These results suggested potential use of these P-values Number drugs for OSA treatment (22,23). Variables of dogs PFS OS Vascular endothelial growth factor is detectable in both Age 20 0.82 0.40 human and canine OSA, and has been associated with increased Body weight 20 0.01 0.11 malignancy and poor prognosis (24–29). Toceranib, a small Concurrent metronomic treatment 6 0.94 0.49 molecule RTK inhibitor, has generated interest in veterinary Dose of toceranib 20 0.84 0.05 Duration of toceranib treatment 20 0.11 0.03 medicine as a potential treatment option for metastatic OSA. Longest length of initial pulmonary nodules 20 0.01 0.02

ARTICLE Toceranib targets several members of the split-kinase family such Gender 0.16 0.39 as VEGFR, platelet-derived growth factor receptor (PDGFR), Castrated male 8 Spayed female 11 Kit, colony stimulating factor-1 receptor (CSF-1R), and Fms Intact female 1 Related Tyrosine Kinase 3 (Flt-3) (30–32). A previous study Number of initial pulmonary nodules 0.33 0.72 revealed that a 2.4 to 2.9 mg/kg body weight (BW), q48h dose Low 9 Intermediate 6 of toceranib significantly increased plasma VEGF, indicating High 5 VEGFR2 inhibition, suggesting that this concentration of Previous treatment 0.35 0.38 toceranib may be considered for the treatment of VEGF-driven Surgery alone 4 Surgery and carboplatin 10 metastatic tumor (33). Surgery, carboplatin, and In the setting of metastatic canine OSA, a retrospective metronomic treatment 3 multi-institutional study showed that 11/23 (47.8%) dogs Others 3 Tumor location 0.31 0.44 experienced clinical benefit including 1 partial response and Thoracic limbs 11 10 stable disease (no progression nor new lesion for at least Pelvic limbs 9 10 wk) with toceranib treatment (13). The reported median duration of treatment for the 11 dogs that experienced clinical benefit was 24 wk, which suggested potential use of toceranib dose of 2.5 mg/kg BW, PO, 3 times per week on Monday, for the treatment of macroscopic metastatic OSA. In a recent Wednesday, and Friday (MWF). Monthly 3-view thoracic randomized prospective clinical trial (12), however, the addi- radiographs were recommended to monitor tumor response. tion of toceranib to metronomic piroxicam/cyclophosphamide The primary endpoint of toceranib treatment was the time therapy following limb amputation and adjuvant carboplatin when evidence of disease progression was observed. All dogs had chemotherapy failed to show any improvement in the outcome baseline complete blood (cell) counts (CBC) and biochemistry of dogs with appendicular OSA. This study raised a question before toceranib treatment. To monitor for toxicity during regarding the benefit of toceranib treatment for microscopic toceranib treatment, CBCs were performed every 2 wk for the metastatic OSA. The efficacy of toceranib treatment, however, first month and repeated monthly; serial biochemistry panels is difficult to evaluate solely based on these studies because were performed monthly. standardization of treatment and recheck protocols were lacking Medical records review. Information recorded included in the retrospective study while most dogs were removed from signalment, thoracic radiography results, histology or cytology the prospective study once metastasis was present. results, primary tumor location, date of diagnosis of pulmonary Conclusive data to support the use of toceranib for metastatic metastasis, number and size (recorded as longest length) of pul- canine OSA has not been established. Therefore, the purpose monary metastases, previous treatments, dose and duration of of the current study was to evaluate the efficacy of toceranib toceranib treatment, and adverse effects. Follow-up information treatment for macroscopic pulmonary metastasis of appendicular was documented including monitoring pulmonary metastases OSA in dogs. A secondary goal was to identify prognostic factors via radiographs to determine progression-free survival (PFS) in this subset of the population. and overall survival (OS) (Table 1). Progression-free survival was defined as the time from the first toceranib treatment to Materials and methods progression of the disease or death from any cause. Overall sur- Case selection vival was defined as the time from the first toceranib treatment Electronic and hard copy medical records from the Ontario to death from any cause. Progression-free survival and OS were Veterinary College from October 2011 to June 2016 were obtained from the medical records or by contacting the referring reviewed. Dogs that were cytologically or histologically diag- veterinarians and/or the owners. Toxicities were graded accord- nosed with appendicular OSA, had pulmonary metastasis ing to the Veterinary Cooperative Oncology Group-Common confirmed by thoracic radiographs, and received toceranib Terminology Criteria for Adverse Events criteria (34). treatment were included. For response evaluation, only dogs Response to therapy. Modified response evaluation criteria with follow-up thoracic radiographs were included. in solid tumor (RECIST) was used for assessment of response to toceranib treatment (35). Response to therapy was defined Treatment protocol as: complete response (CR), resolution of all target and non- Following confirmation of pulmonary nodules by 3-view tho- target lesions and no new lesions; partial response (PR), at least racic radiographs, dogs were prescribed toceranib at a target 30% decrease in the longest diameter of the target lesions, no

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1.0 1.0 x Censored

0.8 0.8

0.6 0.6 ARTICLE

0.4 0.4 Cum survival Cum survival

0.2 0.2

0.0 0.0

0 50 100 150 200 250 0 100 200 300 400 500 Progression free survival (days) Overall survival (days)

Figure 1. Kaplan-Meier progression free survival (PFS) curve for Figure 2. Kaplan-Meier overall survival (OS) curve for dogs with dogs with macroscopic pulmonary metastasis of appendicular macroscopic pulmonary metastasis of appendicular OSA treated OSA treated with toceranib (n = 20). The median PFS was with toceranib (n = 20). One dog alive at the end of study was 36 days. censored (1 mark). The median OS was 90 days.

progression of non-target lesions and no new lesions; stable of 14 breeds including Rottweiler (n = 3), Labrador retriever disease (SD), decrease in the longest diameter of target lesions (n = 2), doberman pinscher (n = 2), golden retriever (n = 2), of , 30% or increase of target lesions , 20%, no progression mixed-breed (n = 2), and 1 each of American pit bull terrier, of non-target lesions and no new lesions for at least 10 wk; Australian shepherd, border collie, cocker spaniel, Scottish deer- or progressive disease (PD), . 20% increase in the longest hound, Dogue de Bordeaux, English bulldog, great Dane, and diameter of target lesions, progression of non-target lesions and mastiff. The median body weight was 31.6 kg (range: 13.4 to identification of new lesions. Clinical benefit (CB) was defined 61.2 kg), and the median age was 6.8 y (range: 1.7 to 13.2 y). as CR, PR, or SD. There were 11 spayed females, 1 intact female, and 8 castrated Statistical analysis. Kaplan-Meier survival curves were gen- males. The primary tumor was located in the humerus (n = 5), erated for median PFS and OS. All 20 dogs were included in tibia (n = 5), femur (n = 4), radius (n = 2), scapula (n = 2), ulna PFS analysis while 1 dog still alive at the end of the study was (n = 1), and radius/ulna (n = 1). censored from OS analysis. A Cox proportional hazards univari- The median dose and duration of toceranib were 2.52 mg/kg ate analysis was used on variables including signalment, body BW (range: 2.12 to 2.72 mg/kg) and 60 d (range: 17 to 231 d), weight, primary tumor location, previous treatment, dose and respectively. During the course of treatment, all dogs received duration of toceranib treatment, longest length and number of toceranib 3 times/week on MWF. Nineteen of the 20 dogs pulmonary nodules, and concurrent metronomic treatment. In received other treatments prior to toceranib treatment: surgery order to evaluate the impact of previous treatments, dogs were (limb amputation, n = 15; scapulectomy, n = 1; acetabulectomy, assigned to 1 of 4 treatment groups for analysis; surgery alone n = 1; ulnar ostectomy, n = 1), chemotherapy (carboplatin, (n = 4), surgery and carboplatin (n = 10), surgery and carbo- n = 13; doxorubicin, n = 1; metronomic cyclophosphamide, platin followed by metronomic treatment (n = 3), and others n = 3), and/or radiation therapy (n = 2). Of the 13 dogs receiving [radiation (n = 1); surgery and doxorubicin (n = 1); no therapy carboplatin, 3 dogs also received metronomic cyclophosphamide (n = 1)]. For further analysis of the number of initial pulmonary following carboplatin before starting the toceranib treatment. nodules, dogs were assigned to one of 3 groups based on the Six dogs were treated with toceranib and concurrent metronomic number of pulmonary nodules (low , 3, intermediate . 3 to treatments (chlorambucil, n = 2; cyclophosphamide, n = 4), while # 5, high . 5). For all analyses, a P-value , 0.05 was deemed 2 dogs received concurrent radiation therapy. Two dogs received significant. Statistical software (IBM SPSS Statistics version follow-up chemotherapy after the toceranib treatment was dis- 23 software for Windows; SPSS, Chicago, Illinois, USA) was continued (doxorubicin, n = 1; metronomic cyclophosphamide, used for statistical analysis. n = 1). Other medications used include pamidronate (n = 1 before toceranib; n = 4 with toceranib), non-steroidal anti-inflammatory Results drugs (n = 6 with toceranib), and prednisone (n = 2 with tocera- A total of 29 dogs received toceranib treatment for macroscopic nib; n = 4 after toceranib). pulmonary metastasis of appendicular OSA during the study The most common adverse effects (AE) were gastrointesti- period. Nine dogs were excluded due to absence of follow-up nal (GI), consisting of grade 3 GI AE in 3 dogs and grade 1 thoracic radiographs (n = 6) or non-confirmation of diagnosis by or 2 GI AE in 4 dogs. Three dogs had changes in the dose cytology or histology (n = 3). The 20 remaining dogs consisted of toceranib during the treatment; the dose of toceranib was

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Table 2. Hazard ratios (HRs) and confidence intervals (CI) of the Table 3. Hazard ratios (HRs) and confidence intervals (CI) of the variables that have significant impact on progression free survival variables that have significant impact on overall survival (OS) in (PFS) in Cox regression analysis Cox regression analysis 95% Cl 95% Cl Variables HR Lower Upper P-value Variables HR Lower Upper P-value Body weight 0.951 0.915 0.990 0.01 Duration of toceranib treatment 0.985 0.973 0.998 0.03 Longest length of initial pulmonary 1.041 1.008 1.075 0.01 Longest length of initial pulmonary 1.087 1.014 1.164 0.02 nodules nodules

ARTICLE reduced in 2 dogs (2.61 to 2.24 mg/kg BW and 2.61 mg/kg vival (. 2-year survival) remains intractably low at 20% in BW to 2.23 mg/kg BW) with grade 3 GI AE; the dose was spite of the adjuvant use of diverse approaches of chemotherapy increased in 1 dog (2.29 mg/kg BW to 2.72 mg/kg BW) due (36,37). Furthermore, most OSA patients die of pulmonary to the progression of pulmonary metastasis. Grade 1 alanine metastasis, and chemotherapy has not been proven effective to aminotransferase (ALT) and alkaline phosphatase (ALP) eleva- delay progression of macroscopic metastases after their devel- tions were found in 1 and 5 dogs, respectively. Only 1 dog had opment. Ogilvie et al (3) evaluated single agent chemotherapy grade 3 neutropenia during the course of toceranib treatment. for macroscopic metastatic OSA in 45 dogs and found 1 dog However, no clinical signs were associated with the neutropenia achieved partial response for 21 d and the remaining dogs had and the neutrophil count returned to normal in 2 wk without a median survival time of 61 d without an objective response any supportive treatment or delay of toceranib treatment. This (3). They concluded that the chemotherapy agents used in the dog received a 2.6 mg/kg BW dose of toceranib for 27 d. The study were ineffective for the treatment of measurable meta- reasons for discontinuation of toceranib were GI AEs (n = 7), static OSA in the dog. A similar poor prognosis was shown in death (n = 6), progression of pulmonary metastasis (n = 4), or retrospective studies by Boston et al (4) and Batschinski et al (5) lameness (n = 3). in which median survival time was reported as 76 d and 95 d, All dogs had pulmonary metastasis confirmed by thoracic respectively. The latter studies corroborated the lack of efficacy radiographs that were reviewed by a radiologist. The median of conventional chemotherapy against macroscopic pulmonary time from the diagnosis of OSA to development of pulmonary metastasis of OSA. These outcomes are comparable with the metastasis was 113 d (range: 0 to 691 d). Three dogs had pul- outcome herein, which suggests that macroscopic metastatic monary metastasis at the time of OSA diagnosis. The median OSA is resistant to chemotherapy, including the kinase inhibitor longest length of pulmonary nodules was 12 mm (range: 5 to toceranib in this study. 99 mm). Based on the number of initial pulmonary nodules on The poor outcome of the present study with 36 d of PFS radiographs, there were 9, 6, and 5 dogs in low, intermediate, contrasts with the previous study by London et al (13), which and high groups, respectively. had a CB rate of 47.8% and a median PFS of 24 wk in the dogs Four dogs had postmortem evaluation, which confirmed the that experienced CB. A possible explanation for this difference presence of metastatic OSA in the lungs. Three of these dogs might be more frequent toceranib treatment in the previous also had metastasis in multiple organs including kidney, pleura, study. In that study, 10/23 dogs received the drug every other pericardium, myocardium, small intestine, subcutaneous tissue, day, whereas all dogs in the present study were treated on MWF and skeletal muscle. schedule. Another potential difference between the 2 stud- The median PFS and OS for toceranib treatment were 36 d ies could be the schedule of the follow-up radiographs. The (range: 17 to 231 d) and 90 d (range: 17 to 433 d), respectively schedule of rechecks was not clearly defined in the previous (Figures 1 and 2). One dog still alive at the time of analysis was study and unlikely standardized due to the nature of a multi- censored from the OS analysis (day 380). There was 1 PR and institutional retrospective study. Thus, it is possible that less 1 SD resulting in a clinical benefit (CB) rate of 10% (2/20). The frequent rechecks with thoracic radiographs might delay the duration of CB in the 2 dogs was 56 d for the PR and 288 d detection of progression, which might have falsely increased for the SD. Of the prognostic factors evaluated (Table 1), the the median PFS. It is also important to note that the previous longest length of initial pulmonary nodules had a significant study solicited the cases by the e-mail-based forum (American impact on both PFS (P = 0.01, HR = 1.041) and OS (P = 0.02, College of Veterinary Internal Medicine Oncology Listserve). HR = 1.087) (Tables 2, 3). Body weight had a significant impact This method might have caused a selection bias in the process on PFS (P = 0.01, HR = 0.951) (Table 2). The duration of by highlighting the minority of cases that had good responses toceranib treatment had a significant impact on OS (P = 0.03, to the toceranib treatment. HR = 0.985) (Table 3). No statistical significance was found in The longest length of initial pulmonary nodules was a prog- the other analyzed variables. nostic factor identified for both PFS (P = 0.01, HR = 1.041) and OS (P = 0.02, HR = 1.087). These results could be explained Discussion by the fact that the longest length of the pulmonary nodules The improvement in median survival times of dogs with appen- might correlate with tumor burden in lungs and suggest a more dicular OSA by the use of adjuvant chemotherapy has demon- advanced stage of metastasis. Another factor that may affect strated that this is a chemosensitive disease in its early stages. tumor burden in the lungs is the number of pulmonary nodules, However, the proportion of dogs cured or with long-term sur- as a heavy tumor burden can be present if the number of small

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nodules is high. However, the number of initial pulmonary in 7 dogs (7/40) and grade 1 and grade 3 ALP elevations were nodules did not have an impact on either PFS or OS in the pres- observed in 10 dogs (10/40) and 1 dog (1/40), respectively (33). ent study, which suggests that the longest length of pulmonary No dogs in that study were reported to have developed clini- nodules might be a better representation of the overall tumor cal evidence of hepatotoxicity. Three dogs had their toceranib burden in the lungs. However, the lack of correlation between treatment discontinued due to progression or new development the number of pulmonary nodules and the outcome of this of lameness. The lameness might be associated with an adverse

study might be the result of type II error due to the small sample effect of the toceranib treatment as lameness has been reported ARTICLE size. The magnitude of the pulmonary metastatic burden in the to be an adverse effect in previous studies (30,31,33). However, dogs from the 2 studies could also have affected the results. This the lameness in 2 of the dogs was suspected to be due to the hypothesis could not be verified at this time since the informa- progression of OSA because the lameness occurred in the same tion used to compare the magnitude of pulmonary metastasis, limb that had been previously diagnosed with primary OSA. such as measurements and numbers of pulmonary nodules, was The other dog might have had the lameness as a true adverse absent in the previous study. However, given that the addition effect from the toceranib treatment, but other possibilities such of toceranib to metronomic chemotherapy/pir­ oxicam adjuvant as metastasis cannot be ruled out as no further evaluation was treatment in a previous study did not improve the outcome in performed at that time. microscopic metastatic OSA, it is possible that the magnitude Some limitations exist in the present study because of its of pulmonary metastatic burden might not impact the out- retrospective design with a relatively small number of patients come with toceranib treatment. In the present study, 6/20 dogs and absence of standardization of treatments. The statistical received concurrent metronomic treatments during the tocera- power for this study is weak because each group in the Cox nib treatment; however, it was not found to have a significant analysis had limited sample sizes, which increases the chance of impact in the evaluation of prognostic factors. type II error. Due to the small number of patients some valu- There were other factors affecting PFS or OS in this study. able analyses could not be performed. For example, the effects Body weight was found to impact PFS (P = 0.01, HR = 0.951). of follow-up chemotherapy could not be evaluated because only The reason for this finding is not clear. It is possible that the 2 dogs received follow-up chemotherapy after the toceranib dogs’ body condition scores (BCS) affected the toceranib treatment failed. However, positive effects of follow-up chemo- doses for each patient, as weight-based prescriptions tend to therapy are not expected given that no study has demonstrated overexpose obese patients (38). This speculation could not be chemosensitizer effects of toceranib and the general prognosis of confirmed because BCS was not consistently recorded. The this disease with conventional chemotherapy is poor. Similarly, duration of toceranib treatment also had a positive impact on the prognostic value of ALP elevation was not analyzed since OS (P = 0.03, HR = 0.985). This result should be interpreted only 2 dogs had ALP elevation before the toceranib treatment. with caution, as dogs with longer survival were likely to have The lack of complete information in this study also caused received toceranib for longer periods of time. limitations; possible adverse effects including proteinuria and The most common toxicity was GI AE (7/20, 35%), charac- hypertension might have been overlooked because urinalysis terized by inappetence, vomiting, diarrhea, or a combination of and blood pressure measurement were not routinely conducted these. However, due to the presence of systemic OSA and the during the toceranib treatment. A lack of full staging tests retrospective nature of the study, it is not possible to differenti- before toceranib treatment and a lack of antemortem biopsy ate these adverse events from signs related to disease progression or postmortem evaluation meant that some of the pulmonary although OSA is less likely the cause of the GI signs given the nodules might not have been due to OSA. Another limitation is usual metastatic pattern of OSA (39). Hematologic toxicity was that thoracic radiographs were used to measure the pulmonary rare. Grade 3 neutropenia occurred in 1 dog (1/20) and it was nodules. According to the recommendation from the RECIST resolved in 2 wk without any further supportive treatments or working group, thoracic radiograph measurement of lesions drug holidays. No other hematologic toxicities were observed. surrounded by pulmonary parenchyma is acceptable, but not This AE profile of common GI and rare hematologic toxicities preferable as the measurement represents a summation of den- is consistent with the previous report of the study evaluating sities. In conjunction with poor identification of new lesions the efficacy of toceranib in dogs with solid malignancies. In within the thorax on radiograph as compared with CT, CT is that study, GI toxicity was commonly seen (diarrhea 51.8%; a preferable modality for detection or measurement of pulmo- anorexia 35.3%; vomiting 18.8%), neutropenia was only seen nary nodules. However, availability and cost of CT scan pose in 10.6% of patients (13). This similarity in toxicity profiles limitations in use of this modality for regular staging tests and might be explained by the similar toceranib doses that were used recheck evaluations. The findings with radiographs in this study between the previous (median doses between 2.67 to 2.87 mg/kg might be practical and relevant in many clinical settings. The BW) and present studies (median dose: 2.52 mg/kg BW). other limitation was the various toceranib doses that were used Alterations in biochemical parameters were noted in 5 dogs in this study and the fact that 6/20 dogs received , 2.4 mg/kg (5/20). The most common biochemical toxicity was grade 1 BW on the MWF schedule. A previous study showed dogs dosed ALP elevation (4/20) followed by ALT elevation (1/20). The with . 2.4 mg/kg BW toceranib achieved a plasma concentra- clinical relevance of these abnormalities was not investigated. tion predicted to produce effective target inhibition (33). Given Transient liver enzyme elevations are consistent with the results the study result, it is possible that the 6 dogs might not have of a study in which transient grade 1 ALT elevation was noted achieved sufficient plasma concentrations to show efficacy of

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the treatment. This limitation could be addressed by setting 17. Carmeliet P, Jain RK. Molecular mechanisms and clinical applications up a minimum required dose of toceranib of 2.4 mg/kg BW of angiogenesis. Nature 2011;473:298–307. 18. Asahara T. Isolation of putative progenitor endothelial cells for angio- in future studies. genesis. Science 1997;275(5302):964–966. In conclusion, the outcome of dogs with pulmonary metas- 19. Lyden D, Hattori K, Dias S, et al. Impaired recruitment of bone- tasis from appendicular OSA treated with toceranib was similar marrow−derived endothelial and hematopoietic precursor cells blocks tumor angiogenesis and growth. Nat Med 2001;7:1194–1201. to that of dogs treated with conventional chemotherapy, with 20. Stoelting S, Trefzer T, Kisro J, Steinke A, Wagner T, Peters SO. short response duration and low CB rate. The prognosis for dogs Low-dose oral metronomic chemotherapy prevents mobilization of with metastatic OSA was guarded in the present study with a endothelial progenitor cells into the blood of cancer patients. In Vivo 2008;22:831–836. median OS 90 d. This result suggests that single agent toceranib 21. Willett CG, Boucher Y, di Tomaso E, et al. Direct evidence that the

ARTICLE treatment might not be an effective treatment for macroscopic VEGF-specific antibody bevacizumab has antivascular effects in human pulmonary metastasis of appendicular OSA. The longest length rectal cancer. Nat Med 2004;10:145–147. 22. Kumar RMR, Arlt MJ, Kuzmanov A, Born W, Fuchs B. Sunitinib of initial pulmonary nodules was a prognostic factor identified malate (SU-11248) reduces tumour burden and lung metastasis in an for both PFS and MST. Prospective studies using standardized intratibial human xenograft osteosarcoma mouse model. Am J Cancer criteria are warranted to evaluate the efficacy of toceranib for Res 2015;5:2156–2168. 23. Mei J, Zhu X, Wang Z. VEGFR, RET, and RAF/MEK/ERK pathway the treatment of macroscopic pulmonary metastasis in dogs with take part in the inhibition of osteosarcoma MG63 cells with sorafenib appendicular OSA. CVJ treatment. Cell Biochem Biophys 2014;69:151–156. 24. Kaya M, Wada T, Akatsuka T, et al. 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1064 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Evaluation of the effect of umbilical hernias on play behaviors in growing pigs

Melissa Atkinson, Rocio Amezcua, Josepha DeLay, Tina Widowski, Robert Friendship

Abstract — Umbilical hernias (UH) are common in pigs and are an animal welfare concern. This study used an assessment of play behavior to evaluate the welfare of pigs with UH. Twenty-one grower pigs with UH and 17 without hernias (WUH) were assigned to 16 playing groups (PG) of 2 or 3 pigs (with at least 1 UH pig per PG). The time each animal was engaged in any of the defined playing behaviors for locomotor/social or toy play behaviors was recorded. Mixed Poisson or negative binomial and linear models were used to determine the effect of UH and day of session, accounting for the cluster of pigs within groups, on the frequency of each play behavior, and playing times. Pigs with UH had the same frequency of most play behaviors and playing times as pigs without hernias. There was no indication that the presence of UH-affected play behavior or performance in pigs.

Résumé — Évaluation de l’effet des hernies ombilicales sur les comportements de jeu chez les porcs en croissance. Les hernies ombilicales (HO) sont communes chez les porcs et elles représentent une préoccupation liée au bien-être animal. Cette étude a utilisé une évaluation du comportement de jeu afin d’évaluer le bien-être des porcs ayant une HO. Vingt-et-un porcs en croissance ayant une HO et 17 sans hernies (SHO) ont été assignés à 16 groupes de jeu (GJ) de 2 ou 3 porcs (avec au moins 1 porc HO par GJ). Le temps consacré par chaque animal pour participer à l’un des comportements de jeu définis pour les comportements de jeu de locomotion/social ou de jouet a été consigné. Des modèles mixtes de Poisson ou binomiaux et linéaires négatifs ont été utilisés pour déterminer l’effet de HO et le jour de la séance, en tenant compte des regroupements de porcs au sein des groupes, de la fréquence de chaque comportement de jeu et des moments de jeu. Les porcs avec une HO avait la même fréquence pour la plupart des comportements de jeu et des moments de jeu que les porcs SHO. Il n’y avait aucune indication que la présence d’une HO affectait le comportement de jeu ou la performance des porcs. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1065–1072

Introduction umbilical hernia is detected early, the pig is typically culled or sold at a low price (6,7), but umbilical hernias are often not hernia is an abnormal protrusion of an organ or tissue detected until the pig is close to market weight. through a defect or natural opening in skin or muscle (1). A Raising pigs with UH may pose a welfare problem. Studies in In pigs, umbilical and inguinal hernias are common, affecting humans and calves conclude that hernias cause abdominal pain anywhere from 1.7% to 6.7% of the animals in a herd (2–5). and discomfort, particularly when complications such as stran- Inguinal hernias are typically identified in the first week of life gulation, incarcerations, nerve compression, and/or infection are at the time of castration and affected pigs are generally culled present (1). Large hernias may affect an animal’s mobility and early, whereas pigs with umbilical hernias (UH) tend to enter growth performance and cause an increased risk of mortality the grower-finisher barn before the umbilical outpouchings are (5,6). Canadian regulations prohibit the transportation of pigs noticed (5). Umbilical hernias result in economic loss because with UH if the hernia impedes movement, touches the ground they can affect pig performance and market value (2,6,7). If an when the animal stands naturally, or has any open wound or infection (8,9). Certain abattoirs may not accept herniated Department of Population Medicine (Atkinson, Amezcua, pigs for processing because special handling and precautions Friendship), Animal Health Laboratory (DeLay), and are required (6). Department of Animal Bioscience (Widowski), University of Although the economic aspect of hernias has been widely Guelph, Guelph, Ontario N1G 2W1. reported in the literature, there are few publications on how the Address all correspondence to Dr. Robert Friendship; e-mail: welfare of the animals is affected by the presence of moderate- [email protected] sized umbilical hernias. However, Schild et al (10,11) recently Use of this article is limited to a single copy for personal study. examined the behavior of pigs during the day of slaughter and Anyone interested in obtaining reprints should contact the concluded that there was no significant difference between CVMA office ([email protected]) for additional pigs with umbilical outpouchings and controls for any of the copies or permission to use this material elsewhere. measures considered relevant for fitness for transport. They did,

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however, find behavioral differences during the 6 h pre-transport solid cement flooring. No bedding was used, there was 1 water holding that suggested pigs with hernias may be less fit for mix- nipple per pen, and feed was provided ad libitum. Umbilical ing and housing in the crowded and barren environments of hernias were measured at the beginning and end of the trial. the holding pens. These studies did not determine the welfare The circumference (measured at the midpoint between the base of pigs with hernias under the less challenging environment of and apex), depth (from the base of the hernia to the tip/apex a grower-finisher barn. There are various methods available to of the hernia), and consistency/firmness of the hernias were measure animal welfare and recently play behavior has been recorded. Firmness was determined by palpation and the umbili- proposed as a potential technique for this purpose (12–15). cal outpouchings were categorized as either “soft” if the hernia Animals play only if they are healthy, and not stressed (12). The was reducible or “hard” if the contents of the pouch could not

ARTICLE main types of play evaluated in animal studies are locomotor- be readily determined by palpation and the hernia could not be rotational (alone or in company), social play (involving 2 or manually reduced. more animals), object play, and vocalization (12–16). The occurrence of a jump, spring, hop, sprint, scamper, trot, head- Experimental design tossing or lever, are play markers defined as locomotor and social Pigs were assigned to 16 play groups (PGs) in order to assess play in swine (15,17). The provision of enrichment objects, like locomotor play. The pens housing 3 pigs were tested as a group plastic dog toys or hanging rope, can increase both social and and pens with 4 pigs were divided into 2 PGs with 1 pig with solitary play, and the play behavior can be used as an indicator UH and 1 pig WUH. It was determined that PGs with 3 pigs of welfare (17). In addition, pigs produce various vocalizations: were able to be monitored by video, whereas PGs of 4 proved grunts, squeals, and barks that can vary in duration, frequency, to be too difficult to keep track of each individual animal’s and amplitude (18), which may show emotional states in pigs. behavior. Moreover, testing in small groups was preferred over Juvenile pigs seem to bark at a broad range of stimuli such as individual testing, because social interaction encourages the the sudden appearance of humans and non-threatening stimuli, display of play behavior (14). Pigs were tested with the same but in particular pigs utter barks within playing bouts (18,19). partners every time to avoid aggression during the testing time. Although tail wagging has not been reported as a play marker Two different experiments using the same PGs were run on or welfare indicator in pigs, these behaviors commonly occur different days of the week to determine the incentive/motivation during locomotor play in this species (20). to exhibit specific locomotor and social play behaviors or playing Play behavior may be a good indicator of the welfare of pigs, behavior with a toy. In each experiment, pigs were videotaped and may be useful in assessing whether pigs with hernias are using a HD camcorder (CX405 Handyman; Sony, Tokyo, experiencing pain. The objective of this study was to determine Japan). In order to easily identify the pigs in the videos, pigs whether umbilical hernias reduce play behavior in pigs. within the playing groups were sprayed on their backs with dif- ferent colors. One pig was identified with a blue marker; 1 pen Materials and methods mate was identified with a red marker, and in the case of PGs This study was approved by the University of Guelph Animal with 3 pigs, the third pig was not marked. The observer evaluat- Care Committee following the guidelines of the Canadian ing the videos was not blinded to the status of the hernias due Council on Animal Care. to the obvious outpouched bellies of most of the herniated pigs.

Animals and housing Locomotor play trial A total of 21 pigs with UH (UH pigs) from 1 commercial farm In this experiment, each PG was videotaped to determine the and 17 healthy pigs without umbilical hernias (WUH pigs) from frequency of locomotor behaviors (scamper, pivot, head-toss, the Arkell Swine Research Station at the University of Guelph flop, and paw); social play behaviors (lever and pushover), were transported to the Ponsonby General Animal Facility, vocalization (barks), and tail wagging in one 7-minute session University of Guelph. The pigs with UH were chosen on the per wk for 3 wk. Table 1a includes the definitions of each of the basis that they were all the animals detected with umbilical out- play markers evaluated in the locomotor play trial. Two video pouchings in a 2000-head grower-finisher barn that had been cameras were used in this experiment. An overhead camera was filled 1 mo previously with feeder pigs. Although the owner of centrally located in the play area at approximately 4 m from the the commercial farm was willing to sell the pigs with UH, he ground. The other camera was placed at one end of the play area would not sell pigs WUH. Therefore, these control pigs were at a height of 0.75 m to achieve a lateral view of the pigs. Time obtained from a second source and matched by weight with of recordings was initiated when the door was closed behind the the UH pigs. Because pigs were from 2 sources the animals last pig entering the playing area. were allowed to acclimatize for 3 wk before the play study was Prior to the start of the trial, the playing groups were each undertaken. At the time of arrival, pigs were ear tagged and introduced to the play area. This was done on 3 separate occa- weighed. The mean weight at entry for UH pigs was 53.0 kg sions and each time cookies were left on the ground in the play [6 standard deviation (SD) = 13.3] kg and for WUH pigs was area as a reward. The purpose of this pre-trial exposure to the 54.3 kg (6 SD) = 11.1 kg. Pigs of similar size and weights play area was to familiarize the pigs with the trial conditions, were assigned to 1 of 11 pens. Five pens each housed 3 pigs and so the behaviors would not be affected by the stress of a novel 6 pens each housed 4 pigs (all pens had at least 1 WUH pig environment. The play area was rectangular, about 5 m wide and and 1 UH pig). Pens were all identical, measuring 3.2 m2 with 10 m long. The flooring was cement with a roughened surfaced

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Table 1. Ethograms for evaluating playing criteria a — Ethogram used to evaluate playing criteria in “locomotor” play trial (13–16) Playing criteria Locomotor play Scamper Sequence of at least 2 forward hops in rapid succession, usually accompanied by ear flapping ARTICLE Pivot Jump on spot in which body is rotated rapidly at least 90° in horizontal plane Head toss Exaggerated lateral displacements of the head and neck in the horizontal plane, involving at least 1 full movement to each side Flop A rapid drop from an upright position to sternal or lateral recumbence (lying on belly or side). Pig appears to fall down by itself and not as a result of contact with another pig Paw A sequence of 2 or more repetitive movements of the leg(s) towards and away from the belly in the horizontal plane while lying in lateral recumbency Tail wagging Pig wagged its tail at least once during the evaluation time: Yes/No Social play Lever S nout lifts opponent so that at least 2 feet are raised off the floor Push-over Pushes another pig with head and shoulder in an apparently playful manner, leading the recipient to lose balance and stumble or fall Play vocalization Bark Bark-like sound at non-threatening stimuli Play time Time when locomotor and social play occurred b — Ethogram used to evaluate playing criteria in “object” play trial (13–16) Playing criteria Shake object Perform vigorous lateral movements of head and neck while holding object or material which protrudes from mouth, (e.g., straw, wood). Includes shaking and tugging at loose end of fixed object (e.g., baler twine) Bite object Attempt to gnaw or bite the object in any way (including nibbling on the object’s edge) Play time Time when object play and social play occurred designed to minimize the risk of livestock slipping but easy to length and  4 cm in circumference, a soft cotton knotted rope clean. The play area was adjacent to the room housing the pigs designed for large dog breeds) in one 5-minute session per wk on trial. The play area did not have provision for feed or water. for 2 wk. The toy was suspended by a cotton rope attached It was well lit with a high ceiling, solid walls on 2 sides, and to the toy’s center so that it hung somewhat horizontal to the spindle penning along the other 2 sides. ground and was lowered into the pen using a shepherd’s crook In this experiment, 1 observer evaluated the videos of all PGs until it was within easy reach of the pigs. We chose a knotted of days 1, 2, and 3. In order to evaluate the agreement between rope as a toy because “pigs prefer to play with pliable objects 2 observers on the evaluation of each behavior, an additional compared to tough ones (like chains) when given the chance” observer evaluated a subset of videos: day 1 and the first 8 PGs (21). Similar to the first trial, a total of 16 PGs of 2 or 3 pigs of day 3. An ethogram (Table 1a) and recording sheets were at a time were tested. When 4 pigs were housed in 1 pen, PGs used to tally the frequency of the playing behavior of each piglet with 2 pigs were left in the home pen, the other PGs of 2 pigs (13–16). The frequency of barks was recorded by 1 person at were moved into an alternate pen until their turn to be exposed the time the pigs were in the playing area, because of the dif- to the play object, then they were moved back to their home ficulty of identifying which animal was vocalizing on the videos. pen. Prior to the trial, the rope toy was lowered into each pen Tail wagging was recorded as present or not present. Pigs were on 2 separate occasions for about 2 min each time, to allow the considered to wag their tails if they exhibited this behavior at pigs to become familiar with the toy. least once during each 7-minute session. The total time spent One video-camera held by a researcher was used to videotape playing (the time each animal was engaged in any of the defined the PGs in their home pens. The video was not started until all playing behaviors) was recorded using a cellular timer. The time the pigs were standing. The videos were watched by 1 observer. spent playing was reported in seconds. An ethogram (Table 1b) and recording sheets were used to tally/ record the frequency of bite and shake of the object by pigs Object play trial (13–16). The total time spent playing (the time each animal In the second trial, the PGs were videotaped in their home pen was engaged playing with the toy) was recorded using a cellular to determine the frequency of bite and shake of a dog toy (0.6 m timer. The time spent playing was reported in seconds.

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Tissue samples Results At the end of the trial, all pigs were slaughtered at the University A total of 38 pigs were included in the trial: 21 UH pigs and of Guelph abattoir. Hernias were excised en bloc and gross 17 WUH pigs. One WUH pig died before the trials started. examination was conducted by 1 pathologist at the Animal The median depth of the hernias at the start of the trial was Health Laboratory, University of Guelph. The size and consis- 12 cm (range: 2.5 to 19 cm). The median circumference of the tency of the hernia, hernia content, and presence or absence and hernias at the start of the trial was 37 cm (range: 11 to 57 cm). dimensions of a hernial ring were recorded. The external and At the end of the trial, the median depth was 15 cm (range: 0 to transversely sectioned appearance of each sample was recorded 25 cm) and the median circumference of the hernias was 45 cm by digital photography. (range: 0 to 64 cm). The mean circumference and longitudinal ARTICLE diameter of the hernias within each consistency category at the Statistical analysis start and end of the trial are summarized in Table 2. At the start STATA 13 (Stata Corp, College Station, Texas, USA) was used of the trial, the depth and circumference of soft hernias were for statistical analyses of the data. Agreement of the subset of significantly less than for the medium/firm and hard hernias videos that were watched by 2 observers in the locomotor trial (P , 0.01) (Table 2). A total of 8 (38.1%) pigs with umbilical was analyzed using a Kappa coefficient. Normality of all data hernias were classified as having soft hernias, 8 (38.1%) were was analyzed by the Shapiro-Wilk test. The simple association considered to have medium/firm hernias and 5 (23.8%) were between pigs with UH and WUH with the frequency of loco- considered to have a hard/firm hernia. At the end of the trial, motor, social, vocal, and object play behaviors was determined there were 10 pigs (47.6%) with hard/firm and 11 pigs (52.4%) using a Wilcoxon rank-sum test. The simple association of the with soft and reducible hernias. The depth and circumference size of PGs with the locomotor, social, vocal, and object play of the hernias were significantly different between soft and hard behaviors was determined using a Wilcoxon rank-sum test. The hernias at the end of the trial (P , 0.05) (Table 2). Only 1 pig simple association between UH pigs and WUH pigs with weight with a hernia considered soft at the beginning of the trial had a at the beginning and the end of the trial and with average daily hard/firm hernia at the end of the trial, the rest of the pigs with gain was determined using Student’s t-test. The simple associa- soft hernias (7) had a soft reducible hernia at the end of the tion of the size of PGs with playing times was determine using trial. One of these pigs had a completely reduced hernia at the Student’s t-test. The simple association of the hernia depth, end of the trial (confirmed by postmortem examination). This circumference, and consistency at the beginning and end of the pig had the lowest values for the circumference and depth of trial was determined using a Student’s t-test or 1-way analysis the hernia at the start of the trial. A total of 4 pigs (50%) with of variance (ANOVA). Results were expressed as mean 6 SD. medium firm hernias had a soft reducible hernia at the end of Pair-wise correlation among the sizes of hernias and weight of the trial and 4 (50%) had a hard/firm hernia at the end of the pigs and their significance were evaluated. The locomotor, social, trial. All 5 pigs with hard hernias at the start of the trial had firm vocal, and object play behaviors were summed. Spearman’s cor- non-reducible hernias at the end of the trial. Initial and final relation coefficients of the locomotor, social, vocal, and object circumference and depth of the hernias were all positively cor- play markers and their significance were also determined. The related, ranging from r = 0.61 to r = 0.88 (P , 0.001; df = 20). simple association between UH pigs and WUH pigs with tail However, the circumference and depth of the hernias were not wagging were determined using a Chi-square test. The simple significantly correlated with the weights of the pigs. association of tail wagging with play time was determined using a Student’s t-test. Agreement among observers General linear models with a log link for negative binomial Less than a chance agreement among observers was noted for or Poisson models were used to model the effect of the hernia the pivot (K = 20.03). Poor agreement among observers was status and day of session on locomotor, vocalization, social, or observed for scamper, head toss and lever (K # 20). Moderate object playing behaviors. Interactions between hernia status and agreement was observed for pushover (K = 0.55) and only flops day of session were evaluated in each model. The command “irr” had a substantial agreement among observers (K = 0.70). For was included in the models to express the results as incidence analysis, only the data of the observer who watched all videos rate ratios. The use of a negative binomial model, as opposed were used. to a Poisson model, was based on the statistical significance of the over-dispersion term, alpha. A linear mixed model was built Locomotor and the object play behavior to determine the association of hernia status and day of session markers with locomotor or object playing times. A mixed logistic regres- The means (6 SD) of the locomotor, social, and vocalization sion model was used to determine the effect of hernia status, behaviors and object play behaviors (bite and shake) between day of session and play-time on tail wagging. The random effect UH and WUH pigs are summarized in Table 4, using the num- portion of the models was built to account for clustering of ber of times that a specific activity was observed in a 7-minute pig within playing groups. The variance partition coefficients play session as the unit of measure. The most frequent locomo- (VPCs) were calculated from the random portion of the locomo- tor behavior was scamper, followed by pivot and barking. Flop, tor and object playing time mixed linear models to determine lever, and pushover were less frequent. Lever and pushover were the percentage of variance explained by a higher level clustering. summed and considered as social behaviors. The paw playing

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Table 2. Mean (6 SD) depth and circumference (cm) of soft, medium, and hard hernias and their consistency and reducibility at the beginning and end of the trial Consistency of hernias at the Consistency of beginning of Beginning Beginning hernias at the End the trial deptha circumferenceb end of the trial End depth circumference Soft (n = 8) 7.62 (3.03)c 27.87 (7.29)c Soft (reducible) 12.63 (5.73) 31.81 (15.19) (n = 11) ARTICLE Medium firmness 14.12 (3.08) 43.5 (6.34) — — — (n = 8) Hard (n = 5) 13.8 (3.83) 43.6 (8.79) Hard/Firm 19 (5.59) 51.1 (11.22) (n = 10) P-value , 0.01 , 0.001 , 0.05 , 0.01

SD — Standard deviation. a Depth in cm, from the base to the tip of the hernia. b Circumference: diameter in cm of middle point of the hernia. c Significant difference.

behavior was not observed in any of the pigs during the 3 ses- pigs with UH compared to pigs WUH. The rates of scamper sions in the play area. In the simple associations, pigs with UH were less frequent in session 3 (IRR = 0.83, 95% CI = 0.69 to showed more pivot behavior (P = 0.001) than pigs WUH. Head 0.99, P , 0.05) than session 1. The rates of head toss were sig- toss tended to be more frequent among UH pigs than WUH nificantly less frequent in session 2 (IRR = 0.2, 95% CI = 0.08 pigs (P = 0.1). No significant differences were observed in the to 0.48, P , 0.001) than session 1. The rate of barks increased frequency of scamper, social behaviors, flop, barks, and tail by session IRR = 1.37, 95% CI = 0.90 to 2.1 and 2.12, 95% wagging among UH and WUH pigs. In the object trial, biting CI = 1.4 to 3.1 for sessions 2 and 3, respectively (P . 0.05 was more frequent than shaking (Table 3). Tail wagging was sig- and P , 0.001) compared to session 1. Shake and bite of the nificantly associated with play time. Pigs that wagged their tails object did not differ between pigs with UH and pigs WUH. played for a longer time (27 s, 6 SD = 15.7 s) compared to pigs Shake of the toy increased significantly by session 2 (IRR = that did not wag their tail (18 s, SD = 13.2 s) (P , 0.01). No 2.7, 95% CI = 1.8 to 3.9, P , 0.001) compared to session 1. significant differences were observed for bite and shake of the The frequency of tail wagging was not significantly different toy between UH and WUH pigs (Table 3). The size of playing between pigs and days but pigs that wagged their tails played groups was not associated with any of the locomotor or object 8.6 s (95% CI = 8 to 8.8 s) more than pigs that did not wag play behaviors or playing times (P . 0.05). their tails (P , 0.05). Scamper was positively correlated with pivot, flop, and social The mean playing time in the locomotor play trial for pigs behaviors (r = 0.67, P # 0.001; r = 0.52, P , 0.001; r = 0.30, WUH was 20.6 s (6 SD = 14.0 s) and for the pigs with UH P = 0.06, respectively, df = 36). Pivot tended to be correlated was 26.2 s (6 SD = 16.2 s) (P = 0.06). The mean playing time with social behaviors (r = 0.30, P = 0.06, df = 36). Push-over was with the toy for pigs WUH was 87.5 s (6 SD = 56.7 s) and correlated with bite and shake (r = 0.37, P , 0.05 and r = 0.35, for the pigs with UH was 102.1 s (6 SD = 66.6 s) (P . 0.05). P , 0.05, respectively, df = 36). Bite and shake were positively The mixed linear models showed no difference in playing times correlated with each other (r = 0.66, P , 0.001, df = 36). between pigs with UH and pigs WUH in both the locomotor Barks were correlated with scamper (r = 0.61, P = 0.001), and object trial; however, playing time significantly decreased pivot (r = 0.32, P , 0.05), social (r = 0.31, P = 0.05) and flops by session compared to session 1 for both the locomotor and (r = 0.43, P , 0.01) (df = 36). object play trial (P , 0.001) (Table 4). The variance partition The alpha values of pivot, head toss, social, flop, and shake coefficient of the locomotor and object play-time models showed markers were small and not significant; therefore, Poisson that variation of playing time was explained mostly at the pig models were used to analyze these data. The alpha values for level (40% and 32%, respectively) and between pigs within a scamper, barks, and bites were significant; therefore, negative playing group (35.3% and 52.8%, respectively). However, some binomial models were used to analyze these playing markers. amount of variation was explained between playing groups No significant interactions were observed between days and (24.4% and 16.8% for the locomotor and object play-times, the hernia status for any of the playing behaviors. The likeli- respectively) (Table 4). hood ratio test of the head toss, flop, and social models were not significant, suggesting there was not a substantial amount Tissue samples of variation in the observations within pigs and between pigs Postmortem examination found that the content of the 12 her- within playing groups. Therefore, only Poisson models were nia sacs consisted of single or multiple thin-walled cystic struc- used to model the data. The rates of pivot [IRR = 1.6, 95% tures filled with variable amounts of serosanguineous fluid. The confidence interval (CI) = 1.1 to 2.2, P # 0.01] and head toss content of the hernia sacs from the remaining 8 pigs included (IRR = 1.8, 95% CI = 1.04 to 3.2, P , 0.05) were higher in purulent debris (abscess; n = 1 pig); both purulent debris and

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Table 3. Mean (6 SD) of the scamper, pivot, head toss, flop lever, push over, and barks behaviors evaluated during the 3-day locomotor play trial, and the bite and shake of the toy behaviors evaluated during the 2-day object play trial between pigs with umbilical hernias (n = 21) and pigs without hernias (n = 16) Locomotor play trial counting the number of specific behaviors in a 7-minute play session Object play trial Head Social Scamper Pivot toss Flop behaviors Barks Bite Shake Healthy Mean (SD) 7.27 (4.03) 3.66 (2.30) 0.35 (0.66) 0.41 (0.61) 0.56 (0.84) 3.60 (4.36) 16.78 (11.6) 1.84 (4.55)

ARTICLE Hernia Mean (SD) 8.36 (4.96) 6.19 (3.95) 0.65 (1.02) 0.36 (0.57) 0.69 (0.79) 3.28 (3.59) 19.42 (14.6) 1.66 (3.12) P-value 0.4 0.001 0.1 0.6 0.2 0.7 0.6 0.7

SD — standard deviation.

Table 4. Mixed linear models testing locomotor and object play times by hernia status and sessions of playing groups with random effects accounting for the cluster of sessions within pigs and between pigs in playing groups Locomotor play time (s) Object playing time (s) Coefficient 95% CIa P-value Coefficient 95% CIa P-value Fixed-effects parameters Hernia 5.29 21.36 to 11.95 0.11 14.6 220.6 to 49.9 0.4 Day 2 213.54 217.8 to 29.2 , 0.001 228.9 242.5 to 215.4 , 0.001 Day 3 211.6 215.9 to 27.3 , 0.001 Cons 28.9 22.71 to 35.23 , 0.001 101.7 73.3 to 130.2 , 0.001 Variance 95% CI variance VPC%e Variance 95% CI variance VPC%e Random effects parameters Play groupb 5.81 2.11 to 15.97 24.4 16.04 1.23 to 209.3 16.83 Pigc 8.40 5.28 to 13.37 35.3 49.62 34.6 to 71.22 52.08 Residuald 9.53 8.11 to 11 40 29.6 23.6 to 37.2 31.07

a Lower and upper confidence interval. b Variance between playing groups. c Variance between pigs within playing groups. d Residual variance between pig observations. e Variance partition coefficients (%).

fluid-filled cysts (n = 2 pigs); fat (n = 2 pigs); fat mixed with and end of the trial and their association with consistency and fibrous stroma (n = 2 pigs); and necrotic debris suggestive of reducibility of the hernias were analyzed. The impact of the size necrotic fat (n = 1 pig). A distinct abdominal wall defect with of hernias with growth performance of pigs was also evaluated. smooth margins was associated with the hernia sac in 15 pigs. The consistency and reducibility of the hernias was associated Bowel was not present in any of the hernia sacs at the time of with their circumferences. Soft, small (, 12 cm in depth and examination. , 35 cm of circumference) hernias were reducible, while firmer/ hard hernias (. 15 cm in depth and 37 cm of circumference) Discussion were not reducible. The size classification agrees with a study in The effect of hernias on pig welfare has not been studied widely. which the depth of the hernias was classified small (, 12 cm) Information on whether or not hernias are painful or cause to large (13 to 20 cm) (23). In our study almost 90% of the soft discomfort is needed for the development of policies and regu- hernias at the start of the trial remained small and reducible. lations. Pain and discomfort are difficult to assess in pigs but it Five soft hernias had no postmortem evidence of abdominal wall is reported that play may be an indicator of animal well-being. defects indicating that these might have been resolved umbilical Animals that are healthy and not stressed or suffering will play abscesses. However, 1 soft hernia developed into a hard hernia more than animals in pain or discomfort (14), suggesting that by the end of the study. It is important for pork producers to play could be investigated as a potential welfare indicator and be able to predict if hernias will increase in size or resolve and, also as an instrument for improving welfare (14,22). Locomotor based on this small study, it appears that there are general trends, and object play behaviors as well as vocalizations appear to be but there are also exceptions. Producers probably need to con- the most promising and convenient indicators for assessing sider culling pigs that appear to have small hernias if they are positive experiences in farm animals under commercial condi- detected at the time of filling the grower-finisher barn because tions (15). In our study, specific locomotor, social, vocal, and of the unpredictable nature of this condition. object playing markers were used to determine the impact of The size of the hernias was not associated with the weight of UH on the welfare and performance of growing pigs. Moreover, the pigs or the growth rate of the pigs. This agrees with studies the changes of the circumferences of the hernias at the start showing that differences in weight and age were not significant

1070 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY factors in the development of hernias (4). It has been suggested However, it has been reported that during periods in an animal’s that the presence of an umbilical hernia increases the risk of life when play is naturally less frequent, spontaneous, rare adult mortality, particularly if a loop of bowel becomes trapped in the play in captive species can still be an indicator of good welfare hernia sac and circulation is compromised. In the present study (15). In general, playing times in a playing area and with an there were no complications such as gut strangulation but this object were not significantly different among pigs with UH and has been reported to occur and is a welfare concern. This has pigs WUH, suggesting that the presence of an umbilical hernia been reported previously in calves (24). did not have a negative effect on playing behaviors. However, ARTICLE The assessment of play behavior in domestic pigs is lacking both locomotor and object playing times decreased by sessions. and our study is the first reporting specific locomotor, social, It has been reported that in general, pigs are thought to be vocalization, and object play behaviors among pigs with UH neophilic and tend to lose interest quickly, particularly with and pigs WUH. In agreement with another study (25), the most playing objects (28,29). frequent locomotor behaviors observed in our study were scam- The potential of play as a welfare indicator may encounter per, pivot, and barks. These play markers may be considered as some difficulties because its evaluation is somewhat subjective overt bursts of energy and therefore may be more noticeable and there is animal to animal variability (23). The poor agree- than other behaviors. Pigs that engaged in one of these activi- ment herein among observers scoring certain locomotor play ties were also likely to express other behaviors indicative of play. behaviors supports this concern but, there was strong agreement Correlations were noted between many of the activities, for in scoring other behaviors such as “flop.” It is possible that the example, scamper was associated with pivot, flop, and social variability among scorers can be overcome by implementing behaviors. Scamper and barks were not significantly different good training practices and establishing firm criteria before among pigs with UH and pigs WUH. Scamper is a body activity studies that use play as a welfare indicator. In the present more frequent in pigs between the ages of 2 and 6 wk (16,25) study playing times at the pig level showed considerable vari- and appears to be stimulated by sudden changes and novelty. An ability and likewise wide variation was observed between pigs immediate increase in scampering and running duration and rate in a group. The variability in the amount of play shown in a was observed after releasing 6-week-old pigs into a corridor near group could be attributed to many factors in addition to fear, their home pens (26) or in weaned sows after several weeks of health, or pain; these factors include: gender, age, changes in low activity (25). The novelty of the hallway, and the increased weather, presence of “playful partners,” or random or “error” space per pig, allowed for sudden bursts of this locomotor variability (14). behavior and stimulated barks from all pigs. The overall conclusions from this study were that there was Pivot and head tossing were more frequent in pigs with UH no evidence based on monitoring play behaviors that the pigs than in pigs WUH. Based on sequential analysis of social play with hernias were in pain or their welfare was compromised in markers in piglets, pivoting and head tossing are suggested to that there was no difference among pigs with hernias and those function as play signals to initiate rough-and-tumble play for without hernias in their willingness to engage in locomotor and this species (25) which cues the social partner that behaviors social activities. produced are not as serious as they normally would be in other contexts (27). However, agreement of these play behaviors Acknowledgments between 2 observers in a subset of videos was low; therefore, the This work was supported by Ontario Pork through a grant from increased rates of these play markers in pigs with umbilical her- the Agricultural Adaptation Council Agreement for the Ontario nias need to be studied further before conclusions can be drawn. Farm Innovation Program and the University of Guelph- Social (lever and pushovers) behaviors were not frequently Ontario Ministry of Agriculture Food and Rural Affairs Research observed. These playing markers are considered more subtle Partnership. CVJ social behaviors that may be more difficult to identify (22,25). Flop and tail wagging were also behaviors that did not differ References among pigs with UH and WUH or by session. In an observa- . 1 Miller P, Mezwa D, Feczko P, Jafri Z, Madrazo B. Imaging of abdominal hernias. Radiographics 1995;15:333–347. tional study (20), tail wagging occurred only 5% of the time in 2. Mattsson P. Prevalence of congenital defects in Swedish Hampshire, a novel environment or home pen observations. Tail wagging in Landrace and Yorkshire pig breeds and opinions on their prevalence pigs has been described as not being a useful indicator of welfare in Swedish commercial herds (MSc Thesis). Swedish University of Agricultural Sciences, Uppsala, Sweden, 2011. in pigs because, although it has been associated with positive 3. Bendavid R. The unified theory of hernia formation. Hernia 2004;8: emotional states (e.g., during walking, play, or before feeding), 171–176. it has also been associated with negative emotional states (e.g., 4. Petersen H, Nielsen E, Hassing A, Ersbøll A, Nielsen J. Prevalence of clinical signs of disease in Danish finisher pigs. Vet Rec 2008;162: injury or frustration) (20). However, in our study, tail wagging 377–382. was associated with play time. 5. Searcy-Bernal R, Gardner I, Hird D. Effects of and factors associated The proportion of time that pigs were engaged in locomo- with umbilical hernias in a swine herd. J Am Vet Med Assoc 1994; 204:1660–1664. tor or social and object play (5.6% and 31.9%, respectively) 6. Straw B, Bates R, May G. Anatomical abnormalities in a group of was relatively low. It is reported that the frequency of playing finishing pigs: Prevalence and pig performance. J Swine Health Prod markers are the highest in the first 6 wk of a pig’s life (25), and 2008;17:28–31. 7. Morrow W, Meyer R, Roberts J, Lascelles D. Financial and welfare although playing behaviors persist through the growing period implications of immediately euthanizing compromised nursery pigs. and into adulthood, they do so at a lower frequency (14). J Swine Health Prod 2006;14:25–34.

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. 8 National Farm Animal Care Council (NFACC). Canadian Code of relationship with behavioural and heart rates measures. Appl Anim Practice for the Care and Handling of Pigs 2014. Available from: http:// Behav Sci 2001;72:23–39. www.nfacc.ca/codes-of-practice/pigs Last accessed August 1, 2017. 19. Chan WY, Cloutier S, Newberry RC. Barking pigs: Differences in 9. Ontario Farm Animal Council (OFAC). (2010). Caring for Compro­ acoustic morphology predict juvenile responses to alarm calls. Anim mised Pigs. Available from: https://www.livestockwelfare.com/wp- Behav 2011;82:767–774. content/uploads/Caring-for-Compromised-Pigs-July-2010.pdf Last 20. Groffen J. Tail posture and motion as a possible indicator of emotional accessed August 31, 2017. state in pigs. (Student Report 393). Swedish University of Agricultural 10. Schild S-L A, Brandt P, Rousing T, Jensen HJ, Barington K, Herskin Sciences. Department of Animal Environment and Health. Section of MS. Do umbilical outpouchings affect the behavior or clinical condition Etholology and Animal Welfare. 2012. of pigs during 6 h housing in a pre-transport pick-up facility? Res Vet 21. Apple J, Craig J. The influence of pen size on toy preference of growing Sci 2015;101:126–131. pigs. Appl Anim Behav Sci 1992;35:149–155. 11. Schild S-L A, Brandt P, Rousing T, Herskin MS. Does the presence 22. Donaldson TM, Newberry RC, Špinka M, Cloutier S. Effects of early

ARTICLE of umbilical outpouchings affect the behavior of pigs during the day of play experience on play behaviour of piglets after weaning. Appl Anim slaughter? Livest Sci 2015;176:146–151. Behav Sci 2002;70:221–231. 12. Oliveira AFS, Rossi AO, Finocchiaro L, Silva R, Lau MC, Barreto E. 23. Sneddon L, Elwood R, Adamo S, Leach M. Defining and assessing Play behavior in nonhuman animals and the animal welfare issue. animal pain. Anim Behav 2014;97:201–212. J Ethol 2010;28:1–5. 24. Virtala AMK, Mechor GD, Grohn YT, Erb HN. The effect of calfhood 13. Taylor A, Weary D, Lessard M, Braithwaite L. Behavioural responses diseases in growth of female dairy claves during the first 3 months of of piglets to castration: The effect of piglet age. Appl Anim Behav Sci life in New York State. J Dairy Sci 1996;79:1040–1049. 2001;73:35–43. 25. Newberry RC, Wood-Gush DGM, Hall JW. Playful behaviour of piglets. 14. Held SDE, Špinka M. Animal play and animal welfare. Rev Anim Behav Behav Processes 1988;17:205–216. 2011;81:891–899. 26. Rauw WM. A note on the consistency of a behavioral play marker in 15. Boissy A, Manteuffel G, Jensen MB, et al. Assessment of positive piglets. J Anim Sci Biotech 2013;4:33. emotions in animals to improve their welfare. Physiol Behav 2007;92: 27. Bekoff M. The communication of play intention: Are play signals 375–379. functional? Semiotica 1975;15:231–239. 16. Blackshaw JK, Swain AJ, Blackshaw AW, Thomas FJM, Gillies KJ. The 28. Studnitz M, Jensen MB, Pedersen LJ. Why do pigs root and in what will development of playful behaviour in piglets from birth to weaning in they root? A review on the exploratory behaviour of pigs in relation to three farrowing environments. Appl Anim Behav Sci 1997;55:37–49. environmental enrichment. Appl Anim Behav Sci 2007;107:183–197. 17. Špinka M, Newberry RC, Bekoff M. Mammalian play: Training for the 29. Wood-Gush DGM, Vestergaard K. The seeking of novelty and its rela- unexpected. Quart Rev Biol 2001;76:141–168. tion to play. Anim Behav 1991;42:599–606. 18. Marchant JN, Whittaker X, Broom DM. Vocalizations of the adult female domestic pig during standard human approach test and their

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1072 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Feline meningoencephalomyelitis of unknown origin: A retrospective analysis of 16 cases

Arianna Negrin, Sarah Spencer, Giunio Bruto Cherubini

Abstract — This study aimed to describe the signalment, clinical signs, magnetic resonance imaging (MRI) findings, cerebrospinal fluid (CSF) analysis, treatment, and outcome of feline meningoencephalomyelitis of unknown origin (FMUO). Medical records from 16 cats meeting the inclusion criteria of CSF pleocytosis, negative CSF polymerase chain reaction (PCR)-infectious disease results, and characteristic MRI findings were retrospectively reviewed. Median age was 9.4 years. Clinical signs included ataxia, proprioceptive deficits, seizures, and spinal hyperesthesia. The CSF nucleated cell count was increased (median 70.7 cells/mL), with predominantly mixed pleocytosis and CSF protein concentration was increased in 15/16 cats. Magnetic resonance imaging showed intraparenchymal infiltrative ill-defined lesions in 13 cases. All cats received a corticosteroid-based treatment protocol; additional therapies included lomustine, cytarabine, and anticonvulsant medications. Mild neurological signs were recorded in 5/12 cats but 7/12 cats were neurologically normal at re-examination. This represents the first study of feline MUO, highlighting FMUO as an important differential diagnosis in cats with variable neurological presentation. Prognosis appears to be good with immunomodulatory therapy.

Résumé — Méningo-encéphalomyélite féline d’origine inconnue : une analyse rétrospective de 16 cas. Cette étude visait à décrire le signalement, les signes cliniques, les résultats de l’imagerie par résonance magnétique (IRM), l’analyse du liquide céphalorachidien (LCR), le traitement et l’issue de la méningo-encéphalomyélite féline d’origine inconnue (MEOI). Les dossiers médicaux de 16 chats répondant aux critères d’inclusion de la pléocytose du LCR, les résultats négatifs du LCR pour des maladies infectieuses par amplification en chaîne par polymérase (ACP) et les constatations caractéristiques par IRM ont été évalués rétrospectivement. L’âge médian était de 9,4 ans. Les signes cliniques incluaient l’ataxie, les déficits proprioceptifs, les crises d’épilepsie et l’hyperesthésie spinale. La numération des cellules nucléées du LCR a augmenté (médiane de 70,7 cellules/mL), avec une pléocytose à prédominance mixte et la concentration de protéine du LCR était accrue chez 15/16 chats. L’imagerie par résonance magnétique a montré des lésions infiltrantes intraparenchymateuses mal définies dans 13 cas. Tous les chats ont reçu un protocole de traitement à base de corticostéroïde; les thérapies additionnelles incluaient la lomustine, la cytarabine et des médicaments anticonvulsifs. De légers signes neurologiques ont été observés chez 5/12 chats, mais 7/12 chats étaient neurologiquement normaux lors du réexamen. Cela représente la première étude de la MOI, ce qui souligne que la MOI est un diagnostic différentiel important chez les chats ayant une présentation neurologique variable. Le pronostic semble bon avec la thérapie immunomodulatoire. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1073–1080

Dick White Referrals, Six Mile Bottom, Cambridgeshire CB8 0UH, UK (Negrin, Cherubini); School of Veterinary Sciences, University of Bristol, Langford, North Somerset BS40 5DU, UK (Spencer). Address all correspondence to Dr. Arianna Negrin; 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.

CVJ / VOL 58 / OCTOBER 2017 1073 FOR PERSONAL USE ONLY

Introduction Cerebrospinal fluid analysis Cerebrospinal fluid was collected from the cisterna magna nflammatory central nervous system (CNS) disorders are in all cases. Analysis was performed within 1 h of collection. one of the most common causes of neurological dysfunction I Cerebrospinal fluid nucleated cell counts were classified as: in dogs and cats and can be divided into 2 broad classes: CNS normal (, 5/mL), mildly (5 to 80/mL), moderately (81 to inflammation due to an infectious origin and CNS inflamma- 500/mL), or markedly (. 500/mL) increased (8). Cerebrospinal tion without an identifiable infectious cause (1,2). The latter is fluid protein levels were classed as: normal (, 0.3 g/L), mildly commonly referred to as meningoencephalitis or meningoen- (0.31 to 1.0 g/L), moderately (1.1 to 3.0 g/L), or markedly cephalomyelitis of unknown origin (MUO) (2,3). It is useful (. 3.0 g/L) increased (8). Nucleated cell population was

ARTICLE to consider disorders classed within MUO individually when classified as neutrophilic (. 50% neutrophils), mononuclear possible, as clinical features and response to therapy tends to (. 80% mononuclear cells), eosinophilic (. 50% eosinophils), differ between sub-groups. However, as a histological diagnosis or mixed (no predominance of any 1 cell type) (6). The RT-PCR is often not possible, the term MUO is commonly used (2). analysis on all CSF samples was carried out in all cases for the While MUO is extensively reported in dogs (2,4–7), few following infectious agents: feline calicivirus, feline herpesvirus, reports of non-infectious meningoencephalomyelitis have been Chlamydophila felis, Toxoplasma gondii, Bornavirus, feline leuke- described in cats (8–10). Bradshaw et al (10) reported that 11% mia virus, feline immunodeficiency virus, Leishmania infantum, of 286 cats with encephalitis or meningitis had no evidence of feline parvovirus (panleucopenia virus), and feline coronavirus. an infectious agent, while 5 cases of presumed feline MUO were classified in Singh et al (8) as either non-suppurative or steroid- Magnetic resonance imaging protocol responsive based on cerebrospinal fluid (CSF) characteristics and Magnetic resonance imaging was performed using a 0.4T per- response to treatment. Although the underlying cause of MUO manent magnet scanner (Hitachi Aperto Lucent 0.4T; Hitachi remains elusive, it appears to be associated with an aberrant Medical Systems, Wellingborough, UK). Pulse sequences varied immune response directed against the CNS (11) and conse- but in all cats transverse T1WI, T2WI, FLAIR sagittal T2WI, quently immunomodulatory therapy is the mainstay of canine and post-contrast gadoteric acid (Gadovist; Bayer Schering MUO treatment. There are no reported treatment protocols Pharma, Reading, UK), 0.1 mmol/kg body weight (BW), IV, for feline MUO (FMUO), although 2 cases were successfully transverse T1WI were acquired. Images were reviewed by board- treated with prednisolone (8). Response to therapy and outcome certified radiologists who were blinded to the study. Images of canine MUO are highly variable while data on the prognosis were assessed for the presence of lesions, lesion pattern (focal, of cats with the condition are currently unknown (2,9). diffuse or multifocal), and location. The presence of meningeal This report represents the largest study of presumed FMUO involvement was recorded. Lesion margins were described as cases in the literature. The aim of this study was to describe the well-defined, irregular, or infiltrative. Mass effect was indicated signalment, clinical signs, magnetic resonance imaging (MRI) by effacement of sulci, shift of midline structures, cerebellar findings, ancillary diagnostic testing, CSF analysis, treatment herniation (evaluated on sagittal midline T2WI) or ventricular and outcome of FMUO, providing background information system deviation/compression. Pre- and post-contrast T1WI for further studies focusing on clinico-pathological features and were compared to assess for contrast enhancement and the pat- optimal treatment protocols. tern of contrast uptake was described. Materials and methods Treatment Selection criteria Treatment depended on clinician preference and individual case Medical records (2008 to 2016) of cats presented to the requirements. All cats received clindamycin (Antirobe; Zoetis, Neurology and Neurosurgery Service at Dick White Referrals London, UK), 12.5 mg/kg BW, PO, q12h, while waiting for were retrospectively reviewed. Inclusion criteria comprised CSF 5 to 7 d for CSF infectious disease PCR results. All cats were pleocytosis, MR characteristics indicative of inflammatory lesions, treated with a corticosteroid-based protocol (dexamethasone and negative CSF reverse-transcription polymerase chain reaction only, dexamethasone followed by prednisolone, or prednisolone (RT-PCR) infectious diseases results. Where neoplasia was sus- only). Immunosuppressive steroid doses were initially used, pected as a differential diagnosis, further imaging and laboratory including prednisolone (Prednicare; Animalcare, York, UK), tests were performed and reviewed. Additional diagnostic inves- 1 mg/kg BW, PO, q12h and dexamethasone (Dexamethasone; tigations, including Toxoplasma gondii serology, were conducted Aspen, Redditch, UK), 0.2 to 0.3 mg/kg BW, PO, q24h. in some cases. Cats with a history of steroid administration before Corticosteroid therapy was tapered by typically halving the dose presentation were excluded. Signalment, duration of clinical signs, or dosage every 2 to 3 wk unless a relapse was seen. Additional physical and neurological examination findings, neuroanatomical immunomodulatory therapies included lomustine (Lomustine; localization, CSF nucleated cell count and cytological charac- Nova laboratories, Wigston, UK), 10 mg/cat, PO, single dose teristics, CSF protein concentration, diagnostic imaging results on day 1, and cytarabine (Cytarabine; Pfizer, Sandwich, UK), including MRI, treatment, neurological examination findings at 50 mg/m2, SC, q12h for a total of 4 doses, at the clinician’s re-examination(s), and occurrence and therapy at time of relapse discretion. Anticonvulsant medication was used in all cats pre- were recorded. Clinical signs were deemed acute if present for sented with seizures and included phenobarbitone (Phenoleptil; , 2 wk, and chronic if reported for . 2 wk. Animalcare), 1 mg/kg BW, PO, q12h, levetiracetam (Keppra;

1074 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY

UCB Pharma, Brussels, Belgium), 10 mg/kg BW, PO, q8h, or Where the spinal cord was imaged, lesions were intraparen- diazepam (Diazemuls; Actavis, Barnstaple, UK), 0.5 mg/kg BW, chymal in 3/5 and extraparenchymal in 2/5 cases. Meningeal IV, in case of seizure. contrast enhancement was seen in 2/5 cases.

Follow-up and outcome Ancillary diagnostic investigations Re-examination was scheduled in all cats 2 to 3 wk after dis- Complete blood (cell) count (CBC) and serum biochemistry

charge. Clinical and neurological findings and any changes in were performed in all cases; leucocytosis was documented in ARTICLE ongoing medication protocols were recorded. Subsequent follow- 5 cats. Toxoplasma gondii serology was performed in 9/16 cats; up was at the clinicians’ and owners’ discretion. results were not supportive of recent or active infection (high IgM titer) in any case, but in 3 cats (cats 4, 9, 11) results indi- Results cated previous exposure (high IgG titer but IgM titer within The clinical, neurological, and diagnostic findings are sum- normal limits). Other diagnostic investigations, including marized in Table 1. abdominal ultrasound (5/16 cats), inflated chest radiographs (2/16 cats), did not reveal significant concurrent disease in Signalment any cat. Sixteen cats met the inclusion criteria. Median age was 9.4 y (range: 10 mo to 12 y). The cats were domestic shorthair or Treatment longhair (14/16), Persian (n = 1), and Siamese (n = 1). Dexamethasone alone was given to 9/16 cats, dexamethasone followed by prednisolone was administered to 4/16 cats, and Clinical signs prednisolone alone to 3/16 cats. Five cats received an additional Onset of clinical signs was not specified by the owners in 3 cases. immunomodulatory therapy, including cytarabine in 3 cats, and Clinical signs were reported as acute in the majority of cats lomustine in 2 cats. Anticonvulsant medication was used in all (14/16). Systemic signs included obtunded mental status (5/16), cats presented with seizures, including phenobarbitone (4/6) anorexia (4/16), and pyrexia (3/16). The most common abnor- and levetiracetam (2/6). Two cats, admitted for cluster seizure/ malities on neurological examination were ataxia (8/16), paresis status epilepticus, on admission received diazepam in combina- with decreased postural reactions (8/16), and spinal hyperesthe- tion with phenobarbitone (1 case) or levetiracetam (1 cat) to sia (6/16) (see Table 1 for further details). Generalized (4/16) control seizures. or partial (2/16) seizures were the presenting sign in 6 cats. Nystagmus was observed in 3 cats and decreased or absent pupil- Outcome lary light reflexes (PLR) and/or menace responses were noted Median duration of hospitalization was 6.8 d (range: 3 to 12 d). in 3 cats. Localization based on neurological examination was All cats survived to discharge (Table 1). Follow-up was unavail- multifocal brain in 4 cases, forebrain in 4 cases, multifocal CNS able in 4 cases. Median final follow-up was 5.2 mo (range: 0 in 3 cases, and multifocal spinal cord in 5 cases. to 16 mo) after presentation. At first re-examination, 7/12 cats were normal on neurological examination and remained asymp- Cerebrospinal fluid analysis tomatic at all subsequent re-examinations (2, 5, 9, 10, and Cerebrospinal fluid nucleated cell count was mildly increased 12 mo) (Table 1). The remaining cats that were presented for in 12/16 and moderately increased in 4/16 cats (median: re-examination showed persistent mild neurological signs at first 62.2 cells mL, range: 6 to 344) (Table 1). Pleocytosis was re-examination, including mild pelvic limb ataxia, mild tetrapa- mixed in 5/16, lymphocytic in 5/16, mononuclear in resis, intermittent spinal hyperesthesia, and reduced frequency 3/16, neutrophilic in 2/16, and eosinophilic in 1/16 cases. (. 50% reduction) of partial seizures. No further follow-up Cerebrospinal fluid protein was increased in 15/16 as the was available for 2 of these cats, while in the remaining 3 cats sample was of insufficient quantity for measurement in 1 case. stable or improved clinical signs were recorded in subsequent Protein concentration was mildly increased in 12/16 (median: re-examinations. One cat received an increased dose of dexa- 0.50 g/L, range: 0.21 to 22.25 g/L). The PCR results in CSF methasone, which lead to complete and long-term resolution for T. gondii and feline coronavirus were available in 3/16 cases of clinical signs (last follow-up 10 mo). This cat relapsed 1 y and were all negative. subsequent to remission, a few days after routine vaccination. Treatment was successfully stopped in the remaining 2 cats Magnetic resonance imaging findings without deterioration (latest follow-up at 9 mo and 15 mo). The MRI findings (Table 2) correlated with neuroanatomi- cal localization in 14/16 cases. In 10/16 cats, MRI detected Discussion multifocal CNS lesions. Single lesions were observed in 4 cats This study represents the largest description of suspected and meningeal contrast enhancement only in the remaining FMUO. Findings indicate many similarities with canine MUO 2 cases. Lesions tended to be T1W isointense or hypointense, but also some important differences, particularly in apparent T2W hyperintense, and were variable in their contrast uptake. prognosis. Middle-aged and older cats appeared to be at high- Lesions were ill-defined in 9 cats and infiltrative in 3 cats. Mild est risk, as the median age in this study was 9.4 y, although subtentorial or cerebellar herniation was seen in 2/16 cases. disease was seen in much older and younger cats. Age of dogs Hydrocephalus was observed in 1 cat only. affected by MUO can also be highly variable (6 mo to 12 y)

CVJ / VOL 58 / OCTOBER 2017 1075 FOR PERSONAL USE ONLY ARTICLE ild pelvic limb ataxia. FFU 15 mo. 15 FFU ataxia. limb pelvic ild wk. 3 at ataxia limb pelvic ild ild ataxia at 3 wk. 3 at ataxia ild ild partial seizures at 6 wk. wk. 6 at partialseizures ild utcome esolved at 3 wk. FFU 9 mo. 9 FFU wk. 3 at esolved esolved at 2 mo. FFU 5 mo. 5 FFU mo. 2 at esolved esolved at 2 wk. FFU 12 mo. 12 FFU wk. 2 at esolved esolved at 2 mo. FFU 10 mo. mo. 10 FFU mo. 2 at esolved urvived to discharge, LTF. urvived discharge, to urvived to discharge, LTF. urvived discharge, to urvived to discharge, LTF. urviveddischarge, to

vaccination. after Relapsed mo. 12 FFU at Hyperesthesia M M R R M S S R O R M S

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phenobarbitone. then prednisolone prednisolone then phenobarbital. lomustine. + added Phenobarbitone cytarabine, + prednisolone, prednisolone, levetiracetam.

P D D D D D P T D D D D

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A A A

O A A U A A C A A

btunded mental status, status, mental btunded eurological signs eurological eneralized tonic-clonic eneralized mbulatory paraparesis, mbulatoryparaparesis, taxia, decreased taxia, ethargy, pyrexia, obtunded pyrexia, ethargy, ethargy, pyrexia, pyrexia, ethargy, ethargy, generalized ethargy, yrexia, pelvic limbs pelvic yrexia, artial complex seizures, seizures, artialcomplex artial tonic seizures, seizures, artialtonic elvic limb ataxia, ataxia, limb elvic TL hyperesthesia. TL cervicalhyperesthesia. bilateral menace. bilateral eye. left in PLR and horizontal nystagmus, nystagmus, horizontal nystagmus. horizontal decreased mentation, hemiparesis, right-sided postural left-sided decreased menace decreased reactions, decreased bilateral menace. bilateral decreased vestibular ataxia, ataxia, vestibular ambulatory tetraparesis, ambulatorytetraparesis, hyperesthesia. reactions. postural limbs reactions. postural postural reactions, reactions, postural cervical ataxia, decreased seizures, cluster bilateral menace, bilateral depressed ataxia, ambulatorynon hyperesthesia. TL pelvic decreased tremors, intentional limbs pelvic decreased ambulatory and ataxia TL paraparesis, hyperesthesia. right, to circling mentation, P L N P L A L O P G P A

SH SH LH LH SH SH SH SH SH reed ersian iamese B D D D D D D D S P D D

N N N N N ender N N N

G F F M F F F F M M M M

Signalment, clinical, and diagnostic findings, treatment and outcome of 16 cases of feline meningoencephalomyelitis meningoencephalomyelitis feline of cases 16 of outcome and treatment findings, diagnostic and clinical, Signalment,

0 mo 0 y A 3 8 8 1 6 1 1 6 4 9 9

Table 1. Table Case ge 2 y 3 4 y 5 y 1 6 mo 1 7 y 8 y 9 y 10 y 11 m 1

1076 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY

(7,12,13); however, young or middle-aged dogs have been more frequently reported (2,7,13). No breed or gender predisposition was observed, in contrast to canine studies describing a female predilection (2,7); however, the sample size of this study is unlikely to be sufficient to identify gender predispositions for feline MUO.

Clinical signs of FMUO typically corresponded to the dis- ARTICLE tribution of CNS lesions. Onset of neurological signs was acute in most cases, similar to canine MUO (12,14), although the duration of signs may be underestimated in cats due to their ild ataxia and ataxia ild utcome o seizures. FFU 5 wk. 5 FFU seizures. o ood control of seizure and unremarkable and seizure of control ood esolved at 3 wk. FFU 2 wk. 2 FFU wk. 3 at esolved urvived to discharge, LTF. urviveddischarge, to 1 mo from discharge. FFU 4 mo. 4 FFU discharge. from mo 1 tetraparesis. FFU 9 m. 9 FFU tetraparesis. examination neurologic M R G N O S temperament and often less time spent in close proximity to owners. Seizure activity, either partial or generalized, was the major reason for presentation in this study similar to data

reported in multifocal granulomatous encephalitis (GME) in

dogs (7), and NE in pugs (13) and Yorkshire terriers (2). Our

findings highlight feline MUO as an important differential diagnosis for seizures, especially in young to middle-aged cats examethasone examethasone examethasone. examethasone reatment rednisolone rednisolone

levetiracetam. diazepam, diazepam. Phenobarbital, Phenobarbital, prednisolone, then prednisolone. then lomustine. + cytarabine. + diazepam. Phenobarbital, D P

D D T D with no previous history of seizures.

Intracranial multifocal disease was the most common neuro- anatomical localization, as reported in dogs (2) and previously described cases of presumed FMUO (8). Intracranial was the ixed ononuclear eutrophilic SF cytology SF ymphocytic ymphocytic (continued)

N L

M L C M most common localization (50%), with equal distribution

between multifocal and localized to the forebrain, while 31% of cats had a suspected lesion to the spine only, a similar percentage

to the focal presentation of canine MUO (12). 2.25 .52 .49 .67 g/L)

2 CSF CSF protein 0 0 ( 1 Mild CSF pleocytosis was recorded in most cases in this

study; previous reports of suspected FMUO show high cell L)

m count in suppurative disease but lower cell count in non-

suppurative disease (8). Cerebrospinal fluid pleocytosis is highly 30 44

9 10 cells/

TNCC CSF 1 3 6 1 ( 1 variable in canine MUO and may even be normal (2). Severity of CSF pleocytosis did not appear to correlate with disease sever-

ity or prognosis in this study, as with dogs affected by MUO (9).

Moreover, type of pleocytosis did not correlate with duration

of clinical signs, being very variable leucocyte prevalence in the CSF with acute onset in most of the cases. As CSF pleocytosis ultifocal brain ultifocal ultifocal brain ultifocal ocalization orebrain orebrain pinal (T3-L3) pinal M S F F L M is not specific for MUO, it is important to correlate it with

characteristic magnetic resonance imaging (MRI) findings and

negative infectious disease results, as were the inclusion criteria nset nknown nknown cute cute cute

U A A A

O U in this study.

Magnetic resonance imaging characteristics observed in

most of the cases in this study are similar to those in canine

MUO, in which the MRI findings appear to be variable, with

prevalence of focal or multifocal, ill-defined hyperintense lesions on T2WI (4,6,15). T2WI hyperintensity has moder-

ate sensitivity (68%) and a high predictive value (100%) for inflammatory CSF in dogs (4); however, gadolinium btunded mentation, ataxia, ataxia, mentation, btunded eurological signs eurological eneralized tonic-clonic eneralized cluster clonic eneralized ethargy, pelvic limb ataxia, ataxia, limb pelvic ethargy,

tatus epilepticus, epilepticus, tatus contrast has been reported to increase the sensitivity of MR nystagmus. horizontal PLR, on right eye. right on decreased postural reactions. postural decreased bilateral absent tetraparesis, menace decreased seizures, wide-based forelimbs stance, stance, forelimbs wide-based ambulatory seizures, cluster ambulatory and paraparesis. tonic-clonic generalized cervical hyperesthesia. seizures, G L S G N O for detecting inflammatory lesions (15,16). In this study,

2 cats (cases 1 and 13) with indistinct lesions on T2WI as SH SH SH SH SH reed B D D D D D isointense, showed marked contrast enhancement, which

helped to detect and define the nature of brain pathology.

N N N N Interestingly, most intracranial lesions affected white matter ender N G F M M M M only, in keeping with previous data in dogs with GME (6)

and necrotizing leukoencephalitis (NLE) (2). Unfortunately, Signalment, clinical, and diagnostic findings, treatment and outcome of 16 cases of feline meningoencephalomyelitis meningoencephalomyelitis feline of cases 16 of outcome and treatment findings, diagnostic and clinical, Signalment,

y A 2 3 7 4 4 FLAIR sequence, which has been previously reported to — domestic shorthair; CNS — central nervous system. central — CNS shorthair; domestic —

enhance sensitivity of MRI (15) was not available in all cases.

Table 1. Table Case ge 13 y 14 y 15 y 16 count; cell nucleated total — TNCC follow-up; final — FFU follow-up; to lost — LTF pupillary — reflex; PLR light thoracolumbar; — TL (neutered); female — FN (intact); female — F (neutered); male — MN (intact); male — M y DSH 12 In these 2 cats, however, contrast-enhancing lesions were

CVJ / VOL 58 / OCTOBER 2017 1077 FOR PERSONAL USE ONLY

Table 2. Magnetic resonance imaging findings in 16 cases of feline meningoencephalomyelitis Region Cerebellar Case scanned Lesion(s) Margins Hydrocephalus herniation T1WI T2WI Gad uptake 1 Brain Diffuse intraparenchymal cerebral and cerebellar Ill-defined No No Iso Iso Yes lesions. T3-L3 spine Unremarkable. 2 Cervical Intramedullary lesion C6-T2. Ill-defined No No Hypo Hyper Yes 3 Brain Multiple brainstem lesions. Infiltrative No No Iso Hyper No

ARTICLE 4 Brain Swollen cerebrum, decreased gray/white Ill-defined Yes Mild Hypo Hyper Meninges differentiation. 5 Brain, Intraparenchymal multifocal cerebral lesions Ill-defined No No Iso Hyper Yes (cerebral) cervical and intramedullary lesion at C2 and C3 level. No (cervical) 6 Brain and Meningeal contrast enhancement. N/A No No N/A N/A Meninges T3-S3 spine 7 T3-S3 spine Intraparenchymal lesion at L4-L5. Ill-defined No No Iso Hyper Meninges 8 Brain Intraparenchymal lesions in cerebrum and Infiltrative No Mild Iso Hyper No cerebellum (gray and white matter). 9 T3-S3 Intramedullary lesion extending at T13-L2 level. Ill-defined No No Iso Hyper Yes 10 T3-S3 Ventral meningeal contrast enhancement N/A No No N/A N/A Meninges extending at L4-L6 level. 11 Brain, Multiple lesions including right temporal lobe, Ill-defined No No Iso Hyper No cervical left thalamus, and intramedullary lesion extending at C2-C3 level. 12 Brain Multiple intraparenchymal lesions in cerebrum Infiltrative No No Iso Hyper Yes and patchy meningeal contrast enhancement. 13 Brain Intraparenchymal lesion in cerebrum, brainstem, Ill-defined No No Hypo Iso Yes and cerebellum. 14 T3-L3 Intraparenchymal lesion extending at T13-L2 level. Ill-defined No No Iso Hyper No 15 Brain Multifocal intraparenchymal cerebral lesions. Ill-defined No No Iso Hyper No 16 Brain Multifocal meningeal contrast enhancement. N/A No No N/A N/A Meninges Gad — gadoteric acid; N/A — not available.

also heterogeneously hyperintense in FLAIR. Further studies parisons. Corticosteroids were tapered over a range of weeks would be needed to better elucidate the MRI characteristics to months, depending on response to treatment and in 2 cats of presumed MUO in cats and the possible MRI differences long-term (. 10 mo) therapy was required. Additional immu- with infectious encephalitis. nomodulatory drugs, including cytarabine and lomustine, were Feline limbic encephalitis (FLE) has been recently sus- used in 5 cats alongside corticosteroids without adverse effects pected to have a primary immune-mediated etiology, as 36% and complete remission of signs was recorded at the time of of cats presenting partial seizure with orofacial involvement latest follow-up in all cases. Use of cytarabine and lomustine showed increased concentrations of antibodies against voltage- reflected clinician’s preference, mainly based on lack of response gated potassium channel complexes (VGKC-complexes) (17). to corticosteroids while still hospitalized; however, complete Diagnosis of suspected FLE is based on clinical signs, MRI information regarding this clinical decision is lacking in the findings, characterized by the typical bilateral hippocampal T1 records. Cytarabine and lomustine have been used extensively hypo- and iso-intensity and T2 hyperintensity, and pleocytic for chemotherapy against several cancers including lymphoma CSF (17). None of the cats herein showed similar clinical (14,18–20). Moreover, cytarabine (21,22) and lomustine (23) and MR findings; however, an underlying immune-mediated have also been used as immunomodulatory therapy in addition inflammatory etiology may result in shared biochemical fea- to steroids in canine MUO and were therefore used for their tures with FMUO. Therefore, further studies are required to immunomodulatory effect in feline patients with suspected elucidate possible common underlying etiology and to test sera MUO in the present study. The dosages of these 2 drugs were for VGKC-complexes in FMUO patients. based on previous descriptions of their use in feline patients All cats in this study received dexamethasone only, dexa- (14,18–20). Due to the lack of definitive histopathological methasone followed by prednisolone, or prednisolone only; diagnosis, it may be reasonable to consider infiltrative neopla- however, the sample size was too small for statistical com- sia, including lymphoma, as the main differential diagnosis for

1078 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY these patients and the remission of clinical signs as secondary eral authors have suspected non-FIP viral encephalitides as the to use of chemotherapy in potentially misdiagnosed patients. underlying cause of most cases of feline meningoencephalitis The good evolution of the clinical signs in cats reported in the (8,13,14). While it is possible that false negative CSF PCR present study opens one of the major key discussions on MUO, results occurred or agents not tested for by CSF PCR (including both in canine and feline patients, which is the lack of defini- West Nile virus and Aujeszky’s disease virus) were the cause of tive histopathological diagnosis. Brain biopsies do not represent disease in this study, it is highly unlikely given the improvement/ one of the routine tests for diagnosis of MUO in animals, and resolution of clinical signs with immunosuppressive therapy. ARTICLE in feline patients, the small brain volume, may be particularly Ideally all cats would have had T. gondii serology performed to challenging. Canine MUO is usually considered to be an ante- further exclude infection. mortem diagnosis and further studies are required to increase Further studies of feline MUO are needed to determine confidence in diagnostic test findings, especially MRI and CSF prognosis and treatment response, as well as highlight the analysis, in the diagnosis of feline MUO. corresponding histological changes and possible etiologies. Despite the low number of cases with long-term follow-up, Long-term prognosis of feline MUO remains unknown and for the first time in veterinary literature, this study suggests large-scale, prospective randomized trials are necessary to com- prognostic data on feline MUO. All cats survived to discharge pare different treatment protocols for feline MUO as described and more than half of the cats presented for re-examination for canine MUO. were in clinical remission by 2 to 3 wk after diagnosis and In conclusion, MUO is an important differential diagnosis for remained so until final follow-up (2 to 12 mo). Median time variable neurological signs in cats. There was no age, gender, or to final follow-up was 5.2 mo, and it is possible that relapse breed predisposition, although young to middle-aged cats were could have occurred in reported cats at a later date than the more commonly affected in this study. Disease onset was usu- final follow-up in this study. Overall prognosis in cats with ally acute and compatible with multifocal intracranial lesions in inflammatory CSF has been reported as poor, with 77% of most cases, although focal lesions of the brain and spinal cord cats surviving less than 1 y (8,24). However inflammatory were seen. Cerebrospinal fluid pleocytosis and MRI characteris- CSF has been reported in non-inflammatory conditions, tics tended to be similar to most reports of canine MUO, with including neoplasia, and in infectious CNS diseases, including mixed or lymphocytic CSF and ill-defined hyperintensities on feline infectious peritonitis (FIP), which may have an impor- T2W and FLAIR sequences, which show patchy contrast uptake. tant impact on the poor prognosis for cats with inflammatory Definitive conclusions regarding treatment cannot be made lesions in the CNS (4,5,24,25). Good prognosis in feline from this study, but immunosuppressive treatment appeared to MUO is highlighted by the present study and inflammatory be successful in achieving rapid complete or partial remission CSF in cats should not always be associated with a poor out- in all cases that were available for follow-up. Prognosis therefore come. Moreover, in the 12/16 cats in which follow-up was appears to be better than for canine MUO, but further studies available, feline MUO was associated with better medium- of feline MUO are indicated to better understand its origin, term prognosis than in dogs with MUO. Prognosis in dogs treatment and outcome. CVJ affected by MUO has been assessed in several studies, some of which had number of cases similar to the present study (26) References and others with larger numbers (27). However, the prognosis 1. Platt S, Freeman AC. Neck and back pain. In: Platt S, Olby N, eds. remains guarded to poor (9,12,28) in most affected dogs, BSAVA Manual of Canine and Feline Neurology. 4th ed. BSAVA Press, 2013:252–270. for which death was recorded in 50% to 56% (9,28) of the 2. Granger N, Smith PM, Jeffery ND. Clinical findings and treatment of treated dogs. non-infectious meningoencephalomyelitis in dogs: A systematic review This study has a number of limitations. A regimented treat- of 457 published cases from 1962 to 2008. Vet J 2010;184:290–297. 3. Windsor RC, Sturges BK, Vernau KM, Vernau W. Cerebrospinal fluid ment protocol was not used due to the retrospective nature of eosinophilia in dogs. J Vet Intern Med 2009;23:275–281. the study and the need for individual management of cases of 4. Lamb CR, Croson PJ, Cappello R, Cherubini GB. Magnetic resonance MUO. The unpredictability of relapse, differences in disease imaging findings in 25 dogs with inflammatory cerebrospinal fluid. Vet Radiol Ultrasound 2005;46:17–22. severity, and variability in treatment response mean that pro- 5. Bohn AA, Wills TB, West CL, Tucker RL. Cerebrospinal fluid analysis spective studies investigating treatment regimes is not always and magnetic resonance imaging in the diagnosis of neurologic disease practical or ethical. The lack of follow-up in 25% of cases was in dogs: A retrospective study. Vet Clin Pathol 2006;35:315–320. 6. Cherubini GB, Platt SR, Anderson TJ, et al. Characteristics of mag- disappointing and it is possible that some of these cats relapsed netic resonance images of granulomatous meningoencephalomyelitis in or died due to feline MUO; future studies with more complete 11 dogs. Vet Rec 2006;159:110–115. follow-up are required to better understand the prognosis of 7. Muñana KR, Luttgen PJ. Prognostic factors for dogs with granuloma- tous meningoencephalomyelitis: 42 cases (1982–1996). J Am Vet Med this disease. Assoc 1998;15:1902–1906. No histopathological confirmation of MUO was performed 8. Singh M, Foster DJ, Lamb WA. Inflammatory cerebrospinal fluid due to the survival of all cats. It is therefore not possible to analysis in cats: Clinical diagnosis and outcome. J Feline Med Surg 2005;7:77–93. define the precise nature of the inflammatory conditions affect- 9. Lowrie M, Smith PM, Garosi L. Meningoencephalitis of unknown ing these cats. However canine MUO is usually considered to origin: Investigation of prognostic factors and outcome using a standard be an antemortem diagnosis and the aim of this study was to treatment protocol. Vet Rec 2013;172:527. 10. Bradshaw JM, Pearson GR, Gruffydd-Jones TJ. A retrospective study describe the clinical features of cats with this condition rather of 286 cases of neurological disorders of the cat. J Comp Pathol than determine its origin. Based on histological changes, sev- 2004:112–120.

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11. Kipar A, Baumgartner W, Vogl C, Gaedke K, Wellman M. 19. Hamilton TA, Morrison WB, DeNicola DB. Cytosine arabinoside Immunohistochemical characterisation of inflammatory cells in chemotherapy for acute megakaryocytic leukemia in a cat. J Am Vet brains of dogs with granulomatous meningoencephalitis. Vet Pathol Med Assoc 1991;199:359–61. 1998;35:43–52. 20. Podell M, DiBartola SP, Rosol TJ. Polycystic kidney disease and renal 12. Talarico LR, Schatzberg SJ. Idiopathic granulomatous and necrotising lymphoma in a cat. J Am Vet Med Assoc 1992;201:906–909. inflammatory disorders of the canine central nervous system: A review 21. Zarfoss M, Schatzberg S, Venator K, et al. Combined cytosine arabino- and future perspectives. J Small Anim Pract 2010;51:138–149. side and prednisone therapy for meningoencephalitis of unknown origin 13. Levine JM, Fosgate GT, Porter B, Schatzberg SJ, Greer K. Epidemiology in 10 dogs. J Small Anim Pract 2006;47:588–595. of necrotizing meningoencephalitis in Pug dogs. J Vet Intern Med 22. Menaut P, Landart J, Behr S, Lanore D, Trumel C. Treatment of 11 dogs 2008;22:961–968. with meningoencephalomyelitis of unknown origin with a combination 14. Rassnick KM, Williams LE, Kristal O, et al. Lomustine for treatment of prednisolone and cytosine arabinoside. Vet Rec 2008;162:241–245. of mast cell tumors in cats: 38 cases (1999–2005). J Am Vet Med Assoc 23. Uriarte A, Thibaud JL, Gnirs K, Blot S. Lomustine treatment in

ARTICLE 2008;232:1200–1205. non-infectious meningo-encephalitis in 8 dogs. J Vet Intern Med 15. Young BD, Fosgate GT, Holmes SP, et al. Evaluation of standard 2008;22:509. magnetic resonance characteristics used to differentiate neoplastic, 24. Marioni-Henry K, Vite CH, Newton AL, Van Winkle TJ. Prevalence inflammatory, and vascular brain lesions in dogs. Vet Radiol Ultrasound of diseases of the spinal cord of cats. J Vet Intern Med 2004;18:851–8. 2014;55:399–406. 25. Gunn-Moore D, Reed N. CNS disease in the cat: Current knowledge 16. Negrin A, Lamb CR, Cappello R, Cherubini GB. Results of magnetic of infectious causes. J Feline Med Surg 2011;13:824–836. resonance imaging in 14 cats with meningoencephalitis. J Feline Med 26. Rand JS, Parent J, Percy D, Jacobs R. Clinical, cerebrospinal fluid, and Surg 2007;9:109–116. histological data from thirty-four cats with primary noninflammatory 17. Pakozdy A, Halasz P, Klang A, et al. Suspected limbic encephalitis and disease of the central nervous system. Can Vet J 1994;35:174–181. seizure in cats associated with voltage-gated potassium channel (VGKC) 27. Quesnel AD, Parent JM, McDonell W, Percy D, Lumsden JH. complex antibody. J Vet Intern Med 2013;27:212–214. Diagnostic evaluation of cats with seizure disorders: 30 cases (1991– 18. Dutelle AL, Bulman-Fleming JC, Lewis CA, Rosenberg MP. Evaluation 1993). J Am Vet Med Assoc 1997;210:65–71. of lomustine as a rescue agent for cats with resistant lymphoma. J Feline 28. Tipold A, Jaggy A. Steroid responsive meningitis-arteritis in dogs: Med Surg 2012;14:694–700. Long-term study of 32 cases. J Small Anim Pract 1994;35:311–316.

1080 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Use of topical healing agents on scrotal wounds after surgical castration in weaned beef calves

Sonia Marti, Karen S. Schwartzkopf-Genswein, Eugene D. Janzen, Daniela M. Meléndez, Désirée Gellatly, Edmond A. Pajor

Abstract — Angus bulls (n = 48) were randomly assigned to control (castrated without the application of a post- operative healing agent) or surgical castration followed by either the application of a topical germicide, aluminum powder spray, or liquid bandage. The objective of this study was to determine the efficacy of commercial topical healing agents in improving wound healing and reducing inflammation and secondary infection after surgical castration. Indicators of wound healing included scrotal area temperature (determined by infrared thermography), scrotal circumference, clinical state of the scrotum score, and the wound healing score. Pain sensitivity was measured using a Von Frey anesthesiometer. The healing agents used in this study did not improve indicators of healing such as swelling and healing rate scores or indicators of inflammation including scrotal temperature and circumference of surgical castration lesions. Pain sensation associated with surgical castration was found to last 35 d after the procedure.

Résumé — Usage d’agents cicatrisants topiques sur des blessures scrotales après la castration chirurgicale chez des veaux de boucherie sevrés. Quarante-huit taureaux Angus ont été assignés au hasard à la castration témoin (castration sans l’application d’un agent cicatrisant postopératoire) ou à la castration chirurgicale suivie soit de l’application d’un germicide topique, d’un poudre à l’aluminium en vaporisateur ou d’un pansement liquide dans le but de déterminer l’efficacité des agents cicatrisants topiques commerciaux pour l’amélioration de la guérison des plaies et la réduction de l’inflammation et de l’infection secondaire après la castration chirurgicale. Les indicateurs de cicatrisation des plaies incluaient la température de la région scrotale déterminée par thermographie infrarouge, la circonférence scrotale, le pointage de l’état clinique du scrotum et le pointage de la cicatrisation de la plaie; et la sensibilité à la douleur mesurée à l’aide d’un anesthésiomètre Von Frey. Les agents cicatrisants utilisés dans cette étude n’ont pas amélioré les indicateurs de cicatrisation comme l’enflure et les notes de la rapidité de cicatrisation ou des indicateurs de l’inflammation qui incluaient la température scrotale et la circonférence des lésions de castration chirurgicale. Il a été constaté que la sensation de douleur associée à la castration chirurgicale durait 35 jours après l’intervention. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1081–1085 Introduction (1). It is done by creating an incision on the scrotum using a scalpel or Newberry knife to gain access to the testicles so urgical (knife) castration is one of the most commonly they can be removed by pulling or using an emasculator. This employed techniques used in North American beef cattle S procedure results in an open wound that is susceptible to infec- tion and bleeding (2). In many cow-calf operations calves are Department of Production Animal Health, Faculty of Veterinary castrated before weaning (3); however, some are not castrated Medicine, University of Calgary, 3330 University Drive NW, until after weaning (4). The Canadian Veterinary Medical Calgary, Alberta T2N 1N4 (Marti, Janzen, Meléndez, Gellatly, Association (CVMA) recommends that castration be performed Pajor); Beef Welfare Research Group, Lethbridge Research at the youngest age possible and with the use of pain mitigation Centre, Agriculture and Agri-Food Canada, 5403 1st Avenue S, (5), although typically castration is performed without pain Lethbridge, Alberta T1J 4B1 (Marti, Schwartzkopf-Genswein, relief (1). Meléndez, Gellatly). Tissue repair or wound healing follows 4 phases that overlap: Address all correspondence to Dr. Karen Schwartzkopf- hemostasis, inflammation, proliferation, and tissue remodeling Genswein; e-mail: [email protected] (6). During the inflammation phase prevention of infection Use of this article is limited to a single copy for personal study. plays an important role in healing, as this phase persists as long Anyone interested in obtaining reprints should contact the as required to remove bacteria and exudate from the wound (7). CVMA office ([email protected]) for additional A study conducted by Mintline et al (8) evaluated the effect copies or permission to use this material elsewhere. of flunixin meglumine administered at the time of castration

CVJ / VOL 58 / OCTOBER 2017 1081 FOR PERSONAL USE ONLY

on wound healing rate, scrotal size, and inflammation; no as far up as possible. The sterilized emasculator was then used improvements were reported. Several topical wound healing to crimp the cord then held in place for 30 to 60 s to crush products are commercially available with recommended use in the blood vessels. The process was repeated for the remaining improving post-castration wound healing in cattle. However, testicle. Immediately after castration, each healing agent was no studies assessing the efficacy of these products for castration applied according to the manufacturer’s specifications. wounds have been published. The objective of this work was to Animals were weighed on day 21 and BW records were used evaluate whether selected topical wound healing agents applied to block treatment groups on the day of castration. Animals were directly to the wound immediately after surgical castration also weighed on days 0, 1, 2, 5, and 7, and weekly thereafter would improve healing rate and reduce inflammation, secondary until day 49 to calculate average daily gain (ADG).

ARTICLE infection, and associated pain. Inflammation was measured using scrotal temperature and scrotal circumference. Thermographic images of the scrotal Materials and methods area were obtained before scrotal manipulation with a Flir i60 Angus bull calves (n = 48) 4 to 5 mo of age [body weight (BW) infrared camera (Flir systems, Burlington, Ontario) that was 187 kg 6 4.9 kg standard deviation (SD)] were managed held 1 m away from the scrotum of all calves on days 21, 0 according to the principles and guidelines of the Canadian (day of castration), 1, 2, 5, 7, and weekly until the end of the Council on Animal Care and the procedures were approved by experiment, when calves were restrained in the same positon in the local animal care committees at the Lethbridge Research the squeeze chute to maintain a consistent focus and view of Centre (ACC # 1523) and University of Calgary (AC15–0135) the image. The images were then processed with ThermaCam (9). Calves were transported approximately 30 km from a local QuickView 1.3 (Flir systems) which recorded the maximum ranch after weaning and groups of 12 calves were allocated and average temperatures. Scrotal circumference was measured to 1 of 4 feedlot pens (21 m 3 27 m) at the Agriculture and using a scrotal tape (Reliabull; Lane Manufacturing, Denver, Agri-Food Canada Lethbridge Research Centre, Lethbridge, Colorado, USA) on days 21, 0 (day of castration), 1, 2, 5, 7, Alberta, Canada. Animals were blocked by BW and allotted to and weekly until the end of the study (8). The clinical state 1 of the 4 treatments: control (CT, surgical castration without of the scrotum was scored on a 5-point scale, modified from the application of a post-operative wound healing agent), or Molony et al (11): 0 — No swelling, inflammation or infection surgical castration followed by either the application of a topical visible; 1 — Increasing degrees of swelling without obvious germicide (GR, Blue-Kote; Dr. Naylor Blu-Kote, Morris, New erythema; 2 — Increasing degree of swelling with obvious ery- York, USA), aluminum powder spray (AL, Aluspray; Vétoquinol, thema but without pus; 3 — Increasing degree of swelling with Buckingham, UK), or liquid bandage (LB, Champion seal; presence of pus; and 4 — Inflammatory response with presence KeriCure, Tampa, Florida, USA). Treatments were mixed within of pus with intervention needed. each pen (4 treatments per pen, 3 animals per treatment). Pens Wound healing or incision state was assessed following a had a centrally located water system and a concrete apron (2.4 m 5-point scale, also on days 21, 0, 1, 2, 5, 7, and weekly until 3 24.5 m) directly in front of the feed bunk. Calves were fed the end of the study: a total mixed ration (TMR) ad libitum. Two diets were used i) The incision ran the length of the scrotum and tissue was to gradually increase the percentage of silage during the study. exposed in this area. The incision had exudate, either wet During the first 3 d after arrival, calves were fed a diet consisting or dry. Scabbing was uncommon but may have been present of 47% chopped grass hay, 30% barley silage, 20% dry rolled in isolated locations at the edges or across the center of the barley, and 3% vitamin-mineral supplement (as fed basis), once wound; daily. The percentage of chopped grass hay was reduced to 10% ii) The incision was greater than approximately 3/4 the length between days 4 and 7 after arrival and barley silage was gradu- of the scrotum and scabbing was present. The incision may ally increased to 67%. On day 9 after arrival, hay was removed have had exudate either wet or dry; from the ration and calves remained on this diet until the end iii) The incision was scabbed or open and was less than 3/4 of of the trial (77% barley silage, 20% dry rolled barley, and 3% the scrotum. The incision site may also have had exudate, vitamin-mineral supplement). Calves were provided with fresh either wet or dry; water ad libitum. iv) The wound/incision site was less than 1/4 of the scrotum. On the day of castration (day 0) all calves received anesthesia A small scab or discoloration was present at the center of via an epidural injection of xylazine (Rompun 20 mg/mL inject- the scrotum/wound site. This wound may have had exudate, able; Bayer Health, Toronto, Ontario), 0.07 mg/kg BW, 20 min wet or dry; and before castration (10). The scrotum of each bull calf was cleaned v) The incision site was no longer visible, there was no tissue with disinfectant wipes (Wet Ones, Antibacterial hand wipes; exposed anywhere on the scrotum. There was no scabbing Edgewell Operations, St. Louis, Missouri, USA) immediately and or dried exudate (8). before surgical castration. The scrotum was opened using a Castration wounds were considered completely healed when Newberry knife inserted into the side of the scrotum, closed no swelling, inflammation, or infection was observed, and when and pulled down to make a large side-to-side incision across there was no opening along the incision site. the entire scrotum and dividing the septum. With the testes Pain sensitivity was assessed using a Von Frey anesthesiometer descended partially below the bottom of the opened scrotum, (electronic von Frey anesthesiometer with rigid tip; 0 to 1000 g; one testis was extended downward and the cord was isolated IITC-Life Science Instruments, Woodland Hills, California,

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Table 1. Least squares means of scrotal temperature, pain sensitivity, and scrotal circumference of recently weaned beef calves assessed for 49 d after surgical castration without the application of a post- operative healing agent (CT) or with the application of a topical germicide (GR), aluminium powder spray (AL), or liquid bandage (LB) Treatment P-value Item CT GR AL LB SEM HA day HA 3 day

Average scrotal temperature (°C) 27.8 28.5 27.5 28.1 0.33 0.15 , 0.001 0.81 ARTICLE Maximum scrotal temperature (°C) 33.4 33.8 32.6 33.2 0.38 0.18 , 0.001 0.14 Pain sensitivity skina (g) 534 452 554 502 30.8 0.10 , 0.001 0.09 Pain sensitivity wounda (g) 430 400 478 451 36.5 0.47 , 0.001 0.96 Scrotal circumference (cm) 15.7 15.6 16.0 15.6 0.24 0.57 , 0.001 0.60

a Maximum pressures exerted using a Von Frey anesthesiometer. HA — healing agent effect; day — assessed on days 1, 2, 4, 7, and weekly until day 49; CT — control; GR — topical germicide; AL — aluminum powder spray; LB — liquid bandage; SEM — standard error of the mean

USA) in 2 areas, directly on the wound and on the skin sur- on the skin required to obtain a response from the calves was rounding the wound on the same days that wound healing rate 637 g 6 53.9 g. Although no differences were observed among was measured (12,13). To measure pain sensitivity, calves were treatments on days 1 and 2, pressure thresholds were reduced standing in the chute unrestrained; the tip of the anesthesiom- (P , 0.001) to 442 g 6 52.9 g and 331.1 g 6 53.9 g, for days 1 eter was then placed on the surface of the scrotum and pres- and 2, respectively, compared with days 21 and 0. Values of sure was gradually exerted against the scrotum until the calves pain sensitivity remained lower and similar (P . 0.10) to the responded (tail flick, kick, and step forward or backwards). The pain values on days 1 and 3 until day 14, when values started tip of the anesthesiometer was immediately withdrawn and the to increase (P , 0.001). On day 42, when wounds were almost maximum pressure elicited was recorded. Greater values indi- completely healed (no swelling, inflammation or infection, and cated less pain sensitivity. almost complete closure of the incision), pressure threshold With calf as the experimental unit, all data including BW, values increased (P , 0.001) to values similar to those observed scrotal temperature from thermographic images, scrotal circum- on day 21 (708.1 g 6 53.9 g). ference, and pain sensitivity were analyzed using a mixed-effect A HA 3 day interaction (P , 0.09) was observed in pain model (SAS 9.4; SAS Institute, Cary, North Carolina, USA) sensitivity on the surrounding skin from 48 h until day 21 with repeated measures. Healing agent (HA), day, and their post-castration (Figure 1). Calves assigned to the GR treatment interactions (HA 3 day) were included as fixed effects, and exhibited the greatest pain sensitivity (P , 0.10) on days 2, 5, calf within pen as a random effect. Time point was considered 7 and 21 compared to CT calves, and on days 2, 5, 7, 14, and a repeated factor and was subjected to 3 variance-covariance 42 (P , 0.10) compared to AL calves. The calves in the LB structures: compound symmetry, autoregressive order one, and group did not differ from those in the other treatments except unstructured. The covariance structure that minimized Schwarz’s on day 42 (P = 0.05) during which they exhibited more pain Bayesian information criterion was considered the most desir- sensitivity than did AL calves. However, on days 2 and 5, the able analysis. Results are reported as least square means and a pressure threshold was numerically closer to that of GR calves post-hoc test (PDIFF option of SAS) was used to compare the than to those of CT and AL calves. No differences (P = 0.48) adjusted means. were observed in pain sensitivity on the wound. Clinical state of the scrotum and wound healing score were No treatment differences were observed for final BW analyzed with a Wilcoxon-Mann-Whitney test (SAS 9.4; SAS (P = 0.87) or ADG (P = 0.86; Table 2). Institute) to evaluate the effect of HA on healing time (d). Medians and 95% distribution free confidence limits were Discussion calculated with univariate procedure (SAS 9.4; SAS Institute). Although many studies have assessed various pain mitigation For all analyses, significance was declared at P # 0.05 and strategies during and after castration (10,14–16) few studies tendencies were discussed at 0.05 , P # 0.10. have assessed strategies to improve wound healing and reduce the pain associated with the wound (8). Healing is a complex Results event involving multiple interactions of different tissue struc- No treatment differences were observed on maximum (P = 0.18) tures, a large number of biochemical substances and infiltrating or average (P = 0.15) temperatures of the scrotum (Table 1) and cell types (17). In addition, there are several other factors that scrotal circumferences (P = 0.60; Table 1) were similar among could affect the rate of wound healing such as animal age or treatments for 49 d after castration. The time to reach each environmental conditions. For example, surgically castrated wound or incision healing score (Z , 2.96; P . 0.10) and calves have been shown to spend more time standing after the clinical state of the scrotum (Z , 4.72; P . 0.10) did not differ surgery due to the pain caused by the procedure (18). As calves among healing agents over the 49-day study. in the present study were housed in feedlot pens rather than There were no differences in pain sensitivity among calves on pasture, it is likely that the open castration wound came before castration. When the testicles were intact (measurement into contact with the dirt/manure floor and increased the risk taken on days 21 and 0 before castration) the mean pressure of contamination and infection of the wounds. This may have

CVJ / VOL 58 / OCTOBER 2017 1083 FOR PERSONAL USE ONLY ARTICLE Max pressure exerted (g) exerted pressure Max

Time (days)

Figure 1. Pain sensitivity as maximum pressure (g) exerted with an anesthesiometer in relation to time (d) post-castration without the application of a post-operative healing agent (CT) or with the application of a topical germicide (GR), aluminium powder spray (AL), or liquid bandage (LB) on recent weaned beef calves.

Table 2. Least squares means of body weight and average daily after castration in calves castrated at 25 d of age. Based on the gain of recently weaned beef calves after surgical castration without the application of a post-operative healing agent (CT) or results of these studies and the present study, older calves seem with the application of a topical germicide (GR), aluminium powder to take longer to heal than younger calves; therefore, age may spray (AL), or liquid bandage (LB) play a large role in the rate of healing after surgical castration. Treatment P-value Furthermore, castration at younger ages facilitates manage- ment, and reduces stress and risk of disease due to reduced Item CT GR AL LB SEM HA testicular development (22,23). The CVMA recommends that Initial BW, kg 185 187 188 187 4.91 0.98 castration be performed in animals as young as possible to Final BW (d 49), kg 245 248 245 246 2.75 0.87 ADG (d 49), kg/d 1.20 1.25 1.19 1.20 0.056 0.87 reduce the adverse effects of the procedure. However, there is still a large percentage of cattle castrated at weaning and later HA — healing agent effect; ADG — average daily gain; CT — control; GR — topical germicide; AL — aluminum powder spray; LB — liquid bandage; SEM — in life (1). In addition, when castration is performed in recently standard error of the mean. weaned calves, cell types involved in the healing process (mainly leukocyte subsets) may be reduced due to the immunosuppres- reduced the effect of the healing agents and future studies should sive effect associated with weaning stress, making calves more compare pasture-housed versus feedlot housed calves. Complete susceptible to infection and morbidity (24,25). When infection healing of skin wounds normally occurs within 6 to 8 wk (19) occurs during the inflammation phase of the healing process, according to 4 overlapping phases: hemostasis, inflammation, the wound may become chronic (7) as the extended inflam- repair or proliferation, and remodeling (6,20). It is important to mation does not allow the proliferation and remodeling phase note that wound healing after castration not only involves the to proceed normally, thereby extending the healing time (26). skin but also healing of the spermatic cords. In the present study, In the present study, the application of healing agents did not based on the clinical state of the scrotum, the inflammation reduce or prolong the inflammation phase most likely because phase lasted approximately 14 d after surgery, while the healing we did not observe chronic wounds. In addition, the applica- of the incision primarily occurred after 35 d. Molony et al (11) tion of healing agents did not reduce healing time; thereby, not reported that swelling was completely gone 9 d after surgical making the wound healing process in each phase faster. The castration in 5- to 7-day-old calves. However, in a study of 2- wound healing agents tested in this study were selected based on to 4-month-old beef calves by Stafford et al (21), swelling was their ability to facilitate wound drainage. However, as observed gone 14 d after castration, and the wound was completely healed by the greater values of pain sensitivity from days 2 to 14, and after 48 d (21). Similarly, Mintline et al (8) reported the most the numerically greater clinical state values on days 2 and 5, pronounced increase in healing occurred between 21 and 35 d and from days 28 to 35, the AL spray may not have facilitated

1084 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY drainage from the scrotum resulting in the formation of scar 9. Canadian Council on Animal Care. 2009. CCAC guidelines on: The tissue in the spermatic cords. care and use of farm animals in research, teaching, and testing. Canadian Council on Animal Care, Ottawa, Ontario, Canada. Despite the lack of differences in the healing process, we 10. González LA, Schwartzkopf-Genswein KS, Caulkett NA, et al. Pain observed that calves had sensitive skin (measured with the Von mitigation after band castration of beef calves and its effects on per- Frey anesthesiometer) until 35 d after castration when inflam- formance, behavior, Escherichia coli, and salivary cortisol. J Anim Sci 2010;88:802–810. mation had declined (as observed by clinical state of the scrotum 11. Molony V, Kent JE, Robertson IS. Assessment of acute and chronic score , 2) and the incision was less than 3/4 of the scrotum pain after different methods of castration of calves. Appl Anim Behav ARTICLE (as observed by wound healing score , 3). These findings indi- Sci 1995;46:33–48. 12. Lomax S, Windsor PA. Topical anesthesia mitigates the pain of castra- cate that calves continue to feel pain during the inflammation tion in beef calves. J Anim Sci 2013;91:4945–4952. phase and pain is not reduced until the remodeling phase of the 13. Tucker CB, Mintline EM, Banuelos J, et al. Effect of a cooling gel wound is achieved. on pain sensitivity and healing of hot-iron cattle brands. J Anim Sci 2014;92:5666–5673. Our results indicate that the topical wound healing agents 14. Ting STL, Earley B, Crowe MA. Effect of repeated ketoprofen used in this study did not improve wound healing. However, administration during surgical castration of bulls on cortisol, immu- information regarding healing time and the length of pain sen- nological function, feed intake, growth, and behavior. J Anim Sci 2003;81:1253–1264. sation associated with these types of wounds was documented. 15. Pang WY, Earley B, Sweeney T, Crowe MA. Effect of carprofen admin- Further studies on castration methods (both surgical and band istration during banding or burdizzo castration of bulls on plasma  techniques) and wound healing according to age, breed, types cortisol, in vitro interferon- production, acute-phase proteins, feed intake, and growth. J Anim Sci 2006;84:351–359. of incision, and environmental factors are needed to develop 16. Repenning PE, Ahola JK, Callan RJ, et al. Effect of pain mitigation and strategies to reduce healing time and secondary infections in method of castration on behavior and feedlot performance in cull beef castrated beef calves. bulls. J Anim Sci 2013;91:4964–4974. 17. Gillitzer R, Goebeler M. Chemokines in cutaneous wound healing. J Leukoc Biol 2001;69:513–521. Acknowledgments 18. White BJ, Coetzee JF, Renter DG, Babcock AH, Thomson DU, The authors appreciate the invaluable help of Agriculture Andersen D. Evaluation of two-dimensional accelerometers to monitor beef cattle behavior post-castration. Am J Vet Res 2008;69:1005–1012. and Agri-Food Canada research feedlot staff, our technicians 19. Basu S, Shukla V. Complications of wound healing. In: Mani R, Randy E Wilde and Fiona Brown, and Dr. Cassandra Tucker Romanelli M, Shukla V, eds. Measurements in Wound Healing. for help in the statistical analysis. We are very thankful for the Science and Practice. London, United Kingdom: Springer-Verlag, 2012:109–144. funding provided by the Beef Cattle Research Council through 20. Schultz GS, Gibson DJ. Measurement of biomarkers for impaired the Canadian Beef Industry Science Cluster. This article is healing in fluids and tissues. In: Mani R, Romanelli M, Shukla V, eds. Measurements in Wound Healing. Science and Practice. London, United Lethbridge Research Centre contribution # 16054 CVJ Kingdom: Springer-Verlag, 2012:243–258. 21. Stafford KJ, Mellor DJ, Todd SE, Bruce RA, Ward N. Effect of local References anesthesia or local anesthesia plus a non-steroidal anti-inflammatory 1. Coetzee JF, Nutsch AL, Barbur LA, Bradburn RM. A survey of castra- drug on the acute cortisol response of calves to five different methods tion methods and associated livestock management practices performed of castration. Res Vet Sci 2002;73:61–70. by bovine veterinarians in the United States. BMC Vet Res 2010;6:12. 22. Robertson IS, Kent JE, Molony V. Effect of different methods of castra- 2. Turner AS, McIlwraith CW. Techniques in Large Animal Surgery. 4th tion on behaviour and plasma cortisol in calves of three ages. Res Vet ed. Philadelphia, Pennsylvania: Lea and Febiger, 2013. Sci 1994;56:8–17. 3. Moggy MA, Pajor EA, Thurston WE, et al. Management practices 23. Bretschneider G. Effects of age and method of castration on perfor- associated with pain in cattle on western Canadian cow-calf operations: mance and stress response of beef male cattle. A review. Livest Prod A mixed methods study. J Anim Sci 2017;95:958–969. Sci 2005;97:89–100. 4. Warnock TM, Thrift TA, Irisk M, et al. Effect of castration technique 24. Lynch EM, McGee M, Doyle S, Earley B. Effect of pre-weaning con- on beef calf performance, feed efficiency, and inflammatory response. centrate supplementation on peripheral distribution of leukocytes, J Anim Sci 1995;90:2345–2352. functional activity of neutrophils, acute phase protein and behavioural 5. Canadian Veterinary Medical Association. Castration of cattle, sheep, responses of abruptly weaned and housed beef calves. BMC Vet Res and goats. Position statement. Available from: https://www.canadian 2012;8:1. veterinarians.net/documents/castration-cattle-sheep-goats. Last accessed 25. Lynch EM, McGee M, Doyle S, Earley B. Effect of post-weaning man- July 31, 2017. agement practices on physiological and immunological responses of 6. Boughton G, Janis JE, Attinger CE. The basic science of wound healing. weaned beef calves. Irish J Agr Food Res 2011;50:161–174. Plast Reconstr Surg 2006;117:12–34. 26. Schreml S, Szeimies RM, Prantl L, Landthaler M, Babilas P. Wound 7. Harper D, Young A, McNaught CE. The physiology of wound healing. healing in the 21st century. J Am Acad Dermatol 2010;63:866–881. Surgery 2014;32:445–450. 8. Mintline EM, Varga A, Banuelos J, et al. Healing of surgical castra- tion wounds: A description and an evaluation of flunixin. J Anim Sci 2014;92:5659–5665.

CVJ / VOL 58 / OCTOBER 2017 1085 FOR PERSONAL USE ONLY Article

Association of unmeasured strong ions with outcome of hospitalized beef and dairy diarrheic calves

Diego E. Gomez, Jeanne Lofstedt, Luis G. Arroyo, Maureen Wichtel, Tammy Muirhead, Henri Stämpfli, J. Trenton McClure

Abstract — Increased systemic concentrations of L-lactate and unmeasured strong ions (USI) are associated with an increased risk of mortality in human neonates and adults suffering from various diseases. This exploratory study aimed to investigate if values of certain acid-base parameters, especially L-lactate and USI, on admission to hospital are associated with mortality in diarrheic calves. Fifty-five calves , 28 days old admitted to 2 teaching hospitals for diagnosis and treatment of diarrhea were included. Admission demographic, physical examination, blood gas and biochemistry analysis, and outcome data were recorded. Admission acid-base values associated with outcome were assessed using multivariable regression modeling. Calves with elevated plasma L-lactate (OR: 1.30, 95% CI: 1.08 to 1.55; P = 0.005) and USI (OR: 1.40, 95% CI: 1.12 to 1.74; P = 0.003) at admission were more likely to die or to be euthanized. This study revealed that elevated concentrations of L-lactate and USI at admission were positively associated with mortality.

Résumé — Association des ions forts non mesurés avec les résultats des veaux de boucherie et laitiers diarrhéiques hospitalisés. Des concentrations systémiques accrues de L-lactate et des ions forts non mesurés (IFN) sont associées à un risque accru de mortalité chez les nouveau-nés humains et les adultes souffrant de diverses affections. Cette étude exploratoire visait à vérifier si les valeurs de certains paramètres acides, particulièrement L-lactate et IFN, à l’admission à l’hôpital sont associées à la mortalité chez les veaux diarrhéiques. Cinquante-cinq veaux âgés de , 28 jours admis à deux hôpitaux d’enseignement pour le diagnostic et le traitement ont été inclus. Les données démographiques, l’examen physique, les valeurs des gaz sanguins et de l’analyse biochimique du sang ainsi que l’issu des animaux ont été consignés. Les valeurs de l’équilibre acide-base à l’admission associées à l’issu des animaux ont été évaluées en utilisant une modélisation de régression multi-variable. Il était plus probable que les veaux avec du L-lactate plasmatique élevé (RC : 1,30, IC 95 %, 1,08 à 1,55; P = 0,005) et IFN (RC : 1,40, IC de 95 %, 1,12 à 1,74; P = 0,003), à l’admission meurent ou soient euthanasiés. Cette étude a révélé que des concentrations élevées de L-lactate et d’IFN à l’admission étaient positivement associées à la mortalité. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1086–1092

Introduction approach states that plasma [H1] is determined by 3 indepen- , iarrhea is the most important disease in calves 30 d of dent factors: pCO2, strong ion difference (SID), and total weak 2 D age (1). Metabolic acidosis is the most common acid-base acid concentration (Atot ) (10). The PCO2 levels influence pH disorder occurring in calves with diarrhea (2–7). The quantita- through chemical equilibrium and depend on alveolar ventila- tive physicochemical approach is a precise method for assessing tion and metabolic CO2 production (11). Strong ion difference metabolic acidosis and provides insight into the main under­ accounts for the contribution of the strong cations (Na1, K1, lying mechanisms that contribute to the acidemia (8,9). This Ca21, Mg21) and strong anions [principally Cl2, L-lactate2

Department of Health Management, Atlantic Veterinary College (AVC), University of Prince Edward Island, Charlottetown, Prince Edward Island (Gomez, Lofstedt, Wichtel, Muirhead, McClure), Department of Clinical Studies, Ontario Veterinary College (OVC), University of Guelph, Guelph, Ontario (Arroyo, Stämpfli); Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Florida, USA (Gomez). Address all correspondence to Dr. Diego Gomez; e-mail: [email protected] The authors disclose no conflict of interest. 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.

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2 2 2 2 (L-lac ), D-lactate (D-lac ), uremic anions, ketoacids, and HCO3 (mmol/L) were determined using a portable IRMA true unmeasured strong ions] to the acid-base balance (8–10). The point blood gas analyzer [International Technidyne Corporation 2 1 1 2 2 (Atot ), includes important non-volatile weak buffers such as (ITC), Edison, New Jersey, USA]. Plasma Na , K , Cl , L-lac , albumin, globulins, and phosphate that also exert an indepen- and creatinine were measured using a Cobas 6000 C501 auto- dent effect on plasma pH (9,10). The mechanisms contributing mated multianalyzer (Roche Diagnostics, Indianapolis, Indiana, to acid-base disorders in sick and diarrheic calves include hypo- USA). At the OVC, venous blood pH, pvCO2 (mmHg), and 2 1 1 2 natremia, accompanied by normochloremia or hyperchloremia, calculated HCO3 (mmol/L) and strong ions (Na , K , Cl , ARTICLE and increased unmeasured strong anions, commonly D-lac2 and and L-lac2) were assayed using a Radiometer 800 Flex blood gas L-lac2 (6,7,12–14). machine (Radiometer medical APs, Bronshoj, Denmark). The Increased concentration of unmeasured strong ions (USI) concentration of the strong electrolytes was measured on both other than L- and D-lac2 has been reported in critically ill analyzers using ion-selective electrode technology based on direct human patients (15,16). The mechanisms resulting in increased (OVC) and indirect (AVC) potentiometric measuring principles. concentrations of USI are not fully understood; however, con- All blood gas analyses were corrected for the calf’s rectal tem- centrations are increased in patients with endotoxemia (16), perature. Total plasma protein was assessed as total solids using tissue hypoperfusion (16), and renal and hepatic impairment visual refractometry in both hospitals. Plasma D-lac2 was mea- (17,18). Similar to L-lac2, USI are associated with an increased sured with an enzymatic method using D-lac2 dehydrogenase risk of mortality in human neonates and adults suffering from (21) following the manufacturer’s instructions with a range various diseases (15–19). One study in calves assessed the of detection between 0.0 to 30 mmol/L (BioVision; Mipitas, prognostic value of L-lac2 and D-lac2 for hospital mortality California, USA). For D-lac2, all assays were performed in and failed to detect an association between L-lac2 and D-lac2 triplicate and the mean of these measurements was taken as the values and calf mortality (13). There is little information on the plasma concentration of D-lac2. The b-hydroxybutyrate (bHB) association between USI and mortality in calves with neonatal concentration was determined using an electrode specific assay diarrhea. following the manufacturer’s instructions (Precision xtra; Abbot We hypothesized that admission values of biochemical and Diabetes Care, Alameda, California, USA). The range of detec- acid-base parameters, especially L-lac2 and USI, are associated tion of bHB concentration in plasma was 0.0 to 8.0 mmol/L. with hospital mortality in calves with diarrhea. The objective of For both D-lac2 and bHB determination, blood samples were this exploratory study was to investigate if admission values of centrifuged within 30 min of collection and plasma was har- independent acid-base and biochemical variables in calves with vested and frozen at 280°C until analysis. Plasma D-lac2 and diarrhea were associated with mortality during hospitalization. bHB concentrations were also assessed in 10 calves (control) presented to the teaching hospitals for umbilical hernias (n = 5) Materials and methods and non-infectious orthopedic abnormalities (n = 5). The lower Study population and data collection and higher ranges were used as reference range. This prospective study was conducted with 55 calves admit- ted to the Atlantic Veterinary College Veterinary Teaching Calculations Hospital (AVC) (n = 37) and the Ontario Veterinary College Physicochemical variables were calculated as follows (6): 2 (OVC) (n = 18) for diagnostic workup and treatment of acute • Total plasma concentration of weak acids (Atot ) was cal- 2 3 diarrhea. Calves were eligible for enrolment in the study if they culated as: Atot (mmol/L) = [0.343 (TP)], where total were , 28 d of age, had a diagnosis of neonatal diarrhea (20), protein (TP) is in g/L (6). and if blood gas and plasma biochemical profile values were • Total negative charge of the plasma proteins A2 (mmol/L) 2 2 1 (pKa 2 pH) determined within 2 h after admission, and before administra- was calculated as: A (mmol/L) = [Atot ]/(1 10 ), tion of intravenous or oral fluids in the hospital. On admis- where pKa (7.08) is the effective dissociation constant of sion, demographic and physical examination data, volume bovine plasma weak acids. and type of oral fluids, and antimicrobials administered before • Strong ion difference (SID, mmol/L) has 2 components: mea- presentation were recorded. Calves suffering from umbilical sured strong ion difference (SIDm) and unmeasured strong infection, meningitis, or musculoskeletal diseases (e.g., septic ion difference (USI, mmol/L) (6). The SIDm was calculated arthritis) were excluded from the study. Survival was defined using the measured plasma concentrations of 5 strong ions as: 1 1 1 2 1 2 1 2 as discharge from the hospital. This study was approved by the SIDm = (Na K ) — (Cl L-lac D-lac ), whereas 2 2 University of Prince Edward Island’s Animal Care Committee • USI was calculated as: USI = SIDm — HCO3 — A . (Protocol #13-024). Statistical analysis Sample collection and measurement techniques Descriptive analyses were performed on all variables. Normality Venous blood samples were collected in plastic blood collec- of the data was tested by the Kolmogorov-Smirnov test. The tion tubes (BD Vacutainer; Becton Dickinson, Mississauga, mean and standard deviation (SD) were calculated for normally

Ontario) containing K2EDTA (hematology) and sodium heparin distributed variables and the median and interquartile ranges (biochemical profile) from the jugular vein at the time of admis- (q25 and q75) were determined for non-normally distributed sion and before administration of oral or intravenous fluids. At variables. To determine which variables were associated with the AVC, venous blood pH, pvCO2 (mmHg), and calculated initial outcome, a Student t-test (for data normally distributed)

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Table 1. Demographic data, physical examination findings, treatment and outcome of 55 diarrheic calves presented to 2 Canadian veterinary teaching hospitals

Demographic data Treatment Gender AVC Female 43/55 (78%) Fluid therapy Male 12/55 (22%) OES 37/37 (100%) Breed Intravenous 37/37 (100%) Dairy 43/55 (78%) Antibiotics 31/37 (84%) Beef 12/55 (22%) NSAIDs 27/37 (73%) Age (days) OVC Median (range) 14 (2 to 28 d) Fluid therapy , ARTICLE 7 17/55 (31%) OES 18/18 (100%) 8 to 14 14/55 (25%) Intravenous 18/18 (100%) 15 to 21 10/55(18%) Antibiotics 18/18 (100%) 22 to 28 14/55 (25%) NSAIDs 7/18 (39%) Physical examination Outcome Heart rate (bpm) Survivors 33/55 (60%) Median (range) 116 (20 to 160) Non-survivors 22/55 (40%) Respiratory rate (rpm) Median (range) 32 (12 to 66) Treatment by outcome Temperature (°C) OES Median (range) 38.1 (35 to 40) Survivors 33/33 (100%) Nonsurvivors 22/22 (100%) Dehydrationa Intravenous Normal (, 5%) 8/55(15%) Survivors 33/33 (100%) Mild (5% to 7%) 9/55 (16%) Non-survivors 22/22 (100%) Moderate (8% to 9%) 20/55 (36%) Antibiotics Severe (10% to 12%) 18/55 (33%) Survivors 28/33 (85%) Non-survivors 21/22 (95%) Posture NSAIDs Standing 19/55 (35%) Survivors 22/33 (67%) Sternal 15/55 (27%) Nonsurvivors 12/22 (55%) Lateral 21/55 (38%) Etiology of diarrhea Attitude Cryptosporidium 20/48b (42%) Bright 10/55 (18%) BCoV 4/48b (8%) Obtunded 29/55 (53%) BRoV 1/48b (2%) Stuporous 16/55 (29%) Salmonella spp. 0/17b (0%) Suckling reflex Strong 15/55 (27%) Weak 19/55 (35%) Absent 21/55 (38%)

bpm — beats/min; rpm — respirations/min; AVC — Atlantic Veterinary College; OVC — Ontario Veterinary College; OES — oral electrolyte solutions; NSAIDs — non-steroidal anti-inflammatory drugs; BCoV — bovine coronavirus; BRoV — bovine rotavirus; ahydration status was based on extent of enophthalmos, skin elasticity on neck and thorax, capillary refill time and moistness of the mucous membranes; bnumber of samples tested for a given pathogen.

or Mann-Whitney U-test (for data non-normal distributed) was For the model, the Pearson residuals, the standardized Pearson used to compare survivors and non-survivors. Then, Spearman’s residuals, and the Δb values were computed for all covariate correlation coefficient was calculated to characterize associations patterns to determine if any specific covariate pattern had an between parameters. When 2 variables had a high correlation undue influence on the model (22). Goodness-of-fit was evalu- coefficient (R . 0.6) only 1 variable was entered into the model. ated using the Hosmer-Lemeshow goodness-of-fit Chi-square The variable of major clinical and biological importance was statistic. A P-value , 0.05 was considered significant. Statistical entered into the model. The following selected variables, hospi- analyses were done using statistical software (Minitab Software, tal, age (days), breed (dairy and beef), gender (male and female), Philadelphia, Pennsylvania, USA and STATA, StataCorp LP, 1 heart rate, temperature, respiratory rate, glucose, pvCO2, Na , College Station, Texas USA). 1 2 2 2 K , D-lac , L-lac , SIDm, USI, Atot and creatinine were screened using a univariable logistic regression (Student t-test Results or Mann-Whitney U-test). Variables with a P-value , 0.1 on Study population and physical examination univariable analysis were included in the multivariable logistic Data regarding demographic characteristics, physical examina- model (22). The multivariable model was a backward stepwise tion findings, treatment, and causes of the diarrhea are presented model, whereby variables were removed sequentially starting in Table 1. Cases were presented throughout the year, with the with those having the largest P-value. Once the final model was highest number of calves being admitted between April and selected, odds ratios (OR) and 95% confidence intervals (CI) September. Information on administration of oral rehydration were calculated. Interaction and quadratic terms were inves- solution (ORS) and antimicrobials within 24 h before admission tigated for significant predictors in the multivariable models. to the hospital was obtained in 27 (73%) of the calves presented

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Table 2. Admission values of clinical, biochemical, and acid-base parameters of survivors and non-survivors among calves with neonatal diarrhea Survivors Non-survivors Variable (n = 33) (n = 22) Reference range P-value Breed 0.005 Dairy 30 13 N/A Beef 3 9 N/A Heart rate (bpm) 114 (68 to 160) 120 (44 to 154) 80 to 120 0.395 ARTICLE Respiratory rate (rpm) 29 (16 to 60) 36 (12 to 66) 30 to 60 0.324 Temperature (°C) 39 (36 to 39.8) 37.2 (35 to 40) 38 to 39.5 0.003 Glucose (mmo/L) 4.6 (0.7 to 7.4) 4.5 (0 to 24) 2.5 to 4.3 0.971 Urea (mmol/L) 6.5 (2.8 to 23) 12 (1.3 to 42) 7 to 11 , 0.001 Creatinine (mmol/L) 88 (51 to 430) 164 (21 to 611) 67 to 175 0.01 Na1 (mmol/L) 132 6 7.3 137 6 10 132 to 152 0.05 K1 (mmol/L) 4.4 (2 to 10) 5.1 (2.6 to 9) 3.9 to 5.8 0.03 Cl2 (mmol/L) 97 6 8.6 98 6 9.4 95 to 110 0.79 L-lactate2 (mmol/L) 2 (0.5 to 13) 8 (1 to 16) 0.6 to 2.2 , 0.001 D-lactate2 (mmol/L) 2 (0 to 21) 2.1 (0 to 16) 0.0 to 3.2a 0.08 bHB (mmol/L) 0.1 (0 to 0.4) 0 (0 to 0.3) 0.0 to 0.2a 0.14 TPP (g/L) 65 6 11 65 6 13 57 to 81 0.87 pH 7.15 6 0.17 7.09 6 0.22 7.35 to 7.50 0.2

pvCO2 (mmHg) 41 (25 to 71) 48 (26 to 136) 34 to 45 0.01 2 6 6 HCO3 (mmol/L) 16 8 17 8 20 to 30 0.36 SIDm (mmol/L) 26 (16 to 44) 33 (19 to 52) 38 to 42 0.45 USI (mmol/L) 21.5 (28.5 to 3.2) 26 (212 to 1) 22 to 0 0.01 6 6 Atot (mmol/L) 22 4 22 4.5 13 to 25 0.82 Data are presented as mean 6 SD. Data with non-normal distribution are presented as median (range). P-values obtained from Student’s t-test (data with normal distribution) or Mann-Whitney U-test. Reference ranges are from references 22, 46, and 47; b b 2 bpm — beats/min; rpm — respirations/min; HB — -hydroxybutyrate; TPP — total plasma protein; HCO3 — bicarbonate; pvCO2 — venous partial carbon dioxide pressure; SIDm — measured strong ion difference; USI — unmeasured strong ions; a Atot, — total plasma concentration of non-volatile weak acids. Reference value determined in 10 control calves; N/A — Not available.

to AVC and 18 (100%) of the calves admitted to OVC. Of 33 (60%) had increased USI, 14 (25%) were hypoproteinemic, the 27 calves admitted to AVC 23 (85%) received ORS and and 5 (9%) were hyperproteinemic. Plasma bHB concentration 11 (41%) b-lactam antimicrobials (procaine penicillin and in all the diarrheic calves remained within the range determined sodium ceftiofur); 4 (15%) received long acting oxytetracycline, in the control calves (Table 2). and 4 (15%) received trimethoprim-sulfadoxine. All 18 calves admitted to OVC received ORS and 14 (78%) received sodium Factors associated with mortality in ceftiofur. The attending clinician established the treatment pro- hospitalized calves with diarrhea tocol for each calf (Table 1). All calves were treated for at least Spearman’s correlation coefficients of all blood parameters are 24 h and received isotonic intravenous fluids with or without presented in Table 3. Factors associated with hospital mortal- glucose and oral electrolytes. Thirty-three (60%) of the calves ity in the univariate analysis included rectal temperature upon 1 2 2 were discharged from the hospital, while 22 (40%) either died admission, breed, creatinine, pvCO2, Na , D-lac , L-lac , and (n = 4) or were euthanized (n = 18) due to a poor prognosis. USI. The final multivariate logistic regression model for pre- None of the calves were euthanized due to financial constraints. dicting hospital mortality included the variables plasma L-lac2 Survival was significantly different between dairy and beef calves (OR: 1.30, 95% CI: 1.08 to 1.55; P = 0.005) and USI (OR: (P = 0.005). Three (25%) of the 12 beef calves and 30 (70%) of 1.40, 95% CI: 1.12 to 1.74; P = 0.003) (Table 4). The addition the 43 dairy calves survived. There was no difference in survival of interaction terms for significant predictors failed to improve between female and male calves (P = 0.34). the model fit. The Hosmer and Lemeshow goodness-of-fit test confirmed that the data fit the model (P = 0.23). Electrolyte, biochemical, and acid-base abnormalities Discussion The results for venous blood gas analysis, concentrations of This study documents the presence of unmeasured strong electrolytes, plasma protein, and Henderson-Hasselbalch and ions (USI) other than D- and L-lac2 in beef and dairy calves physicochemical variables are presented in Table 2. Acid-base suffering from diarrhea. The etiology and physiopathology of and electrolyte variables, and plasma concentration of D- and increased levels of USI are poorly understood. Endogenous L-lac2 were not significantly different between calves in the anions may be generated in peripheral tissues during global age groups (, 7 d; 8 to 14 d; 15 to 21 d, and 22 to 28 d). At hypoxic states (15) and through hepatic impairment (16,17). admission, 22 calves (40%) were hyponatremic, 1 (2%) was Sepsis has also been implicated as a cause of increased USI in hypernatremic, 16 (29%) were hypokalemic, 12 (22%) were an experimental study (16,17). Inconsistent results have been hyperkalemic, 19 (35%) were hypochloremic, and 4 (7%) found regarding the contribution of Krebs’ cycle (TCA) interme- were hyperchloremic. In addition, 34 (62%) of the calves diates in human patients with anion gap acidosis (23,24). One had hyper-L-lactatemia, 25 (45%) had hyper-D-lactatemia, study found that the USI could be explained by the presence of

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Table 3. Spearman’s coefficients of correlation between selected clinicopathological variables in calves of the study population

2 1 1 2 pH pCO2 HCO3 SIDm USI Atot D-lac L-lac Creat TP Na K l C Urea pH 1.00

pCO2 0.22* 1.00 2 HCO3 0.87** 0.59** 1.00 SIDm 0.78** 0.49** 0.91** 1.00 USI 0.43** 0.1NS 0.33* 0.02NS 1.00 NS 2 NS 2 NS Atot 0.46** 0.00 0.33* 0.13 0.23 1.00 D-lac 20.51** 20.01NS 20.42** 20.47** 20.12NS 0.22NS 1.00 L-lac 0.30* 0.22NS 20.14NS 20.09NS 20.32* 0.24NS 20.01NS 1.00 Creat 20.42** 0.17NS 20.24NS 0.06NS 20.46** 0.50** 0.25NS 0.46** 1.00 ARTICLE TP 20.46** 0.00NS 20.33* 0.13NS 20.23NS 1.00** 0.02NS 0.24NS 0.5** 1.00 Na1 20.11NS 20.17NS 0.04NS 0.06NS 20.25* 20.1NS 0.50** 0.08NS 0.14NS 20.16NS 1.00 K1 20.20NS 0.31* 20.02NS 0.11NS 20.33* 0.28* 0.14NS 0.31* 0.39** 0.27* 0.18NS 1.00 Cl2 20.50** 20.32* 20.53** 20.54** 20.17NS 20.09NS 0.44** 20.00NS 20.01NS 20.1NS 0.61** 0.02NS 1.00 Urea 20.47** 20.11NS 20.41* 20.24NS 20.53** 20.09NS 0.14NS 0.50** 0.63** 20.08NS 0.12NS 0.21NS 0.14NS 1.00

, , NS 2 * P 0.05; ** P 0.001; — not significant; pCO2 — partial pressure of carbon dioxide; HCO3 — bicarbonate; SIDm — strong ion difference calculated from 5 strong cations and anions; USI — unmeasured strong ions; Atot — total weak acid concentration; Creat — creatinine; TP — total protein; L-lac — L-lactate; D-lac — D-lactate.

Table 4. Results of the multivariate logistic regression analysis of metabolism leading to hyper-L-lactatemia (12,28). Several stud- clinical, hematological, and biochemical variables associated with mortality in hospitalized diarrheic calves (n = 55) ies have illustrated that neonatal diarrhea may predispose calves to septicemia (1,22,29). One of the most common consequences Term OR SE 95% CI P-value of the septicemia is L-lactic acidosis (30), which is generated by L-lac 1.297 0.120 1.081 to 1.555 0.005 anerobic glycolysis combined with direct inhibition of pyruvate USI 1.402 0.157 1.125 to 1.748 0.003 dehydrogenase by endotoxin (15,30). In the present study, Constant 0.470 0.366 0.106 to 0.214 , 0.001 the plasma L-lactate concentrations in diarrheic calves appear L-lac — L-lactate; USI — unmeasured strong ions; OR — odds ratio; SE — 2 standard error; CI — confidence interval. higher compared with previous studies (2,3,5,6,12 14) and the mortality rate of diarrheic calves was also higher than previously high concentrations of amino acids (aspartate, isoleucine, and reported (7). A possible explanation for these differences is that ornithine) (0.07%), uric acid (2.2%), and organic acids (espe- our calves were presented later in the disease course with severe cially succinic acid, 5.6%), explaining only 7.9% of the USI dehydration, hypotension, and sepsis. Unfortunately, clinical value (24). Another study evaluating the causes of metabolic scores to assess the severity of the disease were not conducted acidosis in a canine hemorrhagic shock model found extremely and, therefore, conclusions cannot be drawn. high plasma concentrations of acetate and citrate, likely due to Increased USI have been demonstrated during early stages of mitochondrial dysfunction (25). Exogenous anion compounds major vascular injury (15), cardiac surgery (31), malarial sepsis in administered intravenous or oral fluids such as lactate, acetate, (32), and critical illness in children (33), and were associated citrate, and gluconate, as well as medications such as anion- with poor outcomes (15,34). While the source of the USI in containing b-lactam antibiotics, may contribute to USI (24,25). calves in this study was not determined, elevated USI concentra- Acetate and citrate are important components of commercially tions were associated with non-survival consistent with the stud- available oral electrolyte solutions used in the treatment of ies described. Thus admission plasma L-lac2 and USI concen- diarrheic calves. It is possible that exogenous anions included trations can be used to predict survival in calves with diarrhea. in the oral electrolyte products and/or b-lactam antimicrobials The odds ratio (OR) represents the factor by which the odds of contributed to the increased USI in this group of calves with mortality are increased for each one-unit (mmol/L) change in diarrhea (26). Some authors have suggested that bHB may also L-lac2 (OR: 1.30) and USI (OR: 1.40) (35). For example, with be present in elevated concentrations in sick animals (27), and a change in L-lac2 from 1 to 8 mmol/L the odds of mortality contribute to the changes in the acid-base balance. However, the change by OR(32 2 31) = 1.30(8 2 1) = 6.3. Therefore, a calf with results of this study did not support increased concentrations of an admission plasma concentration of L-lac2 8 mmol/L would bHB as a potential contributor to the USI. The equation used have 6.3 times greater odds of death or euthanasia during hos- to estimate the total plasma concentration of non-volatile weak pitalization than a calf with plasma L-lac2 of 1 mmol/L. In the

acids (Atot) in this study assumes a normal plasma concentration case of USI an absolute increase from 0 mmol/L to 5 mmol/L of phosphate (6). However, changes in plasma phosphates will results in an odds of mortality of: OR = 1.40(5 2 0) = 5.3. These 2 affect the calculation of plasma Atot and thus, overestimating findings highlight the importance of determining admission the plasma concentration of USI. Therefore, it is possible that plasma L-lac2 and USI in calves with diarrhea. Further research a marked increase in plasma phosphates (14) could have been evaluating serial L-lac2 measurement and USI calculation to responsible, at least partially, for increases in USI. determine whether delayed return to normal concentrations is This study showed that elevated levels of L-lac2 and USI associated with increased morbidity and mortality in calves with in calves with diarrhea were associated with mortality in the neonatal diarrhea is warranted. hospital. Calves with acute diarrhea develop intraluminal seques- Our study determined that hospitalized diarrheic dairy tration of fluid and profuse watery diarrhea. Hypoperfusion calves were more likely to survive than beef calves. The 2007 due to dehydration may result in tissue hypoxia and anaerobic National Animal Health Monitoring System United States

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(NAHMS-US) dairy report stated that 57% of calf deaths before Acknowledgments weanling resulted from diarrhea, with most cases occurring in The authors acknowledge Matt Saab for his technical assistance, calves , 1 mo of age (1). The 2007 NAHMS-US beef report and Henrik Stryhn and Carol McClure for their assistance in indicated that digestive problems, which were defined to include the statistical analysis. bloat, scours, parasites, enterotoxemia, accounted for 14% of losses in calves , 3 wk old (36). These studies suggest that References mortality associated with calf diarrhea in preweaned calves is 1. USDA. 2002. Part I: Reference of dairy health and management in the ARTICLE higher in dairy than beef farms. The reasons for these differences United States. USDA: APHIS: VS, CEAH, National Animal Health are not well-established, but factors related to calving season, Monitoring System, Fort Collins (CO) #N377.1202. Available from: https://www.aphis.usda.gov/animal_health/nahms/dairy/downloads/ herd size, interventions at calving, colostrum management, dairy02/Dairy02_dr_PartI.pdf Last accessed August 9, 2017. and castration impacted herd-level mortality in preweaned beef 2. Naylor JM. A retrospective study of the relationship between clinical calves (37,38). In dairy calves, management practices including signs and severity of acidosis in diarrheic calves. Can Vet J 1989;30: 577–580. colostrum management (failure of transfer of passive immunity), 3. Naylor JM. Severity and nature of acidosis in diarrheic calves over and treatment, and vaccination protocols for diarrhea can influence under one week of age. Can Vet J 1987;28:168–173. the incidence of diarrhea and therefore the associated mortal- 4. Kasari TR. Metabolic acidosis in diarrheic calves: The importance of alkalinizing agents in therapy. Vet Clinics North Am Food Anim Pract ity rates in each production system. 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Contribution of unmeasured anions to acid-base disorders and its There are several limitations to our findings, most notably association with altered demeanor in 264 calves with neonatal diarrhea. the select population of diarrheic calves referred to a teaching J Vet Intern Med 2013;27:1604–1612. 8. Constable PD. Clinical assessment of acid-base status: Comparison of hospital for treatment, which would tend to bias the study find- the Henderson-Hasselbalch and strong ion approaches. Vet Clin Pathol ings towards sicker calves with diarrhea. Treatment protocols 2000;29:115–128. for calves admitted to 2 different hospitals in this study were 9. Constable PD. A simplified strong ion model for acid-base equilibria: Application to horse plasma. J Appl Physiol 1997;83:297–311. similar; however, participating hospitals were not provided with 10. Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol a specific treatment protocol. This may have had an impact on Pharmacol 1983;61:1444–1446. the survival analysis. A blinded study design would have been 11. Brackett NC, Jr, Cohen JJ, Schwartz WB. Carbon dioxide titration curve of normal man. Effect of increasing degrees of acute hypercapnia ideal to guarantee that no single laboratory result influenced the on acid-base equilibrium. N Engl J Med 1965;272:6–12. decision to euthanize a calf. However, all calves were treated for 12. Ewasshuck JB, Naylor JM, Zelio GA. Anion gap correlates with serum at least 24 h, which decreased the probability that admission D- and DL-lactate concentration in diarrheic neonatal calves. J Vet clinicopathologic results did not affect a decision concerning Intern Med 2003;17:940–942. 13. Lorenz I. Influence of D-lactate on metabolic acidosis and on prognosis whether or not the calf should be treated or euthanized. At both in neonatal calves with diarrhea. 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Splanchnic buffering institutions may have had an effect on the measurement of of metabolic acid during early endotoxemia. J Crit Care 1997;12:7–12. 18. Porta F, Takala J, Weiikert C, et al. Effects of prolonged endotoxemia plasma strong ions, and therefore the calculation of SIDm and on liver, skeletal muscle and kidney mitochondrial function. Crit Care USI (42). The values for Na1, K1, Cl2, measured by indirect 2006;10:1–12. ion selective electrode technology, differ from those measured 19. Kellum JA. Unknown anions and gaps in medical knowledge. Pediatr Crit Care Med 2005;6:373–374. by direct technology whenever the plasma protein concentra- 20. Radostits OM, Gay CC, Hinchcliff KW, Constable PD. Diseases associ- tions are above or below 70 g/L (42–44). Therefore, direct ion ated with bacteria. Appendix 2. In: Radostits OM, Gay CC, Hinchcliff selective electrode technologies are recommended when accu- KW, Constable PD, eds. Veterinary Medicine. 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24. Moviat M, Terpstra AM, Ruitenbeek W, Kluijtmans LA, Pickkers P, 35. Dohoo I, Martin S, Stryhn H. Veterinary Epidemiologic Research. van der Hoeven JG. Contribution of various metabolites to the “unmea- 2003. AVC Inc., Charlottetown, Prince Edward Island. sured” anions in critically ill patients with metabolic acidosis. Crit Care 36. USDA. 2010. Mortality of Calves and Cattle on US Beef Cow-calf Med 2008;36:752–758. Operations. USDA: APHIS: VS, CEAH, National Animal Health 25. Bruegger D, Kemming GI, Jacob M, et al. Causes of metabolic acido- Monitoring System, Fort Collins (CO) #N377.1202. Available from: sis in canine hemorrhagic shock: Role of unmeasured ions. Crit Care https://www.aphis.usda.gov/animal_health/nahms/beefcowcalf/down 2007;11:1–4. loads/beef0708/Beef0708_is_Mortality.pdf Last accessed August 9, 26. Mueller K, Gentile A, Klee W, Constable PD. Importance of the effec- 2017. tive strong ion difference of an intravenous solution in the treatment 37. Dutil L, Fecteau G, Bouchard E, Dutremblay D, Paré J. A question- of diarrheic calves with naturally acquired academia and strong ion naire on the health, management, and performance of cow-calf herds (metabolic) acidosis. J Vet Intern Med 2012;26:674–683. in Québec. Can Vet J 1999;40:649–656. 27. Morgan TJ, Cowley DM, Weier SL, Venkatesh B. Stability of the strong 38. Murray CF, Fick LJ, Pajor EA, Barkema HW, Jelinski MD, Windeyer

ARTICLE ion gap versus the anion gap over extremes of PCO2 and pH. Anaesth MC. Calf management practices and associations with herd-level Intensive Care 2007;35:370–373. morbidity and mortality on beef cow-calf operations. Animal 2016;10: 28. Gomez DE, Arroyo LG, Staempfli HR, Cruz LE, Oliver OJ. 468–477. Physicochemical interpretation of acid-base abnormalities in 54 horses 39. Windeyer MC, Leslie KE, Godden SM, Hodgins DC, Lissemore KD, with acute severe colitis and diarrhea. J Vet Intern Med 2013;27: LeBlanc SJ. Factors associated with morbidity, mortality, and growth 548–553. of dairy heifer calves up to 3 months of age. Prev Vet Med 2014;113: 29. Fecteau G, Paré J, Van Metre DC, et al. Use of a clinical sepsis score for 231–240. predicting bacteremia in neonatal dairy calves on a calf rearing farm. 40. Torsein M, Jansson-Mörk M, Lindberg A, Hallén-Sandgren C, Berg C. Can Vet J 1997;38:101–104. Associations between calf mortality during days 1 to 90 and herd-level 30. Ince C. The microcirculation is the motor of the sepsis. Crit Care cow and production variables in large Swedish dairy herds. J Dairy Sci 2005;9:13–19. 2014;97:6613–6621. 31. Durward A, Tibby SM, Skellett S, Austin C, Anderson D, Murdoch 41. Svensson C, Linder A, Olsson SO. Mortality in Swedish dairy calves IA. The strong ion gap predicts mortality in children following cardio- and replacement heifers. J Dairy Sci 2006;89:4769–4777. pulmonary bypass surgery. Pediatr Crit Care Med 2005;6:281–285. 42. Stämpfli HR, Schoster A, Constable PD. Clinical utility of serum 32. Dondorp AM, Chau TT, Phu NH, et al. Unidentified acids of strong biochemical variables for predicting acid-base balance in critically ill prognostic significance in severe malaria. Crit Care Med 2004;32: horses. Vet Clin Pathol 2014;43:547–556. 1683–1688. 43. Dimeski G, Barnett RJ. Effects of total plasma protein concentration on 33. Balasubramanyan N, Havens PL, Hoffman GM. Unmeasured anions plasma sodium, potassium and chloride measurements by an indirect ion identified by the Fencl–Stewart method predict mortality better than selective electrode measuring system. Crit Care Resusc 2005;7:12–15. base excess, anion gap, and lactate in patients in the pediatric intensive 44. Dimeski G, Morgan TJ, Presneill JJ, Venkatesh B. Disagreement care unit. Crit Care Med 1999;27:1577–1581. between ion selective electrode direct and indirect sodium measure- 34. Kellum JA. Unknown anions and gaps in medical knowledge. Pediatr ments: Estimation of the problem in a tertiary referral hospital. J Crit Crit Care Med 2005;6:373–374. Care 2012;27:326.e9–16.

1092 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Article

Prevalence and clinical features of hypoadrenocorticism in Great Pyrenees dogs in a referred population: 11 cases

Magali Decôme, Marie-Claude Blais

Abstract — Naturally occurring hypoadrenocorticism (Addison’s disease) is uncommon, with an estimated prevalence in the canine population between 0.06% and 0.28%. This retrospective study evaluated the prevalence and clinical features of hypoadrenocorticism in Great Pyrenees (GP) dogs presented to the Centre Hospitalier Universitaire Vétérinaire of the University of Montreal between March 2005 and October 2014. During this period, 100 dogs were diagnosed with hypoadrenocorticism, representing 0.38% [95% confidence interval (CI): 0.26% to 0.5%] of the canine population studied. The highest prevalence was observed in GP (9.73%, 95% CI: 9.12% to 10.35%, P , 0.0001), followed by West Highland white terriers (4.66%, 95% CI: 4.24% to 5.09%, P , 0.0001), Great Danes (1.87%, 95% CI: 1.6% to 2.14%, P , 0.0001), standard poodles (1.76%, 95% CI: 1.5% to 2.02%, P = 0.0001), Saint Bernards (1.72%, 95% CI: 1.47% to 1.98%, P = 0.018), and Jack Russell terriers (1.48%, 95% CI: 1.24% to 1.72%, P = 0.003). Although most clinical features were nonspecific, Great Pyrenees dogs were more frequently presented with anemia, azotemia, and eosinophilia, or with hypotension and cachexia compared with dogs of other breeds.

Résumé — Prévalence et caractéristiques cliniques de l’hypoadrenocorticisme chez les Montagnes des Pyrénées au sein d’une population référée : 11 cas. L’hypoadrénocorticisme (maladie d’Addison) est une maladie rare dont la prévalence est estimée à 0,06 % à 0,28 % au sein de la population canine générale. L’objectif de cette étude rétrospective est d’évaluer la prévalence et les caractéristiques cliniques de l’hypoadrénocorticisme chez les Montagne des Pyrénées présentés au Centre Hospitalier Universitaire Vétérinaire de l’Université de Montréal entre mars 2005 et octobre 2014. Cent chiens ont été diagnostiqués avec l’hypoadrénocorticisme, représentant 0,38 % (95 % CI : 0,26 % à 0,5 %) de la population canine étudiée. La prévalence la plus élevée est observée pour les chiens Montagnes des Pyrénées (9,73 %, 95 % CI : 9,12 % à 10,35 % P , 0,0001), suivie des West Highland white terriers (4,66 %, 95 % CI : 4,24 % à 5,09 %, P , 0,0001), Grand Danois (1,87 %, 95 % CI : 1,6 % à 2,14 %, P , 0,0001), Caniches standards (1,76 %, 95 % CI : 1,5 % à 2,02 %, P = 0,0001), Saint-Bernards (1,72 %, 95 % CI : 1,47 % à 1,98 %, P = 0,018), et les Jack Russell terriers (1,48 %, 95 % CI : 1,24 % à 1,72 %, P = 0,003). Bien que les caractéristiques cliniques soient non spécifiques, comparativement aux autres chiens atteints d’hypoadrénocorticisme les Montagnes des Pyrénées étaient plus souvent présentés avec une anémie, une azotémie et une éosinophilie, ou encore en hypotension ou cachectique. (Traduit par les auteurs) Can Vet J 2017;58:1093–1099

Introduction primary or secondary based on whether the deficit is due to the destruction of the adrenal cortex (primary) or the lack of adreno- anine hypoadrenocorticism, or Addison’s disease, is an endo- corticotropic hormone (ACTH), which normally is produced and C crine disorder characterized by inadequate secretion of ste- secreted by the anterior pituitary gland (secondary) (1–3). Primary roid hormones (glucocorticoid and mineralocorticoid hormones) hypoadrenocorticism is the most common form in dogs. In from the adrenal glands. Adrenal insufficiency is categorized as humans, an immune-mediated process has been clearly identified

Department of Clinical Sciences, Université de Montréal, Faculté de médecine vétérinaire, 1500 rue des Vétérinaires, Saint Hyacinthe, Quebec J2S 7C6. Address all correspondence to Dr. Magali Decôme; 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.

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and autoantibodies to adrenal cortex and/or 21-hydrolase have of naturally occurring hypoadrenocorticism. The results of an been detected in up to 48% to 100% of patients with Addison’s ACTH stimulation test consistent with naturally occurring disease (4–6). Although autoimmune destruction of the adrenal hypoadrenocorticism had to be available (pre- and post-ACTH cortex has been reported in dogs (7), most dogs with spontaneous serum cortisol level # 55 nmol/L) for dogs to be included in the hypoadrenocorticism are simply classified as idiopathic (2). study (8,9). Dogs diagnosed before their first presentation to the Patients with hypoadrenocorticism are typically presented CHUV or newly diagnosed at the CHUV were included. Dogs with nonspecific signs such as lethargy, anorexia, vomiting, were excluded from the study if they had received corticoste- diarrhea, weight loss, polyuria, and polydipsia. The severity and roids (oral, parenteral, or topical) in the 4 wk before the ACTH duration of these clinical findings vary greatly among dogs. Most stimulation test, or they were being treated or had previously

ARTICLE dogs have chronic and often intermittent clinical signs, but signs been treated with trilostane or mitotane. Based on these criteria, can also be acute. Although hyperkalemia and hyponatremia are client-owned dogs with confirmed hypoadrenocorticism were classic hallmarks of the disease, these clinicopathologic findings retrospectively separated into 2 groups: the Great Pyrenees dog are not present in atypical primary and secondary hypoadreno- group (GP) and the control group (CG), defined as affected corticism which result in a glucocorticoid hormone deficiency dogs of other breeds. alone (1,2). An adrenocorticotropic hormone (ACTH) stimula- tion test is required for definitive diagnosis of hypoadrenocorti- Data collected from the medical record cism, but a basal serum or plasma cortisol concentration above The following data were collected from the records of all dogs 55 nmol/L has been suggested as a cut-off value to rule out included in the study: breed, gender, age, history, and reason hypoadrenocorticism with a sensitivity of 100% (8,9). Treatment for presentation, physical examination, laboratory findings, of naturally occurring hypoadrenocorticism consists of lifelong and treatment regime at diagnosis and at last evaluation at the hormone replacement, which can be expensive, especially in CHUV, as well as cause of death (if available). The owners and large breed dogs with mineralocorticoid deficiency. family veterinarians were contacted by telephone to obtain any Naturally occurring hypoadrenocorticism is uncommon in missing information. dogs. Its prevalence in the general canine population is estimated between 0.06% and 0.28% (10). Based on large epidemiologi- Statistical analysis cal studies, certain breeds, including bearded collies, standard The prevalence of hypoadrenocorticism in the studied population, poodles, Portuguese water dogs, and Nova Scotia duck tolling as well as the prevalence per breed, were calculated and compared retrievers, appear to have an increased risk of developing the using a t-test. In addition, a Bonferroni correction for multiple disease with reported prevalences of 9.4%, 8.6%, 1.5%, and comparisons was applied, based on the number of comparisons 1.4%, respectively (2,11–13). Data on increased risk for hypoad- (number of breed, n = 34); P-values , 0.05 after Bonferroni cor- renocorticism are reported in many other breeds including West rection were regarded as significant. Epidemiologic criteria, age at Highland white terriers (WHWT), Great Danes, soft-coated diagnosis, reason for presentation, clinical and laboratory findings wheaten terriers, rottweilers, and Saint Bernards (2,14). An were compared between the 2 groups using a t-test (for continu- autosomal recessive inheritance has been identified in standard ous variables) or a z-test (for categorical variables). The z-test poodles and Nova Scotia duck tolling retrievers (13,11). was used to compare the proportions between the 2 populations. To our knowledge, this is the first paper reporting an Statistical significance was set at P , 0.05. The 95% confidence increased risk of developing naturally occurring hypoadrenocor- interval (CI) for prevalence was calculated with exact tests based ticism in Great Pyrenees dogs. Only 1 case report of a 4-year-old on binominal distribution. female Great Pyrenees dog diagnosed with hypoadrenocorti- cism has previously been published. This dog was diagnosed Results with polyendocrinopathy due to lymphocytic adrenalitis and Study population primary hypophysitis (15). The objective of the present study The database search of all dogs presented to the CHUV dur- was to evaluate the prevalence and clinical features of naturally ing the study period (n = 26 450) identified 105 dogs with an occurring hypoadrenocorticism in Great Pyrenees dogs presented ACTH stimulation test consistent with hypoadrenocorticism. to the Centre Hospitalier Universitaire Vétérinaire (CHUV) of Five dogs were excluded from the study: 4 dogs had been treated the University of Montreal. We hypothesized that the prevalence for hyperadrenocorticism with trilostane or mitotane and of naturally occurring hypoadrenocorticism in Great Pyrenees 1 dog had received corticosteroids a few days before the ACTH dogs was significantly higher compared to the prevalence of the stimulation test. Therefore, a total of 100 dogs with a diagnosis disease in the hospital population. We also hypothesised that of naturally occurring hypoadrenocorticism were included in clinical features in naturally occurring hypoadrenocorticism were our study. Fourteen dogs had already been diagnosed upon similar between Great Pyrenees dogs and dogs of other breeds. first presentation to the CHUV and ACTH stimulation test results were provided by their regular veterinarian. A total of Materials and methods 114 Great Pyrenees dogs were presented to the CHUV during Selection of cases the study period. Medical records of dogs presented to the CHUV of the In addition to Great Pyrenees dogs (GP: n = 11), 34 breeds University of Montreal between March 2005 and October 2014 (control group: n = 89) were represented among the dogs diag- were reviewed retrospectively to include dogs with a diagnosis nosed with hypoadrenocorticism (Table 1).

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Twenty-four dogs were diagnosed with concurrent diseases: Table 1. Dogs diagnosed with hypoadrenocorticism presented to the CHUV of the University of Montreal between March 2005 and 4 with recurrent cystitis (including 1 GP); 3 with herniated disk October 2014 (including 1 GP); 2 each with epilepsy, dilated cardiomyopathy, diabetes mellitus (1 of which had concurrent glomerulopathy Breed Number of dogs and the other had concurrent hypothyroidism); 1 each with Great Pyrenees 11 megaesophagus with secondary bronchopneumonia, sick sinus Control group (N = 89) syndrome, degenerative valvular disease with concurrent hypo- West highland white terrier 9 ARTICLE thyroidism, immune-mediated hemolytic anemia, bladder stone, Standard poodle 7 dirofilariasis, pancreatitis, laryngeal paralysis, chronic kidney Cross-bred dog 7 Great Dane 7 disease, glaucoma, hip dysplasia (1 GP). Miniature poodle 6 Labrador retriever 5 Prevalence of hypoadrenocorticism per breed Golden retriever 5 Shih tzu 4 The overall prevalence of hypoadrenocorticism in the study pop- Maltese 4 ulation was 0.38% (95% CI: 0.26% to 0.5%). The prevalence Jack Russell terrier 4 per breed varied between 0.17% and 9.73%, with the highest Yorkshire terrier 2 Saint Bernard 2 prevalence observed in GP, which was significantly higher than Collie 2 the overall prevalence of hypoadrenocorticism in our study Boxer 2 population (9.73%, 95% CI: 9.12% to 10.35%, P , 0.0001). Boston terrier 2 German shepherd 2 A significantly higher prevalence was also observed in WHWT Basset hound 2 (4.66%, 95% CI: 4.24% to 5.09%, P , 0.0001), Great Danes Beagle 1 (1.87%, 95% CI: 1.6% to 2.14%, P , 0.0001), standard Australian shepherd 1 Bichon frisé 1 poodles (1.76%, 95% CI: 1.5% to 2.02%, P = 0.0001), Saint Border collie 1 Bernards (1.72%, 95% CI: 1.47% to 1.98%, P = 0.018), collies German shorthaired pointer 1 (1.52%, 95% CI: 1.27% to 1.76%, P = 0.033), Jack Russell Toy poodle 1 Chihuahua 1 terriers (1.48%, 95% CI: 1.24% to 1.72%, P = 0.003), and Doberman pinscher 1 miniature poodles (1.14%, 95% CI: 0.93% to 1.35% P = 0.004) Lhasa apso 1 (Figure 1). After Bonferroni correction, the prevalence of hypo- Malamute 1 Pomeranian 1 adrenocorticism per breed remained significantly higher than the Rottweiler 1 overall hypoadrenocorticism prevalence in our study population Samoyed 1 in certain breeds including: GP, WHWT, Great Danes, and Newfoundland 1 Wheaten terrier 1 standard poodles. Tibetan terrier 1 Weimaraner 1 Clinical features of Great Pyrenees dogs with hypoadrenocorticism The clinical features and epidemiological factors compared between the 2 groups are detailed in Table 2. Median age at both groups, most dogs were presented with typical electrolyte diagnosis was not statistically different between GP and the abnormalities, i.e., hyperkalemia (GP: n = 7/9; CG, n = 55/82) control group (Table 2). Males were over-represented in the and hyponatremia (GP: n = 7/9; CG, n = 56/81). The average control group (P = 0.004) and in the overall canine popula- Na:K ratio in dogs was not significantly different between the tion seen at the CHUV during the study period (P , 0.0001), 2 groups (GP: 21.25, CG: 23.77, P = 0.26), neither in dogs but the proportion male/female was not significantly different with typical hypoadrenocorticism (GP: 18.94, CG: 20.97, between these 2 groups (P = 0.61). Similarly, the proportion of P = 0.117). The proportion of atypical hypoadrenocorticism was males was not significantly different in GP compared with the not significantly different between the 2 groups (GP: n = 2/9, control group. CG: n = 21/82, P = 0.824). The main reasons for presentation in the GP were lethargy Other major laboratory findings in both groups included and anorexia, whereas the main reasons for presentation for the azotemia, anemia, lack of a stress leukogram, eosinophilia, and dogs in the control group were gastrointestinal signs, lethargy, hypoalbuminemia. Compared to the control group, GP were and anorexia. Great Pyrenees dogs were less frequently presented more likely to be presented with azotemia (GP: n = 8/8, CG: with gastrointestinal signs than dogs in the control group, but this n = 42/81, P = 0.004), anemia (GP: n = 7/9, CG: n = 31/80, difference was not significant (P = 0.05). Moreover, GP were sig- P = 0.01), and eosinophilia (GP: n = 3/8, CG: n = 11/79, nificantly more often presented with hypotension (P , 0.0001), P = 0.04). defined as a systolic blood pressure , 90 mmHg (measured by The treatment initiated following diagnosis was known for Doppler method or petMap blood pressure technology), and 87 dogs including 9 GP. Following diagnosis, dogs were ini- cachexia (P = 0.004), defined as a body condition score (BCS) of tially treated with either prednisone alone (GP: n = 2/9, CG: # 3/9 than were dogs in the control group (Table 2). n = 20/78), or prednisone with fludrocortisone (GP: n = 7/9, There was no significant difference in frequency and sever- CG: n = 47/78), or desoxycorticosterone pivalate, DOCP (GP: ity of serum electrolyte abnormalities between the 2 groups. In n = 0/9, CG: n = 11/78). Sixty-seven dogs, including 5 GP, came

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Figure 1. Prevalence of hypoadrenocorticism and total population of dogs in 8 breeds with a significantly higher prevalence of hypoadrenocorticism compared with the overall prevalence of hypoadrenocorticism at the CHUV during the study, with (*) and without Bonferroni correction. WHWT — West Highland white terrier

back to the CHUV for at least 1 revaluation following diagnosis. hospitalization because of lack of significant improvement. All Treatment at last recheck was known for 61/67 dogs, including 4 were large breed dogs [1 Labrador retriever (32.5 kg), 1 GP 5 GP. Forty-one dogs were treated with fludrocortisone, includ- (48.5 kg), and 2 Great Danes (50 and 53.5 kg)]. ing 4/5 GP, with an average maintenance dose of 0.025 mg/kg body weight (BW) per day, which was significantly higher than Discussion the initial dosage (average: 0.018 mg/kg BW per day, P = 0.042). The most important finding of our study is a significantly The increase in dose of fludrocortisone was however not signifi- higher prevalence of hypoadrenocorticism in Great Pyrenees cant when considering the groups separately between the initial dogs (9.73%) compared with the canine hospital population dosage at time of diagnosis (GP: 0.020 mg/kg BW per day, CG: (0.38%). The prevalence of hypoadrenocorticism was also found 0.019 mg/kg BW per day) and at time of the last recheck (GP: to be significantly higher in WHWT (4.66%), Great Danes 0.022 mg/kg BW per day, CG: 0.025 mg/kg BW per day). At (1.87%), and standard poodles (1.76%). time of the last recheck, prednisone was administered only as The high prevalence of naturally occurring hypoadrenocor- needed during stressful events in 25/61 dogs including 4/5 GP, ticism in Great Pyrenees dogs in a referral center in Quebec, and administered regularly (daily or every other day) for 36/61 Canada, strongly suggests genetic inheritance of this disease. An dogs, (including 1/5 GP). In both groups, the maintenance inherited susceptibility for Addison’s disease has been demon- prednisone dosage was significantly decreased compared to the strated in standard poodles (11) and suspected in the WHWT, initial dosage (average dosage at time of diagnosis 0.43 mg/kg soft-coated wheaten terrier, Great Dane, and other poodle BW per day and 0.26 mg/kg BW per day at time of the last breeds (2,10,14,16,17). Saint Bernards have previously been recheck, P = 0.001). The DOCP dosage was not significantly over-represented (18), but although they had an increased different for both groups between time of diagnosis and time of prevalence of hypoadrenocorticism in the current study, this was last recheck (2.16 mg/kg BW per 25 days and 2.07 mg/kg BW not statistically significant once the Bonferroni correction was per 25 days, respectively). applied. The previously reported prevalence in standard poodles The Na/K ratio at time of last recheck was 29.02 in GP and was 8.6%, which is higher than the prevalence in our study for 31.63 in CG, which is not significantly different. this breed and may be explained by the genetic variance of sires One GP and 2 CG dogs were euthanized at diagnosis. These and dams in Quebec. Although the mode of inheritance (auto- 3 dogs were presented in hypovolemic shock (weakness, pale somal recessive) has been well-identified in standard poodles mucous membrane, weak pulse and hypotension, tachycardia, (11), it remains unknown in other breeds (19). and dehydration), and were euthanized for financial reasons. The overall prevalence of hypoadrenocorticism in our stud- Another dog, presented in shock, was euthanized after 2 d of ied population was 0.38% (95% CI: 0.26% to 0.5%), which

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Table 2. Comparison of the proportion of clinical features and comparison with Addisonians of other breeds, Great Pyrenees epidemiological factors between the 2 groups: Great Pyrenees dogs (GP) and control group (CG) dogs were less frequently presented with gastrointestinal signs, but this difference was not significant, yet more frequently Criteria GP CG P-value presented with hypotension and cachexia which may reflect Epidemiologic factors misdiagnosis/late diagnosis because Great Pyrenees dogs are Age at diagnosis (y) 3.56 4.85 0.22 not known to be at higher risk of developing hypoadrenocorti- (1.02 to 8.21) (0.39 to 11.07) Female 4/11 40/100 0.79 cism. The main clinical signs in GP were lethargy (77.7%) and ARTICLE Male 7/11 60/100 0.79 anorexia (55.5%). Gastrointestinal signs (diarrhea, vomiting, or Reason for presentation regurgitation) were noticed in 33.3% of GP and 61% of dogs in Lethargy 7/9 48/86 0.18 Anorexia 5/9 41/86 0.66 the control group. Findings for our control group are consistent Gastrointestinal signs 3/9 53/86 0.05 with literature data (vomiting or regurgitation present in 68% to Lameness 3/9 12/86 0.08 75% of cases, and diarrhea in 35% of cases) (2,17,20). Weakness 3/9 18/86 0.36 Weight loss 2/9 14/86 0.64 Anemia, increased blood urea nitrogen (BUN), and creatinine PU/PD 0/9 10/86 0.24 and eosinophilia were also more common in the Great Pyrenees Shaking 0/9 11/86 0.22 breed than in other breeds with hypoadrenocorticism. Azotemia Clinical findings Hypotension 6/9 14/84 , 0.0001 is reported in 66% to 95% of dogs with primary hypoadrenocor- Cachexia 3/9 7/84 0.0041 ticism at the time of initial diagnosis (2,3,21,23). In our study, Dehydration 3/9 28/84 1 all Addisonian GP were azotemic, which was significantly higher Heart murmur 3/9 18/84 0.36 Abdominal pain 2/9 16/84 0.80 than the control group (51.8%). They were also more frequently Laboratory findings anemic than the control group. In the veterinary literature, Anemia 7/9 31/80 0.01 a mild normochromic nonregenerative anemia is commonly Eosinophilia 3/8 11/79 0.04 No stress leukogram 5/8 50/79 0.96 reported in Addisonians (21% to 25% cases) (3,19,20,21). As Azotemia 8/8 42/81 0.004 Great Pyrenees dogs were more frequently presented with hypo- Hypoalbuminemia 3/8 22/81 0.49 tension, they could be more prone to have intestinal bleeding Hypoglycemia 2/9 10/82 0.33 Hyperphosphatemia 4/8 24/81 0.18 and pre-renal azotemia than dogs of the control group. Hyponatremia 7/9 56/81 0.55 Although not a consistent feature in Addisonian patients, Hyperkalemia 7/9 55/82 0.87 lack of a stress leukogram can be a valuable finding particularly Mean Na/K ratio 21.25 23.77 0.26 (13.9 to 28.2) (13.5 to 44.7) in glucocorticoid only deficient dogs (17). The lack of a stress Hypochloremia 4/9 21/83 0.75 leukogram was a common finding in our study (GP: 62.5%, PU/PD = polyuria and polydipsia. Bold numbers indicate P-values , 0.05. CG: 63%), although less common than the 92% reported in the veterinary literature (17,20,21). Absolute eosinophilia is reported in 10% to 20% of cases (10,17,21,24). In our study, eosinophilia was observed in 37.5% of GP and in only 13.9% is higher compared to previously reported prevalences (0.06% of the CG. This difference is surprising since eosinophilia has to 0.28%) (10). This difference could be explained by the fact not been reported in Great Pyrenees dogs in the literature, nor that the study was performed in a secondary and tertiary refer- was it observed in the entire Great Pyrenees dog population ral practice. seen at the CHUV during the time of the study, except in our A female predisposition has previously been described for Addisonian population. Although this suggests that eosinophilia hypoadrenocorticism, with approximately 70% of affected dogs is a common finding in Great Pyrenees dogs with hypoadreno- being female (3); however, no gender predisposition has been corticism, no information regarding potential parasitism was demonstrated in the standard poodle, Portuguese water dog, recorded, which may be an alternate explanation. Nova Scotia duck tolling retriever, or bearded collie, nor was In North America, DOCP is the only mineralocorticoid this observed in Great Pyrenees dogs in our study. Although supplement approved for veterinary use. Because of financial males with hypoadrenocorticism were over-represented in both concerns, all of the GP diagnosed with a primary typical groups (GP: 63%, CG: 60%), the higher proportion of males hypoadrenocorticism in our study were treated with fludrocor- was significant only in the control group (P = 0.04), and likely tisone, a synthetic glucocorticoid with significant mineralocor- reflects the male distribution of the overall canine population of ticoid activity. The starting dosage of fludrocortisone is usually the CHUV during the study period. The median age at time of 0.02 mg/kg BW, divided and given twice daily (10,21,22). The diagnosis was not significantly different between the 2 groups median starting dosage in our study was 0.018 mg/kg BW per in our study (GP: 3.56 y, CG: 4.85 y), and was similar to the day. The dosage of fludrocortisone was significantly increased median age of onset for all breeds (13,20,21). during follow-up when considering our entire Addisonian Clinical signs of hypoadrenocorticism are well-described population, but no significant difference was observed when in the veterinary literature (2,3,22). Although the reasons for evaluating the 2 groups separately. Nevertheless, a tendency presentation, clinical signs, and laboratory findings were non- for fludrocortisone dosage to be increased was observed in the specific, this retrospective study was able to highlight some CG only. Veterinarians were possibly less eager to increase the specific features in the clinical presentation of Great Pyrenees dosage of fludrocortisone in GP than in dogs of other breeds dogs with hypoadrenocorticism presented at the CHUV. In either because of financial concerns or because of cumulative

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corticosteroid side effects, given the weight of the GP. There was required to obtain more representative values. Nevertheless, our missing information on the long-term follow-up, and time and results raise awareness about a breed predisposition. cause of death in these cases to support any conclusion. In conclusion, Great Pyrenees dogs diagnosed with hypo- Although evidence supports a similar autoimmune etiology adrenocorticism had a prevalence of hypoadrenocorticism of as in humans leading to the destruction of the adrenal cortex, 9.73% and were over-represented in the study population. the pathogenesis of hypoadrenocorticism in dogs is not well-­ Therefore, an inherited susceptibility is suspected. Although established (21,25). In humans, the enzyme steroid 21-Hydrolase clinical features were nonspecific, Great Pyrenees dogs were (21OH) has been shown to be a major adrenal autoantigen in more frequently presented with signs of hypotension, anemia, Addison’s disease, and 21OH antibodies (21OH-Ab) and/or azotemia, and eosinophilia. A prospective study is necessary

ARTICLE adrenal autoantibodies are present in 48% to 100% of patients to evaluate the prevalence of hypoadrenocorticism in a larger with idiopathic Addison’s disease (4,6,26–30). The genetic fac- population of Great Pyrenees dogs and to establish its rate and tors involved in determining susceptibility to Addison’s disease mode of inheritance. CVJ remain poorly understood, despite numerous studies. However, human leucocyte antigen (HLA) DRB1 is recognized as one of the main susceptibility loci involved, with additional risk References provided by the major histocompatibility complex (MHC) . 1 Kintzer PP, Peterson ME. Diagnosis and management of primary spon- taneous hypoadrenocorticism (Addison’s Disease) in dogs. Semin Vet class I region (29). Similarly, in dogs, several studies support an Med Surg (Small Anim) 1994;9:148–152. immune-mediated process with an immune mediated adrenalitis 2. Scott-Moncrieff JC. Hypoadrenocorticism. In: Ettinger SJ, Feldman being the most likely etiology for the majority of spontaneous EC, eds. Textbook of Veterinary Internal Medicine. 7th ed. Vol. 2. St. Louis, Missouri: WB Saunders, 2010:1847–1857. cases of canine primary hypoadrenocorticism (21,25). Two loci 3. Kintzer PP, Peterson ME. Primary and secondary canine hypoadreno- have been identified in Portuguese water dogs on the Canis famil- corticism. Vet Clin North Am Small Anim Pract 1997;27:349–357. iaris (CFA) chromosomes CFA 12 and 37 (12). Another study 4. Falorni A, Nikoshkov A, Laureti S, et al. High diagnostic accuracy for idiopathic Addison’s disease with a sensitive radiobinding assay for suggests an association between dog leukocyte antigen (DLA) autoantibodies against recombinant human 21-hydroxylase. J Clin class II haplotype and the development of hypoadrenocorticism Endocrinol Metabol 1995;80:2752–2755. in Nova Scotia duck tolling retrievers (30,31). As Short et al 5. Blizzard R, Chee D, Davis W. The incidence of adrenal and other antibodies in the sera of patients with idiopathic adrenal insufficiency (29) have already emphasized, pedigree dogs, because of their (Addison’s disease). Clin Exp Immunol 1967;2:19–31. relatively small population and existence for a relatively short 6. Betterle C, Pra CD, Mantero F, Zanchetta R. Autoimmune adre- time period, have a high linkage disequilibrium and long haplo- nal insufficiency and autoimmune polyendocrine syndromes: Autoantibodies, autoantigens, and their applicability in diagnosis and types within a breed. This provides a considerable advantage in disease prediction. Endocr Rev 2002;23:327–364. veterinary medicine compared to human medicine in increasing 7. Boag AM, Christie MR, McLaughlin KA, Syme HM, Graham P, the potential of identifying novel genes that contribute to canine Catchpole B. Autoantibodies against Cytochrome P450 side-chain cleavage enzyme in dogs (Canis lupus familiaris) affected with hypoad- genetic diseases. Moreover, strong similarities have been shown renocorticism (Addison’s Disease). PLoS One 2015;10:e0143458. in the genetic background of hypoadrenocorticism between dogs 8. Lennon EM, Boyle TE, Hutchins RG, et al. Use of basal serum or and humans, thereby enabling dogs to be spontaneous, genetic plasma cortisol concentrations to rule out a diagnosis of hypoadre- nocorticism in dogs: 123 cases (2000–2005). J Am Vet Med Assoc models for human Addison’s disease (29). The discovery of a new 2007;231:413–416. at-risk breed could be helpful to better understand the genetic 9. Bovens C, Tennant K, Reeve J, Murphy KF. Basal serum cortisol con- background of this endocrine disorder. centration as a screening test for hypoadrenocorticism in dogs. J Vet Intern Med 2014;28:1541–1545. Further studies are needed to infer a genetic basis of the 10. Keich W, Lynn R, Smith C, New J, Jr. Canine hypoadrenocorticism disease in Great Pyrenees dogs as well as its inheritance rate (Addison’s disease). Compend Cont Educ Pract Vet 1998;20:8. and mode. The small population of Great Pyrenees dogs in 11. Famula T, Belanger J, Oberbauer A. Heritability and complex segrega- tion analysis of hypoadrenocorticism in the standard poodle. J Small Quebec with a high prevalence of the disease may provide an Anim Pract 2003;44:8–12. opportunity to identify the etiology and implicated genes in the 12. Chase K, Sargan D, Miller K, Ostrander EA, Lark KG. Understanding breed. Unfortunately, it was not possible to establish the degree the genetics of autoimmune disease: Two loci that regulate late onset Addison’s disease in Portuguese Water Dogs. Int J Immunogenet of relatedness of the Great Pyrenees dogs in our study. 2006;33:179–184. Limits of this study include those inherent to a retrospective 13. Hughes AM, Nelson RW, Famula TR, Bannasch DL. Clinical fea- study (i.e., missing data, lack of standardization). Moreover, the tures and heritability of hypoadrenocorticism in Nova Scotia Duck Tolling Retrievers: 25 cases (1994–2006). J Am Vet Med Assoc population size of Great Pyrenees dogs was small, which can lead 2007;231:407–412. to type 2 statistical error. Multiple comparisons were performed 14. Haviland RL, Toaff-Rosenstein RL, Reeves MP, Littman MP. Clinical between the 2 groups to identify specific clinical features of features of hypoadrenocorticism in soft-coated wheaten terrier dogs: 82 cases (1979–2013). Can Vet J 2016;57:387–394. Great Pyrenees dogs suffering from hypoadrenocorticsm, which 15. Adissu H, Hamel-Jolette A, Foster R. Lymphocytic adenohypophysitis can lead to type 1 statistical error. Our results, therefore, need and adrenalitis in a dog with adrenal and thyroid atrophy. Vet Pathol to be confirmed by further studies. Finally, since the study was Online 2010;47:1082–1085. 16. Adler JA, Drobatz KJ, Hess RS. Abnormalities of serum electrolyte performed in a referral center, the population studied may not concentrations in dogs with hypoadrenocorticism. J Vet Intern Med be representative of the general canine population and therefore 2007;21:1168–1173. our results should be considered carefully. The real prevalence of 17. Klein SC, Peterson ME. Canine hypoadrenocorticism: Part I. Can Vet J 2010;51:63–69. hypoadrenocorticism in the general Great Pyrenees dog popu- 18. Thompson AL, Scott-Moncrieff JC, Anderson JD. Comparison lation remains unknown and large epidemiological studies are of classic hypoadrenocorticism with glucocorticoid-deficient

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hypoadrenocorticism in dogs: 46 cases (1985–2005). J Am Vet Med 26. Falorni A, Laureti S, Nikoshkov A, et al. 21-hydroxylase autoantibodies Assoc 2007;230:1190–1194. in adult patients with endocrine autoimmune diseases are highly specific 19. Kintzer PP, Peterson ME. Treatment and long-term follow-up of for Addison’s disease. Clin Exp Immunol 1997;107:341–346. 205 dogs with hypoadrenocorticism. J Vet Intern Med 1997;11:43–49. 27. Chen S, Sawicka J, Betterle C, et al. Autoantibodies to steroido- 20. Peterson ME, Kintzer PP, Kass PH. Pretreatment clinical and labora- genic enzymes in autoimmune polyglandular syndrome, Addison’s tory findings in dogs with hypoadrenocorticism. J Am Vet Med Assoc disease, and premature ovarian failure. J Clin Endocrinol Metabol 1996;208:85–91. 1996;81:1871–1876. 21. Scott-Moncrieff JC. Hypoadrenocorticism. In: Feldman EC, 28. Colls J, Betterle C, Volpato M, Prentice L, Smith BR, Furmaniak J.

Nelson RW, Reusch CE, Scott-Moncrieff JCR, eds. Canine & Immunoprecipitation assay for autoantibodies to steroid 21-hydroxylase ARTICLE Feline Endocrinology. 4th ed. St-Louis, Missouri: WB Saunders, in autoimmune adrenal diseases. Clin Chem 1995;41:375–380. 2015:485–520. 29. Short AD, Boag A, Catchpole B, et al. A candidate gene analy- 22. Klein SC, Peterson ME. Canine hypoadrenocorticism: Part II. Can Vet sis of canine hypoadrenocorticism in 3 dog breeds. J Hered J 2010;51:179–184. 2013;104:807–820. 23. Guyton AC, Hall EJ. Adrenocortical hormones. In: Hall EJ, ed. 30. Hughes A, Jokinen P, Bannasch D, Lohi H, Oberbauer A. Association of Textbook of Medical Physiology. 12th ed. Philadelphia, Pennsylvania: a dog leukocyte antigen class II haplotype with hypoadrenocorticism in WB Saunders, 2011:921–938. Nova Scotia Duck Tolling Retrievers. Tissue Antigens 2010;75:684–690. 24. Lefbom BK, Peckens NK. Impact of collaborative care on survival time 31. Hughes AM, Bannasch DL, Kellett K, Oberbauer AM. Examination of for dogs with congestive heart failure and revenue for attending primary candidate genes for hypoadrenocorticism in Nova Scotia Duck Tolling care veterinarians. J Am Vet Med Assoc 2016;249:72–76. Retrievers. Vet J 2011;187:212–216. 25. Schaer MS, Riley WJ, Buergelt CD, et al. Autoimmunity and Addisons disease in the dog. J Am Anim Hosp Assoc 1986;22:789–793.

Book Review Compte rendu de livre

Crow & Walshaw’s Manual of New procedures now found in this text include placement Clinical Procedures in Dogs, Cats, of arterial catheters, central venous pressure measurements, and Rabbits & Rodents, 4th edition CPR. Routine clinical procedures outlined include restraint, injection techniques, dermatologic procedures, urethral cath- Boyle JE. Wiley-Blackwell. Ames, Iowa, USA. 2016. 408 pp. eterization, enemas, and anal sac expression. ISBN: 9781-1189-8570-0. $76.32. A unique feature of this text is the inclusion of a small selection of procedures common to exotics. This includes ow in its 4th edition, Crow & Walshaw’s Manual of Clinical blood collection and fluid administration in rabbits, and car- N Procedures in Dogs, Cats, Rabbits & Rodents has become rying, restraining, and examination of a variety of small exotic somewhat of a classic. Intended for veterinary technicians, vet- pocket pets. erinary students, and new veterinarians, it tends to cover more of Finally, there is an interactive webpage associated with this the basic and less advanced procedures used in clinical practice. text that provides multiple choice questions and answers for This is in no way a bad thing. We all need to feel comfortable each chapter, as well as PowerPoint slides of all figures used in carrying out the “bread and butter” techniques used most often. the text. It is an advantage that illustrations can be copied for Each procedure is clearly outlined in step-by-step fashion, future reference. Overall though, I think the webpage could have using a decent number of color and black and white illustra- been made more valuable, as its use is limited. tions. Subheadings for equipment needed, and rational for an As the text implies, it has been used over the years in teaching action or complications and safety issues involved, organize the settings, and I can see it being very useful in that regard. So too, material into a very user friendly format. Since the first edition would it be handy for new veterinary graduates and those vets was published, you will find that some procedures are no longer wishing to brush up on some clinical skills. included as they are now rarely used, while others have been left out because our clinical abilities have developed the procedure Reviewed by Janeen Junaid, DVM, MVSc, Hamilton, Ontario. beyond an introductory text level.

CVJ / VOL 58 / OCTOBER 2017 1099 FOR PERSONAL USE ONLY Case Report Rapport de cas

Hypocholesterolemia and nonregenerative, suspected immune-mediated, anemia: Report of 3 canine cases

Rachel Robbins, Katrina R. Viviano

Abstract — This report describes hypocholesterolemia in 3 dogs with nonregenerative, suspected immune-mediated anemias. Common causes of hypocholesterolemia were ruled out, raising suspicion for a mechanistic link between anemia and hypocholesterolemia in dogs. As observed in humans with concurrent anemia and hypocholesterolemia, cholesterol concentrations increased to within the reference interval once the dogs’ anemia resolved.

Résumé — Hypocholestérolémie et anémie non régénérative suspectée d’origine immunitaire : rapport de 3 cas canins. Ce rapport décrit l’hypocholestérolémie chez trois chiens atteints d’une anémie non régénérative suspectée d’origine immunitaire. Les causes communes d’hypocholestérolémie ont été écartées, soulevant des doutes pour un lien mécanistique entre l’anémie et l’hypocholestérolémie chez les chiens. Tel qu’il a été observé chez les humains atteints d’anémie et d’hypocholestérolémie concomitante, les concentrations de cholestérol ont augmenté dans l’intervalle de référence une fois que l’anémie des chiens s’est résorbée. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1100–1104

ypocholesterolemia has been described in humans with disease via antibody or cell-mediated immune mechanisms H nonmalignant anemias resulting from various causes, (15–17). Despite immune-mediated anemias being a relatively including hereditary spherocytosis (1), glucose-6-phosphate common clinical presentation in middle-aged dogs, an asso- dehydrogenase (G6PD) deficiency (2), thalassemias (3,4) and ciation between anemia and hypocholesterolemia has not been sickle cell disease (5,6), as well as other hematologic abnormali- reported (16,17). In dogs, hypocholesterolemia typically is ties, including aplastic anemia (7) and myelodysplastic syndrome associated with malabsorption (i.e., protein-losing enteropathies (8). The level of hypocholesterolemia is variable and considered or lymphangiectasia) and maldigestion (i.e., exocrine pancreatic secondary to the anemia with resolution of hypocholesterolemia insufficiency), decreased production by the liver (i.e., cirrhosis, following normalization of the patient’s hematocrit (9). In some liver failure, or portosystemic shunts), or hypoadrenocorticism. reports the degree of hypocholesterolemia has been described This report describes 3 dogs presented to UW Veterinary Care to have prognostic significance, including increased morbidity/ (UWVC) with a nonregenerative anemia, suspected to result mortality (6,10) and poor response to immunosuppression (7). from immune-mediated mechanisms, and concurrent hypocho- Mechanisms underlying this interaction remain unexplained, lesterolemia, in which the more common causes of hypocho- but increased cholesterol utilization and altered cholesterol lesterolemia were ruled out. For all 3 dogs, the bone marrow metabolism have been suggested (3,11–14). aspirates and histologic sections were reviewed by 2 clinical Destruction of erythrocytes or erythroid precursors is associ- pathologists at UWVC. ated with various etiologies, including drugs/toxin exposure, infections, and neoplasia, and may also occur as a primary Case descriptions Case 1 An 11-year-old, spayed female, English coonhound dog was evaluated by the local veterinarian for persistent anemia [hema- College of Agriculture and Life Sciences (Robbins) and School tocrit (HCT) 28%; reference interval (RI): 35% to 55%] nonre- of Veterinary Medicine, Department of Medical Sciences sponsive to 3 to 4 wk of treatment with doxycycline following a (Viviano), University of Wisconsin-Madison, Madison, positive SNAP 4Dx test (IDEXX Laboratory, Westbrook, Maine, Wisconsin 53706, USA. USA) for Ehrlichia canis. The dog had been diagnosed with pure Address all correspondence to Dr. Katrina R. Viviano; e-mail: red cell aplasia (PRCA) 2 y before admission based on diagnostic [email protected] testing at UWVC that included complete hematologic evalua- Reprints will not be available from the authors. tion [HCT 10%; RI: 39% to 57%, total protein (TP) 60 g/L; Use of this article is limited to a single copy for personal study. RI: 56 to 80 g/L; reticulocyte count 2000/mL; RI: 11 000 to Anyone interested in obtaining reprints should contact the 111 000/mL] and bone marrow aspirate examination, which CVMA office ([email protected]) for additional revealed the absence of erythroid precursors and unremarkable copies or permission to use this material elsewhere. granulocytic and megakaryocytic lineages. Underlying causes

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Table 1. Results of complete blood cell count, reticulocyte count, direct antiglobulin (Coombs’) test, and 4Dx SNAP test at initial presentation for cases 1 to 3 Case 1 Case 2 Case 3a Units Reference interval HCT 24 12 23 % 39% to 57% MCV 69.1 89.8 66.8 mm3 61 to 73 MCHC 19.9 17.6 21.4 mmol/L 21.1 to 23.6 CASE REPORT CASE Platelets 211 523 406 3 103/ mL 175 to 500 WBC 6.11 9.83 11.13 3 103/ mL 5 to 14 Reticulocyte count 0.044 0.025 0.004 3 106/ mL 0.013 to 0.102 Agglutination None None None — — Spherocytes None None None — — DAT Weak Positiveb Positivec N/A — — 4Dx SNAP test Positived Negative Negative — —

a Initial CBC performed following a packed red blood cell transfusion. b Direct antiglobulin (Coombs’) test performed at UWVC. Result details: (37°C): C3 16; IgG , 2; IgM 2; poly 4. c Direct, antiglobulin (Coombs’) test (37°C) performed at Marshfield laboratories (Waukesha, Wisconsin, USA) prior to referral to UWVC. d 4Dx SNAP test performed prior to referral and was positive for Ehrlichia canis/ewingii. HCT — hematocrit; MCV — mean cell volume; MCHC — mean corpuscular hemoglobin concentration; WBC — white blood cell count; N/A — not applicable/available; DAT — direct antiglobulin test; 4Dx SNAP test — antibody enzyme-linked immunosorbent assay (ELISA) for heartworm, Ehrlichia canis and Ehrlichia ewingii, Anaplasma phagocytophilium and Anaplasma platys, and Borrelia burgdorferi.

(i.e., toxin/drug, infection, or neoplasia) for the dog’s severe lymphadenopathy. The resting cortisol concentration was nor- nonregenerative anemia were ruled out. The dog was responsive mal (Table 2) and ruled out hypoadrenocorticism as the cause to treatment with immunosuppressive doses of prednisone and of hypocholesterolemia. cyclosporine. Both drugs were tapered slowly over the course An aspirate and a core biopsy of bone marrow were collected. of 1 y based on resolution of the anemia. Immunosuppressive Cytologic evaluation revealed erythroid hyperplasia with mildly treatment was discontinued 8 mo before presentation based on left-shifted erythroid maturation and the presence of occa- a stable HCT of 47%. sional polychromatophilic erythrocytes (reticulocytes). Frequent When presented to the UWVC for follow-up, the dog was rubriphagocytosis (i.e., phagocytosis of erythroid precursors reported to be clinically well at home with normal appetite and by macrophages) of early- and middle-stage erythroid precur- energy level, and no vomiting, diarrhea, coughing, or sneezing. sors was seen. The granulocytic and megakaryocytic lineages The dog weighed 25.5 kg with a body condition score (BCS) of appeared unremarkable. Histopathologic evaluation of bone 6/9, body temperature of 38.6°C, pulse rate of 116 beats/min marrow agreed with the cytologic abnormalities and in addition (bpm), and respiratory rate described as panting. Mucous mem- revealed mild myelofibrosis, confirmed by staining for reticulin branes were pink with a capillary refill time (CRT) of , 2 s, (Gomori methenamine silver stain) and collagen (Masson’s tri- cardiac auscultation revealed a normal rhythm and no murmurs, chrome stain). Occasional macrophages contained phagocytosed and pulses were strong and synchronous. Abnormalities were nuclear debris, supporting rubriphagocytosis seen on the bone not detected on palpation of all peripheral lymph nodes and marrow aspirate. The bone marrow findings were interpreted the abdominal cavity. as ineffective erythropoiesis with evidence of erythroid precur- Diagnostic testing included a complete blood (cell) count sor destruction, which, in association with other hematologic (CBC), reticulocyte count, direct antiglobulin (Coombs’) test findings, was consistent with a diagnosis of precursor-targeted (DAT), biochemical profile, abdominal ultrasonographic exami- immune-mediated anemia (PIMA). nation, chest radiographs, and baseline cortisol concentration. Immunosuppressive therapy with prednisone (Watson Results indicated nonregenerative anemia with platelets and Laboratories, Parsippany, New Jersey USA), 20 mg [0.8 mg/kg white blood cells within reference intervals, a weak positive body weight (BW)], PO, q12h, and cyclosporine (Atopica; DAT (Table 1), mildly increased alkaline phosphatase activ- Novartis Animal Health, Larchwood, Iowa, USA), 100 mg ity and hypocholesterolemia with concentrations of other (3.9 mg/kg BW), PO, q12h, was initiated. One and 2 wk after analytes, including albumin, globulin, glucose, blood urea restarting the prednisone and cyclosporine, the dog’s HCT was nitrogen (BUN), and total bilirubin, within reference intervals stable (HCT 29%, TP 73 g/L, and HCT 30%, TP 74 g/L, (Table 2). Ultrasonographic findings consisted of multifocal respectively). One month later, the HCT (32%; TP 70 g/L) hyperechoic foci in the liver, a subjectively enlarged spleen with continued to increase, and over the course of the next 4 mo, a single hypoechoic nodule that did not bulge the capsule, and prednisone was slowly tapered and then discontinued when the 2 ill-defined pinpoint hyperechoic foci that were unchanged HCT reached 42% (TP 72 g/L). Six weeks after discontinuing the from the previous examination performed 2 y earlier. Intra- prednisone, anemia (nonregenerative) recurred (HCT 18%; TP abdominal lymphadenopathy and gastrointestinal thickening 72 g/L; reticulocytes 21 000/mL). A packed red blood cell (pRBC) were not found, and the left adrenal gland was described as transfusion was administered and the prednisone was restarted at normal. Chest radiographs revealed a normal cardiac silhouette 20 mg, PO, q12h. The dog was maintained in remission (HCT and pulmonary vasculature with no pulmonary nodules or 38%, 75 d after restarting prednisone) over the next 3 mo with

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Table 2. Summary of the results of the relevant serum biochemistry, baseline cortisol, ACTH stimulation test, bile acids test, and urine specific gravity at initial presentation for cases 1 to 3 Case 1 Case 2 Case 3 Units Reference interval ALT 73 100 40 U/L 14 to 87 ALP 162 77 59 U/L 20 to 157 Total bilirubin 3.4 , 1.7 , 1.7 mmol/L 1.7 to 13.7 Cholesterol 3.5 3.6 3.2 mmol/L 3.9 to 8.3 BUN 7.1 2.9 4.6 mmol/L 2.5 to 11.4 Creatinine 61.9 44.2 79.6 mmol/L 44.2 to 132.6 Glucose 5.3 5.7 4.8 mmol/L 3.7 to 7.3 Albumin 29 32 31 g/L 23 to 39 Globulin 34 37 32 g/L 22 to 35 Sodium 149 149 145 mmol/L 141 to 150 RAPPORTCAS DE Potassium 4.9 4.3 4.3 mmol/L 3.9 to 5.3 Resting cortisol 57.9 223.5 46.9 nmol/L $ 55 ACTH stimulation test (pre/1 h post) N/A N/A 52/361 nmol/L 28 to 138/276 to 552 Serum bile acids (pre/2 h post-prandial) N/A N/A 9/19.6 mmol/L 10 to 12/5 to 25 Urine specific gravity 1.025 1.021 1.036 — —

ALT — alanine transaminase activity; ALP — alkaline phosphatase activity; BUN — blood urea nitrogen concentration; N/A — not applicable/available; ACTH — adrenocorticotropic hormone.

cyclosporine 100 mg (3.9 mg/kg BW), PO, q12h, and prednisone Both the left and right adrenal glands were reported as normal. tapered to 15 mg (0.6 mg/kg BW), PO, per day, at which time Chest radiographs revealed cardiovascular structures and pul- the dog was lost to follow-up. During the routine monitoring of monary vasculature within normal limits and mild right-sided the dog’s anemia over the 9-month observation period, the dog’s heart enlargement with a vertebral heart score of 10. There cholesterol concentration was ­re-checked twice and reported to be was no evidence of pulmonary metastasis. A resting cortisol 11.2 mmol/L (HCT 35%) and 13.8 mmol/L (HCT 40%) while concentration ruled out the differential diagnosis/suspicion of receiving prednisone and cyclosporine therapy. hypoadrenocorticism as the cause of the dog’s low cholesterol concentration. Case 2 A bone marrow aspirate and core biopsy sample were col- A 7-year-old, spayed female, miniature Dachshund dog was lected. The bone marrow aspirate yielded a nondiagnostic speci- examined for assessment of pica for 5 mo and 3 collapsing (or men with no hematopoietic particles available for examination. syncopal) episodes. Eight months before presentation the dog Histopathologic assessment of the bone marrow core biopsy had an anemia [HCT 29%, positive DAT (Table 1)] noted on revealed mild to moderate erythroid hypoplasia with distinct pre-dental blood analysis that responded to a short, 30-day small islands of erythropoiesis and moderate myelofibrosis, course of prednisone. When presented to UWVC, the dog’s which may explain why an evaluable aspirate could not be activity and appetite were normal. The dog weighed 6.2 kg with obtained. Myelofibrosis was confirmed by examination of histo- a BCS of 7/9. Physical abnormalities included pale pinnae, very logic sections stained with Gomori silver and Masson’s trichrome pale and mildly tacky mucous membranes, tachycardia (HR stains. The granulocytic and megakaryocytic lineages appeared 160 bpm), and a soft grade 2/6 cardiac murmur. Palpation of unremarkable, and there was equivocal mild plasmacytosis. all peripheral lymph nodes and the abdominal cavity revealed Bone marrow findings did not provide definitive support no abnormalities. for immune-mediated anemia. However, immunosuppressive Diagnostic testing included a CBC, reticulocyte count, treatment was initiated based on clinical history and ruling out biochemical profile, urinalysis and bacterial culture, blood any known toxin/drug exposure, or an infectious or neoplastic pressure measurement, echocardiogram (ECG), abdominal cause for the dog’s anemia. The dog’s anemia was previously ultrasonographic examination, and chest radiographs. Results responsive to prednisone therapy increasing the clinical suspi- indicated nonregenerative anemia with unremarkable platelet cion of immune-mediated erythroid destruction (response to and white blood cell counts (Table 1). Before referral, the DAT immunosuppressive treatment alone does not support or rule was positive. The only abnormalities in the biochemical profile out an immune-mediated mechanism). were mildly increased ALT activity, mild hyperglobulinemia, Treatment included a blood transfusion (100 mL pRBC), and hypocholesterolemia (Table 2). The urine culture isolated prednisone (predniSONE; Qualitest Pharmaceuticals, Huntsville, . 100 000 colony-forming units (CFU)/mL of Escherichia Alabama, USA), 10 mg (1.6 mg/kg BW), PO, q24h, and cyclo- coli. The dog was normotensive, with a systolic blood pressure sporine (cycloSPORINE, Watson Laboratories), 25 mg (4 mg/kg of 114 mmHg and the electrocardiogram (ECG) documented BW), PO, q12h. The dog’s HCT 8 h after transfusion was 23% a sinus rhythm. Ultrasonographic abnormalities included the and TP was 78 g/L. The dog’s urinary tract infection was treated presence of biliary sludge, minimal bilateral renal dystrophic with amoxicillin/clavulanate (Clavamox; Zoetis Animal Health, mineralization, and urine echogenicity. Intra-abdominal lymph- Parsippany, New Jersey, USA), 125 mg (20 mg/kg BW), PO, adenopathy and gastrointestinal thickening were not found. q12h. Twenty days after initiating treatment with prednisone and

1102 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY cyclosporine the dog’s HCT remained stable at 22%; however, the 10 mo, the dog’s HCT increased to 45% to 50% and treatment cholesterol concentration (2.9 mmol/L) continued to decrease. with prednisone and cyclosporine was slowly tapered. During Six weeks following immunosuppression with prednisone and a routine re-check (9 mo following the initiation of immuno- cyclosporine, the HCT had increased to 34% (TP 77 g/L) with suppression), the results of a biochemical profile indicated the no additional syncopal episodes or pica. At day 90, the dog was cholesterol concentration had increased to within the refer- no longer anemic (HCT 42%) and the cholesterol concentration ence interval and the HCT was stable at 47%. Treatment with REPORT CASE (7.6 mmol/L) was within the reference interval. Over the next prednisone and cyclosporine was discontinued 11 mo after the 12 mo, the prednisone and cyclosporine were slowly tapered. initial admission. Treatment with prednisone was discontinued 1 y after the ini- tiation of therapy and cyclosporine was continually decreased. Discussion The dog was then managed with low-dose cyclosporine, 5 mg Hypocholesterolemia in 3 dogs with nonregenerative, suspected (0.8 mg/kg BW), PO, q12h and at last re-check, 4 y following to be immune-mediated, anemia is reported. In the cases pre- admission, the dog’s HCT was stable at 34% and TP was 83 g/L. sented, the diagnoses were made based on history, bone marrow findings, and diagnostic testing that ruled out other possible Case 3 underlying causes (i.e., toxin/drug, infectious, or neoplasia) for A 1.5-year-old, spayed female, Welsh terrier dog was evalu- anemia. In addition, common causes of hypocholesterolemia, ated for progressive anemia, lethargy, and inappetence by the including GI disease, liver failure, and hypoadrenocorticism local veterinarian 3 wk before referral for 2 collapsing episodes were ruled out based on absence of hypoproteinemia, hyper- during physical activity (e.g., climbing stairs and playing with bilirubinemia, hypoglycemia, decreased BUN, increased hepatic the other dogs in the household). It was determined that the enzyme activities, and cortisol concentrations (either resting dog was anemic (HCT 20%). When the dog was presented to cortisol concentrations or ACTH stimulation testing) within UWVC, the dog weighed 10.4 kg with a BCS of 4 to 5/9, body reference intervals. These 3 cases suggest a possible link between temperature of 101.4, pulse rate of 128 bpm, and respiratory non-regenerative immune-mediated anemia and hypocholester- rate of 24 breaths/min. Mucous membranes were light pink and olemia, which has not been previously reported in dogs. In all moist with a CRT of , 2 s. Physical abnormalities included 3 cases, serum cholesterol concentrations returned to within the a grade 3/6 heart murmur, hyperkinetic pulses, and a small reference interval following resolution of the anemia. mass on the tongue. Abdominal and thoracic radiographs and In humans, hypocholesterolemia has been described in vari- abdominal ultrasonographic studies revealed no abnormalities. ous non-malignant anemias (1–6). Mechanisms underlying this Due to the dog’s persistent nonregenerative anemia (PCV 17%, interaction are not well-understood. Proposed mechanisms TP 56 g/L) a pRBC transfusion (120 mL) and fluid therapy include plasma dilution as a result of the anemia (9), increased were initially given to address the dog’s clinical anemia. The cholesterol utilization due to altered erythropoiesis [accelerated dog’s post transfusion HCT was 23% (Table 1). erythropoiesis (14), stress erythropoiesis (12,13)], increased but Further diagnostic testing included a biochemical profile, ineffective erythropoiesis (3), increased uptake by the reticu- urinalysis, blood pressure measurement, ECG, and abdominal loendothelial system (3,4), or altered cholesterol metabolism ultrasonographic examination. The only abnormality on the induced by macrophage system activation and cytokine release biochemical profile was hypocholesterolemia (Table 2). ACTH and/or oxidative stress (3,4,11,12). stimulation test results ruled out the differential diagnosis of The mechanism for the concurrent hypocholesterolemia hypoadrenocorticism (Table 2). The dog’s blood pressure was in the reported 3 dogs, diagnosed with a non-regenerative, 134 mmHg and the ECG documented a sinus rhythm. suspected immune-mediated anemia, is unknown and is likely Cytologic evaluation of bone marrow revealed marked ery- multifactorial. Pathophysiologic mechanisms as proposed in throid hypoplasia with the presence of rare early-stage precur- humans are possible but remain unclear. Nonregenerative sors and absence of later stages. The granulocytic and mega- immune-mediated anemias in dogs encompass a spectrum of karyocytic lineages appeared unremarkable. Rubriphagocytosis diseases in which the immune system is suspected to target was not seen. Bone marrow findings raised suspicion for and mediate destruction of erythrocytes at different stages of immune-mediated anemia (early-stage PIMA or marked ery- maturation. Bone marrow findings range from ineffective eryth- throid hypoplasia progressing to PRCA), and immunosuppres- ropoiesis with erythroid hyperplasia and erythroid left-shift or sive treatment was initiated with prednisone (predniSONE; maturation arrest [as is commonly seen in precursor-targeted Qualitest Pharmaceuticals), 20 mg (2 mg/kg BW), PO, q24h immune-mediated anemia (PIMA)], to erythroid aplasia char- and cyclosporine (cycloSPORINE, Watson Laboratories), 30 mg acterized by absence of erythroid precursors [as seen in pure (2.5 mg/kg BW), PO, q12h. One week after starting treatment, red cell aplasia (PRCA)] (16–19). Evidence of concurrent cyclosporine was stopped for 2 to 3 d due to an episode of vom- hemolysis (i.e., IMHA), characterized by evidence of peripheral iting and was then re-started at 25 mg (1.25 mg/kg BW), PO, erythrocyte destruction, such as spherocytosis, hemoglobinemia, q12h. Two days later, the HCT decreased to 18% (TP 74 g/L) icterus, agglutination, or DAT positivity is uncommon in dogs and a second blood transfusion of pRBC (150 mL) was given. with PIMA (18,20). Two of the 3 dogs described were direct The dog’s HCT remained stable for 14 d then dropped to 18% antiglobulin tested and were DAT positive [case 1, weak posi- (TP 62 g/L). Following a third pRBC transfusion, cyclosporine tive for C3 (complement), likely non-specific; case 2, positive], was increased to 2.5 mg/kg BW, PO, q121h. Over the following suggesting the possibility of concurrent IMHA or false positive

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result, as both dogs lacked definitive evidence of hemolysis Ambrosius for her initial assistance with the medical record (21). To the authors’ knowledge dogs with IMHA (15,20) or search and data collection. CVJ suspected nonregenerative immune-mediated-anemia (16,17) have not been reported to have concurrent hypocholesterolemia. References Mechanistic studies would be needed to further determine . 1 Johnsson R, Saris NE. Plasma and erythrocyte lipids in hereditary spherocytosis. Clin Chim Acta 1981;114:263–268. and define the possible relationship between hypocholesterol- 2. Muntoni S, Batetta B, Dessi S, Muntoni S, Pani P. Serum lipoprotein emia and nonregenerative immune-mediated anemias in dogs. profile in the Mediterranean variant of glucose-6-phosphate dehydro- Mechanisms to consider include the role cholesterol plays in genase deficiency. Eur J Epidemiol 1992;8:48–53. 3. Hartman C, Tamary H, Tamir A, et al. Hypocholesterolemia in erythropoiesis. Erythropoiesis requires the consumption of children and adolescents with beta-thalassemia intermedia. J Pediatr circulating cholesterol for cell membrane production; therefore, 2002;141:543–547. ineffective or accelerated erythropoiesis may be reasonable 4. Papanastasiou DA, Siorokou T, Haliotis FA. beta-Thalassaemia and fac-

RAPPORTCAS DE tors affecting the metabolism of lipids and lipoproteins. Haematologia possible mechanisms for the reduced serum cholesterol con- (Budap) 1996;27:143–153. centration (14). The erythropoietin activity of these dogs was 5. Rahimi Z, Merat A, Haghshenass M, Madani H, Rezaei M, Nagel RL. not evaluated, but none had reticulocytosis, characterizing the Plasma lipids in Iranians with sickle cell disease: Hypocholesterolemia in sickle cell anemia and increase of HDL-cholesterol in sickle cell trait. anemia as nonregenerative. Even though erythropoietin activity Clin Chim Acta 2006;365:217–220. was not assessed in the 3 reported dogs, at least 1 dog (case 1) 6. VanderJagt DJ, Shores J, Okorodudu A, Okolo SN, Glew RH. had evidence of erythroid hyperplasia in the bone marrow; Hypocholesterolemia in Nigerian children with sickle cell disease. J Trop Pediatr 2002;48:156–161. therefore, increased erythropoiesis may have been associated 7. Yokoyama M, Suto Y, Sato H, et al. Low serum lipids suggest severe with cholesterol consumption in this dog. The mechanisms of bone marrow failure in children with aplastic anemia. Pediatr Int hypocholesterolemia in the 2 other dogs with erythroid hypo- 2000;42:613–619. 8. Allampallam K, Dutt D, Nair C, et al. The clinical and biologic sig- plasia are unclear. nificance of abnormal lipid profiles in patients with myelodysplastic As observed in human anemic patients with hypocholester- syndromes. J Hematother Stem Cell Res 2000;9:247–255. olemia, cholesterol concentrations returned to within the refer- 9. Atac B, Brahaj D, Frishman WH, Lerner R. Anemia and hypocholes- terolemia. Heart Dis 2003;5:65–71. ence interval with resolution of the anemia. In all 3 dogs in this 10. Shores J, Peterson J, VanderJagt D, Glew RH. Reduced cholesterol levels report the hypocholesterolemia also resolved with resolution of in African-American adults with sickle cell disease. J Natl Med Assoc anemia. In the dog (case 2), in which the cholesterol concentra- 2003;95:813–817. 11. Boudrahem-Addour N, Izem-Meziane M, Bouguerra K, et al. Oxidative tion was more closely monitored, anemia and hypocholesterol- status and plasma lipid profile in beta-thalassemia patients. Hemoglobin emia had resolved (HCT 42%, cholesterol 7.6 mmol/L) 3 mo 2015;39:36–41. after the initiation of immunosuppressive therapy. 12. Oztas YE, Sabuncuoglu S, Unal S, Ozgunes H, Ozgunes N. Hypocholesterolemia is associated negatively with hemolysate In summary, this is the first report of hypocholesterolemia lipid peroxidation in sickle cell anemia patients. Clin Exp Med associated with nonregenerative immune-mediated anemia 2011;11:195–198. in dogs. These 3 cases suggest that hypocholesterolemia may 13. Paulson RF, Shi L, Wu DC. Stress erythropoiesis: New signals and new stress progenitor cells. Curr Opin Hematol 2011;18:139–145. be a previously unrecognized feature in dogs with suspected 14. Shalev H, Kapelushnik J, Moser A, Knobler H, Tamary H. nonregenerative immune-mediated anemia. In this study hypo- Hypocholesterolemia in chronic anemias with increased erythropoietic cholesterolemia appears to have resolved with resolution of activity. Am J Hematol 2007;82:199–202. 15. Nidorf D, Saleem A. Immunosuppressive mechanisms in pure red cell the anemia, raising the question of a possible mechanistic link aplasia — A review. Ann Clin Lab Sci 1990;20:214–219. between anemia and hypocholesterolemia in dogs. The under- 16. Stokol T, Blue JT, French TW. Idiopathic pure red cell aplasia and non- lying mechanisms and clinical significance of this observation regenerative immune-mediated anemia in dogs: 43 cases (1988–1999). J Am Vet Med Assoc 2000;216:1429–1436. are unknown. This case report provides awareness that dogs 17. Weiss DJ. Primary pure red cell aplasia in dogs: 13 cases (1996–2000). diagnosed with a nonregenerative, suspected to be immune- J Am Vet Med Assoc 2002;221:93–95. mediated, anemia may have concurrent hypocholesterolemia, 18. Lucidi CA, de Resende CLE, Jutkowitz LA, Scott MA. Cytologic and histologic bone marrow findings in dogs with suspected marrow- which does not seem to be a result of the underlying illnesses directed immune-mediated anemia (abstr). Annual Meeting, Baltimore, most commonly associated with hypocholesterolemia (i.e., Maryland, October 30 to November 1, Am Soc Vet Clin Pathol 2010. gastrointestinal disease, liver failure, or hypoadrenocorticism). 19. Weiss DJ. Bone marrow pathology in dogs and cats with non- regenerative immune-mediated haemolytic anaemia and pure red cell aplasia. J Comp Pathol 2008;138:46–53. Acknowledgments 20. Scott-Moncrieff JC, Reagan WJ, Glickman LT, DeNicola DB, The authors thank Drs. Cynthia Lucidi and Karen Young, Harrington D. Treatment of nonregenerative anemia with human gamma-globulin in dogs. J Am Vet Med Assoc 1995;206:1895–1900. clinical pathologists at the University of Wisconsin-Madison, 21. Parker V, Tormey CA. The direct antiglobulin test: Indications, inter- for their review and interpretation of all bone marrow aspirates pretation, and pitfalls. Arch Pathol Lab Med 2017;141:305–310. and histologic sections. The authors also thank Dr. Lisbeth

1104 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Case Report Rapport de cas

Hemangiosarcoma within an intermuscular lipoma in a golden retriever dog

Claire Leriquier, Marie-Odile Benoit-Biancamano, Hugues Lacoste, Gregory D. Herndon

Abstract — A subcutaneous mass on the right pelvic limb of an 11-year-old neutered male golden retriever dog was surgically excised. A hemangiosarcoma included within an intermuscular lipoma was diagnosed upon histopathological examination. To the authors’ knowledge, this is the first case report of this nature in a dog.

Résumé — Hémangiosarcome dans un lipome intermusculaire chez un golden retriever. Une masse sous- cutanée située sur le membre pelvien droit d’un golden retriever mâle castré de 11 ans a été excisée chirurgicalement. Un hémangiosarcome inclus dans un lipome intermusculaire a été diagnostiqué à l’examen histopathologique. Selon les auteurs, il s’agirait du premier rapport de cas de ce type chez un chien. (Traduit par les auteurs) Can Vet J 2017;58:1105–1109

ipomas are common subcutaneous tumors in small ani- Case description mals in any location on the body (1). Less common are L An 11-year-old, neutered male golden retriever dog was initially infiltrative or intermuscular lipomas. Infiltrative lipomas are presented to his veterinarian for muscle loss of the left pelvic histologically benign but locally invasive into surrounding tis- limb without lameness. At this time, 7 subcutaneous masses sues; intermuscular lipomas are variants of subcutaneous lipo- were identified, including a mass on the right pelvic limb. The mas situated between muscle planes with no local invasion (1). mass on the right pelvic limb was firm, non-ulcerated, and Both types of lipoma are typically found in the pelvic limbs of measured 22 3 22 3 4 cm. The mass adhered to the back of dogs (2,3) and can be difficult to differentiate without surgical the right thigh (from rump to back of stifle) and had increased evaluation (2). Hemangiosarcoma (HSA) is another neoplasm in size over the past year. Fine-needle aspirates (FNA) were diagnosed frequently in dogs compared with those in other spe- taken from each mass. The results of cytological analyses were cies (4). This neoplasm occurs primarily within the viscera of the consistent with lipomas for 3 of the subcutaneous masses, but spleen, the most common location, or less frequently the skin 3 others were too hypocellular to make a definitive diagnosis. and subcutaneous tissues (14% of HSA) (4). It is extremely rare The mass on the right pelvic limb (the 7th mass) was described in both the veterinary and human literature to have a second as benign adipose tissue with rare mature lymphocytes and was tumor growing within another tumor (5–8). Collision tumors therefore diagnosed as a lipoma. A biopsy was recommended, are defined as co-existent but independent neoplasms which can but the owner declined and decided to monitor the mass for be contiguous or intermingled in the same site (9–11). any changes in size. This report describes the diagnostic work-up, surgical inter- Seven months later the patient was re-evaluated by his veteri- vention, and postoperative treatment of a hemangiosarcoma narian because of some weakness and difficulty moving the right within an intermuscular lipoma on the caudal aspect of the right pelvic limb over the previous few days. The mass on the right pelvic limb of a golden retriever dog. To the authors’ knowledge pelvic limb appeared larger and pitting edema was noted on this is the first report of this nature in a dog. the distal limb that was painful on palpation; the other masses seemed stable in size and shape. A surgical consultation was recommended for the right pelvic limb mass. No abnormalities Université de Montréal, Faculté de médecine vétérinaire, were noted after hematology and biochemistry. Medical treat- 3200 rue Sicotte, Saint-Hyacinthe, Québec J2S 2M2 (Leriquier, ment had been started before referral: tramadol (Apo-Tramadol; Benoit-Biancamano, Herndon); Centre vétérinaire DMV, 2300, Apotex, Toronto, Ontario), 150 mg, PO, q12h and meloxicam e 54 Avenue, Montréal (Lachine), Québec H8T 3R2 (Lacoste). (M-Eloxyn; Zoetis, Kirkland, Quebec), 3.75 mg, PO, q24h. Address all correspondence to Dr. Claire Leriquier; e-mail: The dog was then referred to the small animal hospital of [email protected] the Faculty of Veterinary Medicine (University of Montreal) Use of this article is limited to a single copy for personal study. for evaluation of the large subcutaneous mass on the caudal Anyone interested in obtaining reprints should contact the aspect of the right pelvic limb. A grade I/VI left holosystolic CVMA office ([email protected]) for additional murmur was detected on physical examination. Evaluation of copies or permission to use this material elsewhere. the gait revealed mild to moderate lameness in the right pelvic

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made on the caudal aspect of the right thigh. The lipoma was easily identified with a second mass localized in the caudoproxi- mal part of the fat tissue. This second mass was approximately 7 cm in diameter and contained coagulated blood (interpreted as a hematoma). Both masses appeared to be well-encapsulated between the semitendinosus and semimembranosus muscles. The masses were removed together using both sharp and blunt dissection. Once the caudal, lateral, and medial aspects of the mass were dissected, the sciatic nerve was identified and the lipoma was carefully dissected away from the nerve. Once the dissection was complete, the mass was removed (Figure 2A). RAPPORTCAS DE There was no evidence of infiltration into the surrounding tissues. A Jackson-Pratt drain was placed and secured in a Figure 1. Computed tomography image of the right pelvic limb standard fashion to eliminate dead space and reduce the risk of showing 2 masses. A wide (19 3 10 3 14 cm) oval uniform mass with a mean attenuation of adipose tissue (appears black postoperative seroma formation. The area was lavaged and closed on the image) infiltrates the centrocaudal intermuscular space of routinely. The dog did well in the hospital and was discharged the right thigh without involving the femur (appears white on the 2 d after surgery with a short course of medication, tramadol image, black asterisk). Muscles are pushed away and thinned. A capsule is variably present, poorly defined and incomplete. (Tramadol; Gentes, Saint-Hyacinthe, Quebec), 2.5 mg/kg body These characteristics are suggestive of an infiltrative lipoma weight (BW), PO, q8h for 7 d, cephalexin (Apo-Cephalex; (star). The fat mass contains in its centrocaudal portion an oval Apotex, Toronto, Ontario), 22 mg/kg BW, PO, q8h for 10 d mass with a smooth and well-defined outline (9 3 6.7 3 8.6 cm). This mass is minimally heterogeneous and with an attenuation and meloxicam (Zoetis), 0.1 mg/kg BW, PO, q24h for 5 d. The level compatible with some tissue or a richly cellular liquid surgical wound healed without complications. (appears grey on the image). This mass is consistent with a The mass was submitted for histopathological examination. hematoma (white asterisk), interpreted to have resulted from a hemangiosarcoma (not visible within the CT image due to the At gross examination, the mass was multilobulated, soft, white, small size). and measured 21 3 14 3 7 cm. On cut surface, its appearance was greasy and a second mass measuring 10 3 10 3 2 cm, with a consistency and color compatible with a hematoma, was limb. Orthopedic examination found pain upon manipulation enclosed within the capsule of the first mass. Both masses were of the right hip and mild effusion in the right stifle but no fixed in 10% buffered formalin and samples were embedded in cranial cruciate ligament instability. A large firm subcutaneous paraffin. Sections 4 mm thick were stained with hematoxylin- mass (20 3 12 3 8 cm) was identified on the caudal aspect of eosin-phloxin-saffron (HEPS). The first mass was mainly com- the right thigh extending from just distal to the ischium to just posed of adipocytes, characterized by a single, large and clear distal to the right stifle. Based on the previous identification cytoplasmic vacuole and a small nucleus, often pushed to the of a lipoma, an invasive or intermuscular lipoma of the caudal periphery. Anisocytosis and anisokaryosis were mild and no right thigh was the tentative diagnosis. An aspirate of the mass mitoses were observed. A few areas of fat necrosis, accompanied was examined and lipoma was confirmed. by a variable degree of inflammation were noted. Based on the Prior to surgery, metastatic screening was recommended and location, this mass was diagnosed as an intermuscular lipoma. included blood analysis (completed by the referring veterinar- The second mass was mainly composed of a large hematoma, ian), thoracic radiographs, abdominal ultrasound (both had no the periphery of which had small clusters of fusiform cells evidence of metastatic disease), and a preoperative computed (Figure 2B). These cells also focally lined distinctly formed vas- tomography (CT) scan to further define the mass and assess its cular channels (Figure 2C). They had an eosinophilic cytoplasm resectability. A CT scan of the right pelvic limb was performed with poorly delineated cell borders, a round to ovoid nucleus under general anesthesia (Figure 1). Mild osteoarthritis of both with finely granular chromatin, and 1 or 2 small nucleoli. hips was identified and mild enlargement of the right external Anisocytosis and anisokaryosis were moderate and there were iliac lymph node was noted. A large intermuscular mass was 0 to 3 mitoses per 400 3 field (Figure 2D). The histologic identified; its uniform texture with an attenuation of adipose features of this mass were consistent with a hemangiosarcoma tissue and with a poorly defined and incomplete capsule were (Figure 2C). Granulation tissue and hemosiderin-laden macro- consistent with an infiltrative lipoma. However, a second phages were also observed multifocally, within the hematoma. mass was noted within the primary mass that was different in Based on the diagnosis of a hemangiosarcoma, consulta- appearance and was interpreted as a cyst or soft tissue sarcoma. tion with an oncologist was recommended and pursued by Liquid effusion surrounded the mass, suggesting a compres- the owner in the DMV Center. Chemotherapy was initiated sion of the venous or lymphatic vessels. After consultation, the approximately 2 wk after surgery with the intent to complete owner decided to proceed with surgery since there was no sign a doxorubicin-based protocol (Doxorubicin; Hospira Health of metastatic disease at this time. Care, Saint-Laurent, Quebec), 28 to 30 mg/mm2 every 3 wk for The dog was placed in sternal recumbency with his pelvic 5 treatments (1). The dog received 2 doses of chemotherapy limbs hanging over the edge of the surgery table. The limb was without incident except for a mild leukocytopenia, mild neu- prepared aseptically. A 20-cm proximal to distal incision was tropenia, and monocytopenia at 7 d post-treatment, which had

1106 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 2. A — Gross appearance of the mass after surgical resection. B — Microscopic appearance of the masses, including the lipoma (arrowhead), the hematoma (asterisk) and the hemangiosarcoma (framed) (HEPS 23). Bar = 1 mm. C — Microscopic appearance of the hemangiosarcoma, with more solid areas (asterisks) and focally forming vascular channels (arrowhead) (HEPS 103). Bar = 200 mm. D — Moderate anisocytosis and anisokaryosis are present as well as occasional mitoses (arrowhead). A multinucleated cell is also depicted (asterisk). (HEPS 203). Bar = 100 mm. resolved by the following re-check evaluation and hematology. ence. The most common site for intermuscular lipomas is the Before every treatment, an electrocardiogram (ECG) was per- caudal thigh, typically between the semitendinosus and semi- formed and no abnormalities were observed. At the dog’s 8th membranosus muscles (2), as was the case in this dog. However, post-operative week recheck at the small animal hospital the 1 article describes intermuscular lipomas also occurring in the owner reported that the dog was doing well, with the exception axillary region, typically seen between the superficial and deep of 1 day following the most recent chemotherapy administra- pectoral muscles or the serratus and subscapular muscles (15). tion, in which the dog was midly lethargic and confused. This Prior to surgical intervention for suspected infiltrative lipomas, episode had resolved quickly within 24 h without treatment. a CT scan is recommended to aid with surgical planning and Approximately 4 wk after the last evaluation the owner found assess the resectability of these tumors. In the current case, the the dog had died in his sleep with no apparent abnormalities CT scan showed that this was a probable infiltrative lipoma with leading up to the time of death. No necropsy was performed. a secondary mass in the proximal region of the lipoma. However, during surgery the mass was well encapsulated between muscle Discussion planes and thus more consistent with an intermuscular lipoma. Lipomas are common subcutaneous tumors in older dogs. This is consistent with other studies which have shown that dif- They were the third most common nonlymphoid cutaneous ferentiation between an intermuscular lipoma and an infiltrative neoplasm in the dog, comprising 7.1% of 6282 cases in 1 study tumor is often only made at the time of surgery (2). This dif- (1). Although lipomas are benign, infiltrative lipomas can be ferentiation is important because it can change the prognosis for locally invasive into surrounding tissues including muscles, fas- the patient as infiltrative tumors have a recurrence rate of 36% cia, nerves, and bones (1). Infiltrative lipomas are described in to 50% (12,13), whereas intermuscular lipomas are unlikely to dogs as well as cats and horses (1). Depending on their location, recur (2,15,16). they can interfere with limb function and are often found on the Diagnosis of lipomas can easily be performed with FNA; extremities (12), especially in the pelvic limbs (3). Other affected therefore, slides are not often sent to laboratories. That can areas that have been reported include the abdominal/thoracic explain the underrepresentation of lipomas (only 2 cases, with- wall, the head, and the perineal area (13,14). Both infiltrative out details of their location) in 1 study of more than 200 cases and intermuscular lipomas can be associated with lameness, comparing histology with FNA (17). In this study, there was even if there is no local invasion in the latter, because they are 97.9% specificity and 89.3% sensitivity with the correlation situated between muscle planes, causing mechanical interfer- between preoperative aspiration and postoperative histology

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(17). In the current case, the FNA of the mass was consistent cutaneous, subcutaneous, or other tissue involvement of a HSA with a lipoma; however, there was no knowledge of the second (although 3 of the masses initially examined had no diagnosis), mass most likely because it was initially too small and not making it unlikely to be a tumor-to-tumor metastasis. A dif- found during aspiration. Once the second mass was identified ferent phenomenon, collision tumors, has also been reported on CT scan, taking an aspirate of the mass was discussed with in a few cases in the veterinary literature (9–11). However, the the owner. Since no evidence of metastatic disease was found 2 types of tumors cells herein were not admixed while reported on the preoperative examination the owner elected to decline collision tumors are generally described as mixed cell popula- having an aspirate taken and to proceed with the surgical plan tions. Furthermore, these reports always included a melanocytic to remove the mass. In retrospect, aspirates would have likely component (9–11), which was not present in this case. been inconclusive, as the diagnosis of HSA via FNA can be dif- The pathophysiology of a tumor within a tumor is poorly ficult due to poor exfoliation of the tumor and the presence of understood; however, several theories have been proposed (7,8). RAPPORTCAS DE excessive hemorrhage (1,18), as was observed herein. Tumors that are rich in lipids such as lipomas would form micro- Three stages of cutaneous HSA have been defined: stage I is environments that would provide ample nutrients, making it a confined to the dermis, stage II involves the hypodermis but good growth medium for another tumor (8). Neovascularization does not involve invasion of the musculature, and stage III associated with the initial tumor may make it more accessible involves invasion of the musculature (4). This classification sys- to malignant cells in the circulation, thus allowing for the seed- tem showed that there is higher metastatic potential for stages II ing of the initial tumor with another tumor (8) even if lipomas and III (60%) compared with stage I (30%) (4). Thus, following are rather poorly vascularized compared to other tumors (7). surgical excision, chemotherapy should be recommended for Lastly, this phenomenon could be related to the production of stages II and III HSA. In the current case, the HSA was consid- growth factors from the initial tumor, which could then favor the ered a stage II so the treatment of choice was surgical excision development of the second tumor (7,8,22). In the current case, with complete margins followed by a course of chemotherapy. a transdifferentiation phenomenon should also be considered, A standard chemotherapy protocol consisting of doxorubicin as mentioned in a similar case of a sinusoidal hemangioma with dose of 30 mg/m2 every 3 wk for 5 treatments used for splenic lipoma in a human (22). Indeed, in prenatal adipogenesis, adipo- HSA is the treatment of choice for subcutaneous HSA (19,20). cytes come from the perivascular cells which could be a possible Using this grading scale, survival times vary greatly when surgery consideration for the origin of both tumors (22). alone is performed: the stage I median survival time is 780 d The reason for this patient’s death is unknown; however, while the survival times for stage II is only 172 d (4). Limited there are several possibilities. One possibility is the presence of data are available for cutaneous HSA after chemotherapy a metachronous or synchronous right atrial mass that could have (19). In one study of survival rates of various forms of HSA, resulted in complications (pericardial effusion with tamponade the median survival time of 6 cases with a subcutaneous mass and/or arrhythmias) and sudden death. However, the incidence was 425 d after chemotherapy but the protocol was different, of metachronous or synchronous subcutaneous and cardiac HSA consisting of a combination of vincristine, doxorubicin, and is not known. In addition, metastasis of a subcutaneous HSA to cyclophosphamide (21). The number of cases of subcutaneous the right atrium or vice versa has not been described (4). Another HSA in this study was low; however, the median survival was possibility could have been the presence of micrometastatic significantly increased with postoperative chemotherapy when lesions which could have resulted in a neoplastic embolus in given after surgery in all types of HSA (21). brain, heart, or lungs causing sudden death. The side effects of To the authors’ knowledge the presence of a HSA in a lipoma chemotherapy should be considered, but most of these are noted has not been described in the veterinary literature. It is difficult in the first few days following chemotherapy, with the exception to know which tumor developed first, although the larger mass is of cardiomyopathy. In the current case the dog died 5 wk after generally presumed to have developed first. Also the growth rates his second chemotherapy treatment, making acute septicemia of both tumor types would favor the hypothesis of an initial due to neutropenia an unlikely cause. Cardiomyopathy can lipoma. Typically, HSA is a fast-growing and metastatic tumor, occur as a chronic cumulative effect of doxorubicin. In this making it a less likely candidate as the initial tumor, as opposed case, sudden death due to fatal arrhythmias cannot be ruled to the lipoma, which had been diagnosed over a year prior to out, although the dog did not show any evidence of ventricular presentation at the small animal hospital. Only one other case premature contractions during any of the 2 pre-doxorubicin of a tumor within a lipoma has been reported in the veterinary ECGs. He received a cumulative dose of only 58 mg/m² which literature, which was a case of a boxer dog with a cutaneous is below the toxic threshold of 180 to 240 mg/m² (1). No echo- mast cell tumor within a lipoma (5). This phenomenon is rare cardiogram was performed in this patient because he was not and it is important to differentiate between tumor growth from a breed predisposed to dilated cardiomyopathy and had within another tumor and tumor-to-tumor metastasis. In the no signs of heart disease. Lastly, it is important to note that this human literature tumor-to-tumor metastasis is described with was a geriatric patient and his death could be unrelated to his Campbell’s 3 criteria: i) presence of at least 2 primary tumors tumors. Unfortunately, a necropsy could not be performed as with the recipient being a true neoplasm; ii) exclusion of direct the patient died at home and notification of his death was not ingrowth or tumor emboli; and iii) exclusion of metastatic provided for several days. tumor of lymph nodes involved by lymphatic proliferative dis- To the authors’ knowledge, this is the first report describ- ease (6). In the current case there was no evidence of any other ing a hemangiosarcoma within an intermuscular lipoma. This

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­phenomenon of a tumor growing within another tumor is 10. Goldbar HM, Izawa T, Kuwamura M, Fujita D, Sasai H, Yamate J. extremely rare both in the veterinary and human literature. A collision tumor consisting of malignant trichoblastoma and melano- sarcoma in a rabbit. J Comp Pathol 2014;151:63–66. Although there are several theories attempting to explain this 11. Rodriguez F, Castro P, Ramirez GA. Collision tumour of squamous cell rare phenomenon, additional research is required to fully under- carcinoma and malignant melanoma in the oral cavity of a dog. J Comp stand its pathogenesis. Pathol 2016;154:314–318. 12. McEntee MC, Page RL, Mauldin GN, Thrall DE. Results of irradia- tion of infiltrative lipoma in 13 dogs. Vet Radiol Ultrasound 2000;41: REPORT CASE Acknowledgment 554–556. The authors thank Marc-André d’Anjou, DVM, DACVR, for 13. Bergman PJ, Withrow SJ, Straw RC, Powers BE. Infiltrative lipoma in dogs: 16 cases (1981–1992). J Am Vet Med Assoc 1994;205:322–324. his help with interpretation of the CT images. CVJ 14. Gleiser CA, Jardine JH, Raulston GL, Gray KN. Infiltrating lipomas in the dog. Vet Pathol 1979;16:623–624. References 15. Case JB, MacPhail CM, Withrow SJ. Anatomic distribution and clinical findings of intermuscular lipomas in 17 dogs (2005–2010). J Am Anim 1. Withrow SJ, Vail DM, Page R. Withrow and MacEwen’s Small Animal Hosp Assoc 2012;48:245–249. Clinical Oncology. 5th ed. St. Louis, Missouri: Saunders Elsevier, 2013: 16. Huppes RR, Pietro ND, Wittmaack MC, et al. Intermuscular lipoma 112–133, 163–192, 375–401, 425–454, 785–795. in dogs. Acta Sci Vet 2016;44:1–7. 2. Thomson MJ, Withrow SJ, Dernell WS, Powers BE. Intermuscular lipo- 17. Ghisleni G, Roccabianca P, Ceruti R, et al. Correlation between fine mas of the thigh region in dogs: 11 cases. J Am Anim Hosp Assoc 1999; needle aspiration cytology and histopathology in the evaluation of 35:165–167. cutaneous and subcutaneous masses from dogs and cats. Vet Clin Pathol 3. McEntee MC, Thrall DE. Computed tomographic imaging of infil- 2006;35:24–30. trative lipoma in 22 dogs. Vet Radiol Ultrasound 2001;42:221–225. 18. Baker-Gabb M, Hunt GB, France MP. Soft tissue sarcomas and mast 4. Ward H, Fox LE, Calderwood-Mays M, Hammer QS, Couto CG. cell tumours in dogs: Clinical behaviour and response to surgery. Aust Cutaneous hemangiosarcoma in 25 dogs: A retrospective study. J Vet Vet J 2003;81:732–738. Intern Med 1994;8:345–348. 19. Ogilvie GK, Powers BE, Mallinckrodt CH, Withrow SJ. Surgery and 5. Jakab C, Szasz AM, Kulka J, et al. Cutaneous mast cell tumour within doxorubicin in dogs with hemangiosarcoma. J Vet Intern Med 1996; a lipoma in a boxer. Acta Vet Hung 2009;57:263–274. 10:379–384. 6. Laco J, Celakovsky P, Kalfert D, Hornychova H, Rybnikar T, Ryska 20. Schultheiss PC. A retrospective study of visceral and nonvisceral A. Tumor-to-tumor metastasis: Warthin tumor as a recipient of lung hemangiosarcoma and hemangiomas in domestic animals. J Vet Diagn carcinoma and of renal carcinoma — Report of two cases. Pathol Res Invest 2004;16:522–526. Pract 2010;206:458–462. 21. Hammer AS, Couto CG, Filppi J, Getzy D, Shank K. Efficacy and 7. Alonso S, Rodríguez-Peralto JL, Pérez-Espejo G. Metastasis of cutaneous toxicity of VAC chemotherapy (vincristine, doxorubicin, and cyclo- malignant melanoma to angiolipoma: The tumor-to-tumor metastasis phosphamide) in dogs with hemangiosarcoma. J Vet Intern Med 1991; phenomenon. J Cutan Pathol 2003;30:323–325. 5:160–166. 8. Ricketts R, Tamboli P, Czerniak B, Guo CC. Tumor-to-tumor metas- 22. Song BH, Youn SH, Park EJ, Kwon IH, Kim KH, Kim KJ. A tasis. Report of 2 cases of metastatic carcinoma to angiomyolipoma of case of sinusoidal hemangioma with lipoma. Ann Dermatol 2011; the kidney. Arch Pathol Lab Med 2008;132:1016–1020. 23:S250–S253. 9. Jakab C, Balka G. First report of a malignant collision skin tumor with malignant melanoma and anaplastic sarcoma components in a dog. Acta Vet Hung 2012;60:245–255.

CVJ / VOL 58 / OCTOBER 2017 1109 FOR PERSONAL USE ONLY Case Report Rapport de cas

Accidental selenium toxicosis in lambs

Christina M. McKenzie, Ahmad N. Al-Dissi

Abstract — Acute selenium toxicosis occurred in 3-week-old lambs after accidental over-supplementation by intramuscular injection and caused dyspnea, cyanosis, and sudden death. Pathological lesions included myocardial necrosis, skeletal muscle necrosis, pulmonary edema, hydrothorax, and hydropericardium.

Résumé — Toxicose accidentelle au sélénium chez des agneaux. Une toxicose aiguë au sélénium s’est produite chez des agneaux âgés de 3 semaines après une supplémentation excédentaire accidentelle par injection intramusculaire et elle a causé des signes de dyspnée, de cyanose et de mort soudaine. Les lésions pathologiques incluaient une nécrose du myocarde, une nécrose du muscle squelettique, un œdème pulmonaire, de l’hydrothorax et de l’hydropéricarde. (Traduit par Isabelle Vallières) Can Vet J 2017;58:1110–1112

Case description Lambs 1, 3, and 4 had 30 to 50 mL of pale yellow and clear fluid within the thoracic cavity and 10 to 20 mL of similar fluid n March 2012, 40 out of 60 newborn lambs from a within the pericardial sac, indicating hydrothorax and hydro- Saskatchewan herd died over the course of 3 d. There was I pericardium (Figure 1a). Lamb 4 had a stable froth within the a history of sudden death with possible respiratory symptoms trachea extending from the larynx to the tracheal bifurcation. and cyanosis. Four 3-week-old male lambs were submitted The myocardial surface in all lambs had multifocal to coalesc- for postmortem examination to Prairie Diagnostic Services ing pale and dull areas, suggestive of necrosis, with lamb 3 at the Western College of Veterinary Medicine in Saskatoon, displaying biventricular dilation (Figure 1b). Two lambs had Saskatchewan. All of the lambs had been treated with 4 mL of multiple 1- to 2-mm mitral valve hematocysts. In lambs 2, 3, an intramuscular selenium and vitamin E product (Dystosel; and 4 skeletal muscles were diffusely pale. Lambs 3 and 4 had Zoetis Canada, Kirkland, Quebec, 3 mg/mL sodium selenite diffusely red prescapular lymph nodes, but only lamb 3 had an and 136 IU/mL dl-a-tocopherol acetate) 3 d earlier, which the adjacent focal subcutaneous lesion in the left shoulder that was owner considered to be the cause of death. necrotic and hemorrhagic. Lamb 1 had a prominent zonal pat- Each lamb weighed between 3.42 and 4.46 kg and had mildly tern on the surface of its liver indicating congestion and hepatic decreased body condition scores of 2.5/5. This was evidenced by lipidosis. Lamb 4 exhibited multifocal petechial renal cortical limited subcutaneous tissues but persistent abdominal, perirenal, and pancreatic hemorrhages. and pericardial adipose stores. All 4 lambs had clotted milk in A diagnosis of acute to subacute heart failure secondary the abomasum while the small intestine and colon contained to myocardial necrosis was made in all lambs based on gross variable amounts of green to yellow pasty contents. Each lamb findings. had a moderate amount of feces caked on the perineum. All Histologically, sections from each heart showed multifocal 4 lambs had moderate subcutaneous edema in the neck and pale areas of myocyte disarray with variable degrees of swelling, along the cranial thoracic abdomen. Each animal had edema- fragmentation of the sarcoplasm, hypereosinophilia, and nuclear tous, glistening lungs that failed to collapse, had prominent rib pyknosis and karyorrhexis. Areas with contraction band necro- imprints, and oozed fluid and blood on section. The myocar- sis were also seen. Phosphotungstic acid — hematoxylin stain dium in each lamb was diffusely pale. emphasized the contraction bands within areas in which muscle fibers appeared pale (Figure 1c). Skeletal muscles displayed Department of Veterinary Pathology, Western College of similar areas of mild myocyte fragmentation and vacuolation, Veterinary Medicine, University of Saskatchewan, 52 Campus contraction bands and mineralization (Figure 1d). Drive, Saskatoon, Saskatchewan S7N 5B4. Multiple lung sections were examined for each lamb and all Address all correspondence to Dr. Ahmad Al-Dissi; e-mail: showed multifocal mild to moderate dilation of the subpleu- [email protected] ral lymphatics with approximately 50% of alveoli containing Use of this article is limited to a single copy for personal study. variable amounts of homogeneous eosinophilic fluid (edema). Anyone interested in obtaining reprints should contact the Interalveolar capillaries were also congested. Multifocally, alveoli CVMA office ([email protected]) for additional of lambs 1 and 2 contained meconium and squamous epi- copies or permission to use this material elsewhere. thelial cells admixed with few neutrophils indicating in utero

1110 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 1. Thoracic cavity — lamb 4. A — Macroscopic view of the thoracic cavity showing edematous and congested lungs with and hydrothorax. B — Heart — lamb 3. Macroscopic view of the heart showing locally extensive pale myocardium and biventricular dilatation. C — Myocardium displaying areas of contraction band necrosis (arrow) and karyorrhectic nuclear debris. Hematoxylin and eosin (H&E) stain (inset: myocardium stained with phosphotungstic acid — hematoxylin stain to highlight areas of contraction bands. D — Skeletal muscles displaying mild fragmentation contraction bands and mineralization. H&E stain.

­aspiration of amniotic fluid. Lambs 3 and 4 also had mild necrosis, cardiac insufficiency, and death. The heart is the alveolar hemorrhage. primary target of selenium toxicosis, and the resulting heart In lamb 1, hepatocytes contained lipid vacuoles periportally. failure is what causes the secondary lesions including pulmonary In all 4 animals the kidney, adrenal glands, thyroid gland, edema, hydrothorax, and hydropericardium (3). Clinical signs of mesenteric lymph node, ileum, jejunum, duodenum, colon, acute selenium toxicosis include ataxia, dyspnea, and depression esophagus, thymus, and spleen all showed variable congestion. (3–5). After an acute exposure to selenium, lambs die over 3 to Mineral analysis of the liver confirmed toxic selenium con- 4 d, although there is variation in the severity of symptoms and centrations: selenium levels ranged from 3.8 to 10.9 ppm (wet lesions among lambs, even when given identical doses (4,6,7). weight). Reported toxic levels from intramuscular injections of Factors such as stress, exercise, and age can make lambs more sodium selenite range from 3.6 to 18.2 ppm on a wet weight susceptible and some lambs seem to be fundamentally more basis (1). Selenium concentrations were measured using an susceptible to selenosis (8). atomic scan with inductively coupled plasma (ICP) spectrometer Selenium is an essential nutrient for all mammals and is and hydride generator after an acid digestion technique (2). integral as an antioxidant to maintain stable cell membranes, The liver selenium concentrations, combined with the gross as it is an important component of the glutathione reductase and histologic evidence of myodegeneration and necrosis in the enzyme reaction (9–11). Selenium supplementation is a common heart, edema and congestion of the lungs, support a diagnosis practice in western Canada as the soil in some areas is selenium of acute selenium toxicity. deficient, resulting in selenium deficient feed (12). In addition to the type of rock bed, soil pH and rainfall can affect selenium Discussion levels in feed (9,12). Ideally, there should be between 0.1 mg/kg This case demonstrates the typical gross and histological lesions and 0.3 mg/kg dry weight total selenium in feed crops (9,13–15). of acute selenium toxicity in sheep resulting in myocardial Selenium deficiency can manifest as low fertility, unthriftiness,

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and white muscle disease, all of which can be prevented with oral clinical importance of its small therapeutic range. As there is or parenteral supplementation (4,8,9,12,14,16). Prophylactic no specific treatment for selenium toxicity beyond supportive selenium is often given to lambs at approximately 2 wk of age therapy, preventing overexposure through vigilance is the only to prevent delayed white muscle disease (7). possible option. CVJ Selenium has a low therapeutic index and over supplementa- tion is a common cause of acute overdose, as occurred in this References case (5,6,12,13,15,16). Ruminants are better adapted to a diet . 1 Puls R. Mineral Levels in Animal Health. Diagnostic Data. 2nd ed. Clearbrook, British Columbia: Sherpa International, 1994. containing excessive selenium, than are monogastrics, as the 2. Waldner CL, Blakley B. Evaluating micronutrient concentrations in liver ruminal microbiota metabolizes selenium into a less absorbable samples from abortions, stillbirths, and neonatal and postnatal losses in form which is excreted in the feces (17). The product given beef calves. J Vet Diagn Invest 2014;26:376–389. 3. Tiwary AK, Stegelmeier BL, Panter KE, James LF, Hall JO. Comparative intramuscularly in this case contained inorganic selenium in toxicosis of sodium selenite and selenomethionine in lambs. J Vet Diagn RAPPORTCAS DE the form of sodium selenite, which is less bioavailable but more Invest 2006;18:61–70. toxic than organic selenium (selenomethionine) when given 4. Smyth J, Wang JH, Barlow RM. Experimental acute selenium intoxica- tion in lambs. J Comp Pathol 1990;102:197–209. orally, due to differences in solubility and bacterial metabolism 5. Blodgett DJ, Bevill RF. Acute selenium toxicosis in sheep. Vet Hum (3,11). Sodium selenite also contains 41% selenium compared Toxicol 1987;29:233–236. with sodium selenate, another formulation, which contains 6. Blodgett DJ, Bevill RF. Pharmacokinetics of selenium administered parenterally at toxic doses in sheep. Am J Vet Res 1987;48:530–534. only 21% selenium (14). The recommended dose of Dystosel is 7. Gabbedy BJ. Toxicity in sheep associated with the prophylactic use of 0.5 mL/lamb, but the lambs in this case were given 4 mL/lamb selenium. Aust Vet J 1970;46:223–226. for a total of 12 mg of sodium selenite per lamb, or approxi- 8. Gabbedy BJ, Dickson J. Acute selenium poisoning in lambs. Aust Vet J 1969;45:470–472. mately 3 mg/kg body weight (BW). The LD50 of intramuscularly 9. Gupta UC, Gupta SC. Selenium in soils and crops, its deficiencies in injected selenium in lambs is between 0.45 and 0.7 mg/kg BW, livestock and humans: Implications for management. Commun Soil Sci depending on the age of the lamb (1,5,18). Plan 2000;31:1791–1807. 10. Spallholz JE. On the nature of selenium toxicity and carcinostatic activ- Although it is an antioxidant at low levels, selenium is ity. Free Radical Bio Med 1994 Jul 31;17:45–64. metabolized to free radicals, such as superoxide and hydrogen 11. Tokar EJ, Boyd WA, Freedman JH, Waalkes MP. Toxic effects of metals. peroxide, which can cause severe oxidative damage, especially In: Klaassen CD, ed. Casarett and Doull’s Toxicology: The Basic Science of Poisons. 8th ed. New York, New York: McGraw-Hill, 2012. to high-energy tissue such as the myocardium (10,15,16). The 12. Van Metre DC, Callan RJ. Selenium and vitamin E. Vet Clin N Am liver accumulates the highest levels of selenium, making it the Food Anim Pract 2001;17:373–402. ideal sample for laboratory testing, followed by the kidney and 13. Aitken P. Selenium toxicity. In Practice 2001;23:286–289. 14. Kyle R, Allen WM. Accidental selenium poisoning of a flock of sheep. heart (4,5,12). Methylation is the primary form of metabolism, Vet Rec 1990;126:601. and elimination occurs in the urine and feces at normal levels 15. Raisbeck MF. Selenosis. Vet Clin N Am Food Anim Pract 2000;16: and through exhalation at toxic levels (4,11). Selenium toxicosis 465–480. 16. Strugnell BW, Payne JH, Matthews R. Selenium toxicosis in sheep occurs when intake exceeds excretion (16). associated with excessive sodium selenite in a commercial supplement. Selenium toxicosis can either be acute or chronic, depending Vet Rec 2010;167:707–708. on the dosage and the period of exposure. Most chronic forms 17. Colegate SM, Dorling PR. Selenium metabolism in the rumen. In: Plant-associated Toxins: Agricultural, Phytochemical and Ecological of the disease are due to high levels of selenium in the diet Aspects. Wallingford, UK: CAB International, 1994. (9,11,15). Some plants, such as those in the genus Astragalus 18. Caravaggi C, Clark FL, Jackson AR. Acute selenium toxicity in lambs (vetch), Oonopsis (goldenweed), Xylorrhyza (woody aster), and following intramuscular injection of sodium selenite. Res Vet Sci 1970; 11:146–149. Stanleya (prince’s plume), are selenium accumulators and can 19. Davis TZ, Stegelmeier BL, Panter KE, Cook D, Gardner DR, Hall build up very high levels of selenomethionine, even up to JO. Toxicokinetics and pathology of plant-associated acute selenium 1000 ppm in some areas (10,11,13,19). In ewes affected by toxicosis in steers. J Vet Diagn Invest 2012;24:319–27. 20. Glenn MW, Jensen R, Griner LA. Sodium selenate toxicosis: Pathology chronic selenium poisoning major lesions include degeneration and pathogenesis of sodium selenate toxicosis in sheep. Am J Vet Res in cardiac muscles, pulmonary edema and congestion, and liver 1964;25:1486–1494. congestion (20). This report of acute selenium toxicity in lambs illustrates the toxic potential of intramuscular injection of selenium and the

1112 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY What Can’t Be Taught Ce qui ne s’enseigne pas

Strategies for fostering resilience as veterinary care providers

Marie K. Holowaychuk

hile my time since veterinary school spans far beyond I’m often asked the question…what allows a person to stay W 1 year, I feel compelled to write about my experience resilient within this profession, bouncing back from setbacks since I graduated 13 years ago and offer some important advice and not letting failure or disappointment drain her or his to the more recently graduated veterinarians. resolve? I have come to believe and recommend that veterinary If you told me at graduation that I would be engaged in care providers adhere to 5 “S-words” when it comes to fostering a “split-personality” veterinary career divided between small resilience within our profession because difficult clients, unan- animal emergency and critical care and health and well-being ticipated outcomes, challenging cases, and co-worker conflict advocacy, I would have thought you were joking. Prior to are not going away. obtaining my DVM degree, I thought I was destined for a life in 1. Self-care — Self-care means doing something just for your- companion animal practice, working in the Edmonton suburb self and not for anyone else. While this might seem selfish that I grew up in. But life has taken a much different turn for and unimportant, experts suggest that it is unethical for care me, which has led me down an extraordinary path into aca- providers not to tend to self-care (1). We’ve all had days demia, specialty private practice, the speaking circuit, and even when we didn’t get enough sleep the night before, skipped yoga and meditation teacher training. I love the work that I do breakfast, forgot to drink water, and avoided taking breaks and believe that my path has been intentional as it allows me to just to get through the day. Unfortunately, not tending to deliver many important messages regarding veterinary wellness. self-care ultimately harms the clients and animals we are That said, my path has not been easy and has been fraught caring for because we end up making mistakes or experienc- with episodes of burnout, experiences with compassion fatigue, ing compassion fatigue, which is a physical, emotional, and and struggles to manage my mental health and well-being. It is spiritual inability to care for others. Self-care has been shown because of these events that I chose to leave jobs in veterinary to allow physicians to continue to care for their patients medicine that I otherwise loved and at times felt unable to do compassionately and safely (2). So, how can veterinary care the work that I am so passionate about. It is due to these same providers tend to self-care? By setting self-care goals that align difficulties that I know of veterinarian and technician colleagues with the 8 wellness dimensions (i.e., physical, emotional, and friends who have left the profession or even taken their own spiritual, social, intellectual, occupational, financial, and life; feeling inadequate to continue working in veterinary prac- environmental wellness). Veterinary care providers can take tice, but not being able to name (or tame) the underlying cause. a holistic approach to their wellness, allowing an overall sense It is for this reason that I have become passionate about of mental and physical health and wellbeing (3). For example, sharing my story, experiences, knowledge, and advice when it self-care can be as simple as scheduling a massage each month comes to maintaining (and preferably thriving) rather than just (physical wellness), seeing a mental health provider once surviving a career in veterinary medicine. monthly (emotional wellness), writing in a gratitude journal each day (spiritual wellness), scheduling an outing with a friend each week (social wellness), signing up for a new class Marie K. Holowaychuk, DVM, DACVECC is a small animal once a year (intellectual wellness), attending an annual work- emergency and critical care specialist and certified yoga and shop to learn a new veterinary technique (occupational well- meditation teacher who has an invested interest in the health ness), meeting with a financial planner once a year (financial and well-being of veterinary professionals. She facilitates well- wellness), or clearing clutter from the home and workplace ness workshops and retreats for veterinarians, technicians, and (environmental wellness). No matter what resonates with an other veterinary care providers. For more information, please individual regarding what constitutes self-care, it is important visit www.criticalcarevet.ca. to make time for it regularly. Self-care is truly a necessity (not Address all correspondence to Dr. Marie Holowaychuk; e-mail: a luxury) in the work that we do as veterinary care providers. [email protected] 2. Saying no — Most of us struggle with saying no to others Use of this article is limited to a single copy for personal study. because we want to help, appear eager, remain a team player, Anyone interested in obtaining reprints should contact the and avoid disappointing our colleagues, family members, and CVMA office ([email protected]) for additional friends. However, as Steve Jobs said, “it is only by saying no copies or permission to use this material elsewhere. to others that we can say yes to ourselves.” When people ask

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me how to make time for self-care, I urge them to consider caffeine intake and use of electronics. Some pointers to help offloading something from their calendar to free up time. So, improve sleep hygiene, which is the ability to fall asleep (and the next time you are asked to join a committee, coach your stay asleep) for the recommended 7 to 9 hours per night, child’s sports team, or organize a work function, consider include the following: release daytime stress by relaxing your other obligations and priorities, as well as the time com- throughout the day (e.g., stretching), make lists during the day mitment involved. If it is not a resounding “absolutely!” that to avoid trying to remember things in bed, avoid negative self- you want to commit to the new request, then consider passing talk regarding sleep (e.g., “I never sleep well after a stressful on the opportunity. Saying no is not easy, but there are some shift”), allow 30 minutes to unwind before bedtime, exercise strategies that can help: be brief, be honest, be respectful, and, for 30 minutes each day, keep light out of the bedroom, turn if possible, say no in person. That way the desire to help and off electronics (e.g., TV, cell phone) at least 1 hour before thankfulness for being asked are passed along non-verbally, bedtime, get up and go to bed at the same time every day, use rather than the receiver assuming that you are disinterested the bed only for sleep or intimacy, and avoid alcohol 2 hours

CE QUI CE NE S’ENSEIGNEPAS or do not care. As difficult as saying no is, it is essential to before bedtime and caffeine 6 hours before bedtime. fostering resilience and making time for self-care. 5. Sitting still — As veterinary care providers, we spend most of 3. Setting boundaries — While physicians would not consider our days rushing through appointments (often on autopilot), giving out their personal cell number or answering e-mails attempting to multitask (not that it’s truly possible), and to patients on the weekend, veterinary care providers seem reacting to things that happen to us (e.g., a co-worker makes unable to prevent their work from creeping into their per- a rude remark and we shoot back with a snide comment). sonal life. Over time, these actions can lead to resentment, Making time in the day to sit in stillness during meditation frustration, and burnout. It is important to set limits in is a tremendously effective way to practice mindfulness. accordance with what you will and will not tolerate at work Mindfulness is living in the present moment (e.g., not wor- when it comes to client behavior (e.g., contacting you out rying about upcoming appointments or thinking about of hours), co-worker conduct (e.g., treating team members previous clients) and remaining calm when faced with dif- with respect), and even the work that you choose to do ficult situations. Neuroscience research shows that practicing (e.g., whether to perform declaw procedures). Feelings of mindfulness regularly can enhance the brain’s gray matter discomfort or resentment are clues that a person’s bound- within the prefrontal cortex, which is responsible for holding ary has been crossed. Very often, a person might also feel a attention, making decisions, moderating behavior, and solv- loss of energy, knot in the stomach, or urge to cry. If these ing problems. Mindfulness also shrinks the amygdala, which feelings come up, notice what it is about the situation, inter- identifies physical threats and emotional triggers (5). Research action, or expectation that is bothering you. Usually it is a in the medical field demonstrates that mindfulness training sense of being taken advantage of or not feeling appreciated helps nurses cope more effectively with stress by improving that causes resentment. When a boundary has been crossed their ability to think clearly and remain focused and calm or a boundary needs to be expressed, it is important to be during stressful situations. Mindfulness training also assists direct and assertive in your communication, so that others medical students, physicians, and nurses by promoting self- know explicitly what your expectations are. Then stick to awareness and self-care, while reducing risk of professional the boundary so that there is no confusion as to when or to burnout (5). Meditation is easy to do and involves sitting in whom it applies. a comfortable, upright position (back straight, crown of the 4. Sleep hygiene — The benefits of sleep are numerous and head towards the ceiling), closing the eyes (if comfortable), not just related to the restorative effects on the physical body. and focusing attention on the senses. This can be the smells Sleep is required to refresh the mind, process what has been or sounds in the room, as well as sensations in the body. For learned during the day, manage emotional experiences, and many people, the sensation of breathing is a good anchor consolidate memories. The detrimental consequences of not for the mind and counting each breath can allow focusing getting enough sleep are also becoming more well-known and attention. It is completely normal (and expected) that the can include metabolic disturbances (e.g., diabetes, weight mind will wander. The key is to notice when it has and gen- gain) and mental health concerns (e.g., depression). Recently, tly bring the attention back to the breath, body, or senses. a link between Alzheimer’s disease and lack of sleep has also Sitting in meditation for 5 minutes in the morning or even been found, suggesting that sleep is required to rid the body a few moments during a busy day can allow the mind and of waste products that have a degenerative effect on the brain body to refresh and an emotional buffer to form between the (4). Insomnia affects up to 1/3 of adults at some point in triggers and responses that are a part of every day. If you are their life and is typically due to worry and anxiety. However, interested in learning more about mindfulness or trying out there are many other things that can disrupt sleep including meditation, try downloading an application for your phone noise, interruptions, room temperature, humidity, lighting, such as Headspace, Aware, or Calm. diet, naps late in the day, lack of exercise, reduced exposure to outdoor light, negative self-talk, absent bedtime routine, References or inadequate relaxation techniques. Physical stress (e.g., full 1. Green Cross Academy of Traumatology. Standards of self-care guidelines. bladder, poor mattress) or disruptions in circadian rhythm Available from: http://home.cogeco.ca/~cmc/Standards_of_Self_Care.pdf (e.g., shift work), can also inhibit sleep, as can alcohol or Last accessed August 21, 2017.

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2. Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care 4. Sprecher KE, Koscik RL, Carlsson CM, et al. Poor sleep is associated for others: Physicians and their self-care. J Support Oncol 2013;11:75–81. with CSF biomarkers of amyloid pathology in cognitively normal adults. 3. Brandt J. What is wellbeing, why is it important, and what can we do to Neurology 2017;89:445–453. promote it? Veterinary Team Brief 2017;March:12–15. 5. Holowaychuk M. A mindful life: A prescription for wellness. Veterinary Team Brief 2017;July:16–19.

Book Review Compte rendu de livre CE QUI CE NE S’ENSEIGNEPAS Veterinary Medicine: A Textbook of the mind, “You miss more by not looking than by not knowing.” Diseases of Cattle, Horses, Sheep, Pigs, These are the chapters which new graduates might benefit and Goats, 11th edition, Volumes 1 and 2 from by reading — perhaps before they start their first job! The remaining 15 chapters are dedicated to diseases of specific organ Constable PD, Hinchcliff KW, Done SH, et al. Elsevier, St. Louis, systems. The detailed table of contents at the beginning of each Missouri, USA. 2017. 2308 pp. ISBN: 9780-7020-5246-8. chapter helps locate specificities within the subject. The text is broken down into headings, subheadings, and sub-sub headings, found this 2-volume edition of Veterinary Medicine attractively each one a different color. Important key words are in bold type, I put together, easy to navigate, and thoroughly useful as a and each subject culminates in a list of further readings and comprehensive and complete reference text. In its 11th edition references. Two useful features at the beginning and end of each over 56 years it has stayed faithful to its initial ideology while heading is the “Synopsis Box” and a “Differential Diagnosis” encompassing the ever growing amount of new information, box, and 2 small tables easily picked out and handy if just a new diseases, and new diagnostic and therapeutic techniques. quick reference is needed. There are many tables and pathway Both volumes are hefty, coming in at about 1100 pages each, trees throughout; lots of these have been brought over from but the general eye-appeal is catching, from the colorful photos previous editions and some are large and a bit overwhelming, on the front cover to the color-coded chapters, numerous tables, but packed with comparative information that can be studied diagrams, and photographs. thoroughly with time. Color photographs and diagrams are more The 4 main authors are from disparate parts of the world limited, but of good quality and useful. I found the descriptive (United States, Australia, United Kingdom, and Germany), prose very thorough, perhaps too much for some tastes, but one with 9 contributing authors from Canada, the United States, can pick and choose the detail one wants or needs to go into and Australia, giving the book an international perspective (the because of the well-demarcated organization. In this sense the authors having been educated in and/or worked in 12 countries book really is what it purports to being, a comprehensive book and 5 continents). The first few pages are tributes to the 3 senior useful for all walks of large animal medicine, whether it be the authors of past editions, Radostits, Gay, and Blood, making one equine cardiologist (this section seems particularly detailed) or realize that this is an evolving and ongoing project, fueled by the first year student (how to conduct a clinical examination). As Blood and Henderson’s lectures and, at the time, novel approach with most exhaustive texts, there are appendices. Strangely, the to teaching, namely that the principles of pathophysiology conversion tables have a convoluted method for changing metric explain disease syndromes (as opposed to rote learning which to imperial. The Reference Lab Values (compiled from differ- was popular at the time of the first edition, 1960), and that ent labs, one being Prairie Diagnostic Services at the Western pathophysiology plus epidemiology lead to diagnosis, treatment, College of Veterinary Medicine), and the Drug Dosages are and control. handy to have. I did notice a few typos (double/missing words), The current book has adhered to these principles, but also a couple of pages of blurred print, and incorrect page numbers addresses the immense change we have seen in agriculture, in the index, but minor errors considering the tome. politics, climate, trade, economics, and animal welfare since As a practitioner, it might not be the book I grab from the the 1960’s, and how these have impacted large animal practice. shelf while the cow is standing in the chute, but it would proba- There is an excellent 7-page introduction describing the intent bly be the one I sit down with at the end of the day (over a glass of the voluminous information within the text, and is definitely of wine). I would recommend it to anyone starting, or being in, worth reading. a career in large animal practice as a mainstay for the bookshelf. The book is divided into 21 chapters; the first 6 chapters I think it will continue to be one of the most widely used and (examinations, biosecurity, systemic states, body water, antimi- authoritative texts in large animal veterinary medicine today. crobial therapy) concern, perhaps, the more mundane aspects of the profession, but in my mind the building blocks of a solid understanding of large animal medicine. I found these chapters Reviewed by Cathy Patterson, DVM, Private Practitioner, excellent to peruse and the old adage of Otto Radostits came to Box 192, Gladstone, Manitoba.

1116 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Commentary Commentaire

Comments on the Ethical Question of the Month: July 2017 (CVJ 2017;58:651)

Maureen Harper

anada is a major international supplier of horse meat in Japan in wooden crates containing 3 or 4 horses per container C the world. In 2016, over 54 000 horses were slaughtered and the horses are unsegregated. International Air Transport in this country. It is estimated that 65% to 70% of the horses Association (IATA) Live Animal Regulations do not sanction the slaughtered in Canada originate from the United States. This use of such containers for horses and IATA loading densities are is because horse slaughter ceased in the United States in 2007. not being respected with many of these shipments. The result is Also, according to Agriculture and Agri-Food Canada, 5839 live horses have lost their balance and fallen. And without adequate horses were shipped to Japan for slaughter in 2016. room to get up, they have been injured and killed. Horse slaughter in Canada has become a contentious issue Many horses, in particular ones destined for slaughter, also in recent years. There have been numerous undercover record- suffer while being transported by land. As most horses being ings showing the improper stunning of horses. This is normally slaughtered in Canada originate from the United States, many accomplished through the use of a captive bolt or .22 rifle. are transported long distances. The current federal legislation However, the flight response of horses can make it extremely allows for horses to be transported for up to 36 hours without difficult to properly stun the animals. As a result, a number of food, water, and rest. Studies have shown that horses become horses have been documented bleeding out while still conscious. physiologically compromised and severely dehydrated at periods There are also issues with respect to horses being slaughtered of more than 24 hours in transit. that have been treated with drugs such as phenylbutazone and The Health of Animals Regulations for transport of animals clenbuterol. Health Canada deems that such drugs is unac- require that horses be segregated if the hind feet of the horses ceptable in meat destined for human consumption. Unlike are shod. Animals that are incompatible by nature must also be other farm animals, horses are not traditionally raised as food segregated. Compromised horses (nonambulatory, injured, heav- producing animals in North America. ily pregnant and imminently due to give birth on the journey, The Canadian Food Inspection Agency (CFIA) is the man- distressed, sick, weak, and extremely thin animals) are not to be dated agency responsible for ensuring that animals are trans- transported. Also, the animals must not be overcrowded. There ported in a humane manner. The CFIA is also the agency must be adequate ventilation, the conveyance is required to be responsible for the oversight of animal slaughter in all ­federal sound (no weak floors, holes in the flooring, insecure fittings abattoirs. The Health of Animals Regulations Part XII — or foreign objects or protrusions that could cause injuries), Transportation of Animals have been in place for about 40 years and there must be adequate bedding. There is no requirement, and are currently under review, awaiting updating. however, for horses from the United States to be off-loaded at With respect to transporting horses, once again through the points of entry. Therefore, how can a proper assessment of undercover footage, there has been documentation of infractions these issues be made when these animals are arriving in Canada? of humane transport under the Health of Animals Regulations. Also, there are numerous documented cases of “unwanted” Many of the horses being shipped to Japan by air for slaughter horses arriving at auction markets heavily pregnant, that foal are large draft breeds and are well over 14 hands. Section 141 (8) shortly after arrival. of the said regulations dictate that all horses over 14 hands are In summary, overbreeding in the equine industry is leading required to be segregated (so as to prevent injuries). This has not to a huge number of unwanted horses. If slaughter continues been the case with these shipments. As well, section 142 of these to be a solution to this issue, as sanctioned by the very industry same regulations require that each animal is able to stand in its that contributes to the overbreeding, then it is incumbent on the natural position without coming into contact with the roof or authorities to ensure that horses are transported and slaughtered top of the container. There is also documented evidence showing humanely. that this has not been the case with many of the larger horses. As a result of lack of enforcement of the Health of Animals Maureen Harper, DVM, MSc (Epidemiology), Brampton, Regulations, a number of horses in these shipments to Japan have Ontario, [email protected] been injured and have died. These animals are being shipped to

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.

CVJ / VOL 58 / OCTOBER 2017 1117 FOR PERSONAL USE ONLY SAV E THE DATE July 5 - 8, 2018 CVMA CONVENTION Vancouver, BritisH Columbia

canadianveterinarians.net FOR PERSONAL USE ONLY Diagnostic Dermatology Dermatologie diagnostique

Canine Malassezia dermatitis

Jangi Bajwa

alassezia pachydermatis is a commensal yeast that is nor- M mally present in low numbers in the external ear canals and superficial muco-cutaneous sites in dogs. Malassezia pachyder- matis is characterized by its round to oval or classical peanut shape with monopolar budding. This lipophilic, non-lipid dependent, non-mycelial saprophytic yeast organism is most often associated with Malassezia dermatitis (malasseziasis or Malassezia over- growth) in dogs. Other Malassezia may uncommonly be noted as a cause of Malassezia dermatitis such as M. sympodialis, which is smaller than M. pachydermatis and has a more rounded bulbous shape and narrower-based monopolar budding (1). Malassezia dermatitis in dogs is usually a secondary prob- lem due to an underlying skin disease such as allergic disease (including canine atopic dermatitis and flea allergy dermatitis), recurrent bacterial pyoderma, and endocrine diseases (especially hypothyroidism) (2). Many predisposing factors may result in the commensal M. pachydermatis becoming a pathogen. These factors include increased humidity, presence of skin folds, altered cutaneous pH levels, previous antibiotic therapy, and prolonged corticosteroid therapy (2–4). In addition to being a secondary disease, a significant number of dogs affected with Malassezia dermatitis are affected by concurrent staphylococcal pyoderma. Malassezia pachydermatis is thought to have a symbi- otic relationship with commensal staphylococci, which produce mutually beneficial growth factors and micro-environmental alterations (1,2). Clinical findings Figure 1. Malassezia dermatitis. Malassezia dermatitis (Figure 1) is common in dogs and affected sites include lip margins, ear canals, axillae, groin, ventral neck, which can be affected by chronicity of disease, primary underly- interdigital skin, facial folds or tail folds, perivulvar skin, and ing disease, previous therapy, and concurrent bacterial infection. perianal skin (5). Lesions may be localized or generalized. Some common presentations of Malassezia dermatitis include: Pruritus, a major sign, is usually severe and is accompanied by 1. Regional or generalized alopecia with erythema (exfoliative unpleasant odor. Skin lesions may present in various forms, erythroderma); 2. Scaly, waxy, or greasy seborrhea (yellow or slate gray); 3. Crusts or papulocrustous lesions resembling superficial Veterinary Dermatology & Ear Referral Medical Clinic, staphylococcal infection; Vancouver, British Columbia. 4. Lichenification and/or hyperpigmentation (leathery or Dr. Bajwa is a Board-certified dermatologist. elephant-like skin); Address all correspondence to Dr. Jangi Bajwa; e-mail: 5. Paronychia with dark brown nail bed discoloration, with or [email protected] without obsessive paw chewing; Use of this article is limited to a single copy for personal study. 6. Lip margin hypotrichosis and/or crusting; and Anyone interested in obtaining reprints should contact the 7. Intertrigo. CVMA office ([email protected]) for additional Several breeds are predisposed with the West Highland white copies or permission to use this material elsewhere. terrier, basset hound, American cocker spaniel, shih tzu, poodle,

CVJ / VOL 58 / OCTOBER 2017 1119 FOR PERSONAL USE ONLY

boxer, Cavalier King Charles spaniel, German shepherd dog, and tions such as a dietary elimination trial, antibiotic therapy, and dachshund showing an increased risk for Malassezia dermatitis. antipruritic therapy. The overall workload for the pet owner should be evaluated in order to ensure compliance with some- Diagnosis times numerous treatment recommendations made. Diagnostic The most useful and practical method of diagnosis of Malassezia workup and treatment for underlying primary disease should dermatitis is cytologic examination (1,2,4). Samples collected be pursued while treating Malassezia overgrowth, otitis, or using glass slide impression, acetate tape impression, superfi- dermatitis. Therapy should be continued for 7 to 10 d beyond cial skin scraping, or cotton swab method are evaluated under clinical cure (1). the microscope to ascertain the numbers of Malassezia yeast, Follow-up examination is usually recommended 3 to 4 wk bacteria, and inflammatory cells present on superficial skin. after initiation of treatment in order to evaluate clinical response If present, yeast organisms are often observed in clusters or and re-evaluate cytological Malassezia numbers. Clinical adhered to keratinocytes (1). Each collection method has its improvement, though welcome, is not adequate evidence to own benefits based on patient temperament, clinician prefer- confirm treatment success. On the contrary, lack of follow-up

DERMATOLOGIE DIAGNOSTIQUE ence, and sampling site. cytology may lead to further confusion about significance of Cutaneous cytology is not always successful in finding Malassezia yeast in the disease process, if the clinical symptoms Malassezia organisms. While some literature suggests that the or skin lesions were to recur. clinician should rely on clinical lesion patterns to make a tenta- For mild cases or for localized lesions, frequent topical ther- tive diagnosis of Malassezia dermatitis in such a situation (4), apy with antifungal products containing ingredients such as 2% in the author’s experience trial therapy is of minimal benefit in ketoconazole, 1% ketoconazole–2% chlorhexidine, 2% micon- the absence of cytological evidence of Malassezia organisms. azole, 2% climbazole, 2% chlorhexidine, 3% chlorhexidine, 2% Although certain lesion patterns, presence of an offensive yeasty miconazole-2% chlorhexidine, 2% lime sulfur, 0.2% enilcon- odor, and lack of response to previous appropriate therapy may azole, or 1% selenium sulfide is usually effective (1,2,4,8–10). be suggestive of Malassezia dermatitis, these should not be relied Shampoos containing 2 active ingredients may provide better upon as diagnostic criteria without pursuing cutaneous cytology efficacy (4). Medicated antifungal wipes or pads such as those to confirm Malassezia organisms. containing 0.3% chlorhexidine, 0.5% climbazole, and Tris- A further challenge in diagnosis of Malassezia dermatitis is the EDTA solution are effective against M. pachydermatis (11). lack of agreement with regard to the significance of numbers of For patients with generalized or multifocal lesions, oral yeast present on cutaneous cytology (1,6). Varying numbers of antifungal therapy in combination with topical therapy is most yeast are present in different body sites, and normal numbers effective. Oral antifungal drugs effective against Malassezia vary among breeds resulting in overlaps in yeast population organisms include ketoconazole, fluconazole, terbinafine, and densities in samples from clinically normal and diseased dogs itraconazole (5,11–14). Griseofulvin is not effective in the (7). Ultimately the diagnosis of Malassezia dermatitis should treatment of Malassezia infection (1). Patient factors such as rely on the combination of clinical presentation and cutaneous age, clinical history, underlying or concomitant disease, and cytology. Even low numbers of Malassezia organisms noted on breed predisposition should be considered before use of systemic cytology may indicate Malassezia dermatitis if samples are col- drugs; baseline and monitoring blood testing is encouraged. lected from inflamed, pruritic skin. The findings of cutaneous If underlying disease or predisposing factors are not con- cytology can vary between visits, and presence of a previous trolled, or are inadequately managed, regular antifungal therapy normal cytological analysis should not be regarded as current, may be indicated. Pulse therapy protocols using oral antifungal if the patient exhibits new lesions or clinical symptoms. drugs such as ketoconazole, itraconazole, and terbinafine can Fungal cultures are not helpful because M. pachydermatis are be prescribed (12,13). Similarly, application of 2% climbazole commensal organisms, making their isolation in culture of little shampoo for the control of Malassezia overgrowth and preven- or no diagnostic value (1,2). tion of recurrence has been described (9). Clinical management Malassezia hypersensitivity Multiple treatment options for Malassezia dermatitis are avail- One should not reach a diagnosis of Malassezia hypersensitivity able. Treatment is usually tailored according to factors such without a complete and thorough dermatologic workup. Any as localized versus generalized disease, overall patient health, dog with a classical history and cytological findings consistent underlying primary disease, and client preference or compliance. with recurrent or persistent Malassezia dermatitis should be It is preferable to use a combination of topical and systemic suspected of being affected by hypersensitivity to Malassezia therapy in order to achieve rapid and complete remission of organisms as long as underlying primary disease is well-managed clinical signs. Prescribing topical or systemic therapy alone may or ruled out. Higher levels of Malassezia-specific immunoglobu- be adequate for some patients. Extensive topical therapy can lin E have been found in atopic dogs compared with healthy be challenging in dogs with a thick hair coat, for large or non- dogs, suggesting that Malassezia may participate as an allergen compliant dogs, or if the pet owners are unable to meet the in patients with atopic dermatitis (15). Hypersensitivity to physical requirements that are sometimes time-consuming, Malassezia antigens is also thought to be important in atopic which is the nature of the treatment. Often, treatment of humans (16). If Malassezia hypersensitivity is suspected, intra- Malassezia dermatitis is accompanied by other recommenda- dermal allergy testing followed by observation for immediate

1120 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY and delayed reactions may be used to document hypersensitivity 8. Marsella R, Nicklin CF, Nerbonne J. Double-blind, placebo-controlled reactions (1). In dogs diagnosed with Malassezia hypersensitivity, study to evaluate two miconazole conditioners for the treatment of Malassezia dermatitis in dogs. Vet Ther 2000;1:141–149. immunotherapy with M. pachydermatis antigens may be a useful 9. Cavana P, Petit JY, Perrot S, et al. Efficacy of a 2% climbazole shampoo DIAGNOSTIC DERMATOLOGYDIAGNOSTIC therapeutic measure (17), but it may not be effective in some for reducing Malassezia population sizes on the skin of naturally infected dogs suspected to be hypersensitive to M. pachydermatis, and dogs. J Mycol Med 2015;25:268–273. 10. Maynard L, Rème CA, Viaud S. Comparison of two shampoos for the pulse therapy may be needed to prevent recurrence. treatment of canine Malassezia dermatitis: A randomised controlled trial. J Small Anim Pract 2011;52:566–572. Prognosis 11. Cavana P, Peano A, Petit JY, et al. A pilot study of the efficacy of wipes containing chlorhexidine 0.3%, climbazole 0.5% and Tris-EDTA Malassezia dermatitis carries a good prognosis. Thorough efforts to reduce Malassezia pachydermatis populations on canine skin. Vet should be made to identify causative factors such as underlying Dermatol 2015;26:278–e61. allergies, endocrine disease, neoplasia, or skin folds, to help 12. Berger DJ, Lewis TP, Schick AE, Stone RT. Comparison of once- daily versus twice-weekly terbinafine administration for the treat- prevent recurrent infection. Once concurrent infections and ment of canine Malassezia dermatitis—A pilot study. Vet Dermatol primary disease are adequately treated, management of M. 2012;23:418–e79. pachydermatis induced dermatitis is usually straightforward. 13. Pinchbeck LR, Hillier A, Kowalski JJ, Kwochka KW. Comparison of pulse administration versus once daily administration of itraconazole for the treatment of Malassezia pachydermatis dermatitis and otitis in References dogs. J Am Vet Med Assoc 2002;220:1807–1812. 1. Miller WH, Griffin CE, Campbell KL. Muller & Kirk’s Small Animal 14. Guillot J, Bensignor E, Jankowski F, Seewald W, Chermette R, Steffan J. Dermatology. 7th ed. St. Louis, Missouri: Elsevier, 2013:243–249. Comparative efficacies of oral ketoconazole and terbinafine for reducing 2. Mauldin EA, Scott DW, Miller WH, Jr, Smith CA. Malassezia derma- Malassezia population sizes on the skin of Basset Hounds. Vet Dermatol titis in the dog: A retrospective histopathological and immunopatho- 2003;14:153–157. logical study of 86 cases (1990–1995). Vet Dermatol 1997;8:191–202. 15. Nuttal TJ, Halliwell REW. Serum antibodies to Malassezia yeasts in 3. Bond R. Pathogenesis of Malassezia dermatitis. Advances in Veterinary canine atopic dermatitis. Vet Dermatol 2001;12:327–332. Dermatology. Vol 4. Oxford, UK: Blackwell Science, 2002:69–75. 16. Kieffer M, Bergbrant IM, Faergemann J, et al. Immunological reac- 4. Hnilca KA. Small Animal Dermatology: A Color Atlas and Therapeutic tions to Pityrosporum ovale in adult patients with atopic and seborrheic Guide. 3rd ed. Elsevier Saunders, 2011:83–84. dermatitis. J Am Acad Dermatol 1990;22:739. 5. Patterson AP, Frank LA. How to diagnose and treat Malassezia dermatitis 17. Morris DO, Olivier DO, Rosser EJ. Type-1 hypersensitivity reactions in dogs. Vet Med 2002;97:612–623. to Malassezia pachydermatis extracts in atopic dogs. Am J Vet Res 6. Plant JD, Rosenkrantz WS, Griffin CE. Factors associated with and 1998;59:836–841. prevalence of high Malassezia pachydermatis numbers on dog skin. J Am Vet Med Assoc 1992;201:879–882. 7. Bond R, Saijonmaa-Koulumies LEM, Lloyd DH. Population sizes and frequency of Malassezia pachydermatis at skin and mucosal sites of healthy dogs. J Small Anim Pract 1995;36:147–150.

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Answers to Quiz Corner Les réponses du test éclair

1. C) Cavalier King Charles spaniels have a higher incidence of 4. D) The correct answer is lethal lavender foal syndrome. mitral valve endocardiosis than do other breeds. Conditions A, B, and E are not fatal and can occur in any C) L’Épagneul cavalier King Charles possède une plus grande breed of horse. Answer C occurs in overo paint horses, not incidence d’endocardiose de la valve mitrale que les autres Egyptian Arabians, and affected foals display signs of colic races. rather than neurologic signs. D) La bonne réponse est le syndrome létal du poulain lavande. 2. B) The measurement of abdominal fluid BUN can be helpful, but Les réponses A, B, et E ne sont pas des conditions fatales et since BUN is a lower-molecular-weight substance compared peuvent se rencontrer chez n’importe quelle race de chevaux. with creatinine, it will be reabsorbed more quickly across the La réponse C se produit chez les chevaux Paint horse ovéro et peritoneum, lowering its concentration in the abdominal non chez les chevaux Égyptiens arabes; les poulains atteints fluid. Although sodium and potassium are abnormal in this montrent des signes de coliques plutôt que des signes fluid, their presence does not prove that the fluid is urine. neurologiques. Choice D is incorrect. At times, some urine is voided to the outside and some to the peritoneal cavity depending on the 5. C) Papillomatous digital dermatitis (hairy heel warts) can be location of a bladder tear. Choice E is incorrect. It is possible controlled by foot bathing (e.g., copper sulfate) or topi - for a urinary catheter to pass through the tear in the bladder. cal application of antiseptic or antibiotic solutions (e.g., The fluid that is retrieved is assumed to be urine when it fact tetracycline). Alley scraping and hygiene are important in it is modified abdominal fluid (urine 1 fluid shifts). preventing all bacterial digital dermatitides. This disease B) La mesure du BUN du liquide abdominal peut être utile, mais is contagious, so it is important to determine whether the puisque le BUN est une substance de poids moléculaire plus disease was recently introduced by purchased cattle, or is faible comparativement à la créatinine, il sera réabsorbé plus endemic. New, coarse concrete can be a risk factor for sole rapidement à travers le péritoine, abaissant sa concentration disease, not interdigital or other dermatitides. dans le liquide abdominal. Bien que le sodium et le potassium C) La dermatite digitale papillomateuse (verrues poilues des soient des substances anormales dans ce liquide, leur coussinets) peut être contrôlée par des bains de pieds (p. ex., présence ne prouve pas que le liquide soit de l’urine. Le sulfate de cuivre) ou par l’application topique de solutions choix D est incorrect. À certains moments, une certaine antiseptiques ou antibiotiques (p. ex., tétracycline). Le quantité d’urine peut être éliminée à l’extérieur ou dans la grattage et l’hygiène des allées sont importants pour prévenir cavité péritonéale, selon la localisation de la déchirure dans toutes les dermatites digitales bactériennes. Cette affection la vessie. Le choix E est incorrect. Il est possible pour un est contagieuse; ainsi il est important de déterminer si la cathéter urinaire de passer par la déchirure dans la vessie. maladie a été récemment introduite par l’achat de bovins ou On assume que le liquide qui est récolté est de l’urine, alors si elle est endémique. Du nouveau béton grossier peut être qu’en fait il s’agit de liquide abdominal (urine 1 faction de un facteur de risque pour les maladies de la sole et non pour liquide). les dermatites interdigitales ou les autres dermatites. 3. D) This drug has been shown to cause fatal neutropenia in cats and is contraindicated for this species. The other listed drugs are used as immunosuppressive therapies in the cat. D) On a démontré que ce médicament causait une neutropénie fatale chez le chat et il est contre-indiqué pour cette espèce. Les autres médicaments énumérés sont utilisés comme thérapie immunosuppressive chez le chat.

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1122 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY The Art of Private Veterinary Practice L’art de la pratique vétérinaire privée

Catastrophic communication

Myrna Milani

any practices can claim clients who lean toward a more would have a word to describe her response: catastrophizing. M optimistic or pessimistic view of life’s events. Moreover, Catastrophizing is the belief that things are far worse than they those views may extend to how those clients perceive what are and it has emerged as a primary biosocial factor in chronic happens to their animals. Among the pessimists, one small pain perception. Because chronic physical pain serves as the but troublesome subgroup consists of ultra-pessimists like Ms. primary driver of the opioid addiction crisis, treating catastroph- Rodenaur. Whereas the average pessimist views the glass half- izing has emerged as a critical element of the treatment process. empty, she perceives it as having a few drops at most. However, most practitioners know from their own experience “I know Spunky needs his vaccinations, but I’m terrified he’ll and that of their close friends and loved ones that behavioral have a reaction, Dr. Shively. He’s such a little thing and I know and emotion pain hurt every bit as much as physical pain. And, you give the same big dose to every dog. All kinds of things like Drs. Shively and Trudelle, they also recognize that the Ms. could go wrong. The needle might break off when you stick (and Mr.) Rodenaurs of the world would benefit from quality him, or maybe...,” Ms. Rodenaur’s eyes widen and the color mental health therapy. At the same time, though, they realize drains from her face as she considers a new horror. “…he might that in the great majority of their interactions with such clients, have a stroke and drop dead like my father did!” they are in no position to suggest this. Before she continues these unproductive ruminations, Dr. “Aside from the fact that I lack the credentials to make such Shively gently interrupts the woman and reminds her that a suggestion and while I do care about my clients, my first Spunky is a healthy, young adult, mixed breed dog which weighs obligation is to their animals’ well-being,” notes Dr. Shively. almost 27 kg and has never experienced any negative reactions to “If I spend all our time together trying to reassure clients with any vaccinations in the past. But later the veterinarian tells her no desire to be reassured instead of giving my full attention to associate, Dr. Trudelle, that she had no illusion that this would their animals, I’m not doing my job.” comfort the anxious client. However, it is possible to lessen the effects of catastroph- “She kept going on and on about all the asymptomatic izing by more actively engaging these clients in the veterinary problems Spunky might have that the stress of the trip to the procedure. Instead of making more general comments or ignor- clinic and his vaccination might cause to explode,” recalls Dr. ing the clients — both of which could reinforce their already Shively. “Even when I pointed out I’d vaccinated the dog while counter-productive and maddening behavior — Dr. Shively she and he were distracted and he didn’t even notice, it made focuses on getting a detailed history of these clients’ animals no difference. She then worried that the dog would be angry instead. Admittedly the veterinarian does this already. But she with her or feel betrayed because she didn’t comfort him while also acknowledges that in the past she was apt to abbreviate the I stuck needles in him. Thank goodness I had to leave for an process in hopes of ending these client interactions as quickly emergency or I’d still be in that room with her!” as possible. Although it took some practice, Dr. Shively soon Had Ms. Rodenaur succumbed to chronic physical pain learned how to gracefully redirect her clients’ attention to sup- instead of the chronic behavioral and emotional pain associated plying information about their animals as soon as the first sign with her extreme pessimism, the human medical community of catastrophizing arose. Once she had the history, she found that pointing out interesting but normal anatomical features of the animal or asking these clients to assist her in some way Dr. Milani is a behavior and bond practitioner, teacher, and — e.g., massage their animals’ ears, hand her something on author of several books on the interaction of animal behavior, the counter she easily could get herself — distracted them and health, and the human-animal relationship. engaged them in a meaningful way. Use of this article is limited to a single copy for personal study. Difficult as that may be, however, dealing with catastroph- Anyone interested in obtaining reprints should contact the izing clients is a great deal easier than dealing with staff mem- CVMA office ([email protected]) for additional bers who possess that same trait. Dr. Trudelle’s predecessor, Dr. copies or permission to use this material elsewhere. Rubio, approached anything beyond the most routine surgical

CVJ / VOL 58 / OCTOBER 2017 1123 FOR PERSONAL USE ONLY

and medical cases as if he and the animal would be lucky if they The tipping point occurred when a long-time client with survived. Because Dr. Rubio was technically competent despite extensive knowledge about and concern for her many animals his extreme pessimism, initially Dr. Shively let it go. However, presented her 15-year-old dog because he stumbled and then two realizations caused her to change her mind. began limping on a front leg. Radiographs revealed a large inva- First, the veterinarian and the rest of the staff noticed that sive mass affecting the proximal humerus, most likely an osteo- Dr. Rubio’s patients did not do as well. The more serious the sarcoma. Because of the dog’s age and other medical conditions animal’s problem, the greater this effect appeared to be. that ruled out amputation and other options, the client raised “It wasn’t anything like wound contamination or the wrong the possibility of euthanasia. Whereas Drs. Shively and Trudelle medication or dose,” the practice owner admitted. “I think it would have recognized that the client wanted and needed some was just that Dr. Rubio hovered over the animals and fussed compassionate support from her veterinarian at such a difficult over them so much they couldn’t get any rest if he was around. time, Dr. Rubio got so caught up in his catastrophic what-if Consequently, his patients weren’t as relaxed as I thought they scenarios that he just stood there making lame comments that should be and it affected their appetites and interactions with only made the situation worse. other staff members too. While I couldn’t point to anything When the client realized that the veterinarian could not or specific, let alone its cause, I suspect some clients also noticed would not support her in any way and requested that he eutha-

L’ART DE LA PRATIQUE VÉTÉRINAIREPRATIQUE LA DE PRIVÉE L’ART this because they began insisting that I treat their animals.” nize her pet, he then agreed that this was the right choice under However, Dr. Shively had no trouble pinpointing that Dr. the circumstances. However, instead of comforting the client, Rubio’s ultra-pessimistic approach was undermining patient and what she perceived as his complete lack of compassion infuri- client wellbeing during euthanasia because clients complained ated her. In addition to telling her family and friends what a angrily about it. This did not occur because Dr. Rubio did not dreadful experience it was, she wrote a long letter to Dr. Shively care about his clients and their animals at this most difficult that left no doubt in the practice owner’s mind how the client time. If anything, it could be said that he cared too much. He felt about it, either. became so caught up in all the things that might go wrong pre- Unlike the vaguer effects Dr. Rubio’s mindset had on animals ceding and during the event as he interacted with these clients that the practice owner and most clients could attribute to and their animals that he offered them no guidance or support other factors and dismiss, his euthanasia-related catastrophizing whatsoever. caused him so much pain he became oblivious to that of these clients and their animals. At that point, Dr. Shively gave him an ultimatum: he either could seek professional help or she would terminate his employment. Attention Practitioners “I didn’t just drop letting him go on him like a ton of bricks,” she clarified. “I met with him after hours and laid out all my You may not have the time, facilities, or experience concerns and perceived options and asked for his input. He to write scientific articles for review by experts. immediately began going on and on about how much sleep he lost worrying about his cases, making a mistake, how horrible it But you have interesting and valuable experiences all was, etc. That proved my point: He needed professional help.” that are worth sharing. We encourage you to Dr. Shively later confided to Dr. Trudelle that it was the most share by submitting articles to Practitioners’ difficult thing she ever did. But keeping him on under the exist- Corner, The Canadian Veterinary Journal. Simply ing conditions benefitted no one — not the animals, the clients, e-mail your article to Ms. Heather Broughton and certainly not the practice. Later she learned that, although ([email protected]). We will edit Dr. Rubio tried to convince everyone that his life was ruined to ensure the format is correct then we will when she didn’t renew his contract, he ultimately did get help publish your article in The CVJ. and is currently enjoying working in a research facility. We live in an era of media-driven hyperbole that makes it easier for a small sub-set of people to exaggerate the pain associated with negative events and then focus on that pain instead of on some meaningful way to resolve it. Communication strategies that short-circuit such behavior in clients benefit animal wellbeing. When practitioners succumb to this mindset, professional help remains the most viable option in the long run.

1124 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY Classifieds Petites annonces Business Directory

Experts in Autogenous Bacterins, and VetAdvise.com Swine Influenza Virus Vaccines

✓ High quality Autogenous Biologics All About Veterinarians ✓ Licensed by the CFIA ✓ We make Vaccines for We make autogenous vaccines Consulting, Coaching, Valuations, Negotiations, Purchase / Sale • Swine • Poultry For more information, contact: Sam Mostafa • Bovine Phone: 1-888-838-5223 TERRY JACKSON, C.P.A. - C.G.A. e-mail: [email protected] www.gallantcustomlaboratories.com Phone: 604.939.2323 [email protected] See you at the WCASV — October 18, 2017

DOUGLAS C. JACK – Partner • Practice Management Agreements • Incorporations »Digital & Dental X-Ray • Employment Matters »Underwater Treadmills • Discipline Proceedings and Malpractice Defence Canadian Integrated Supplier of • Buying and Selling a Practice »Infusion Pumps/Monitors Veterinary Equipment & Digital »Cages & Cat Condos P 416.367.6389 | TF 800.563.2595 F 416.367.6749 | [email protected] Radiography Solutions »Assisi Loop – Bay Adelaide Centre, East Tower Anti-inflammation 22 Adelaide St W, Toronto, ON 227G Brunswick Blvd. »Centrifuges Canada M5H 4E3 Pointe-Claire, Quebec »Sterilization Calgary | Montréal | Ottawa »Lighting/Tables/ Toronto | Vancouver 1-877-440-4494 Lawyers | Patent & Trademark Agents Treatment Rooms Borden Ladner Gervais LLP [email protected] is an Ontario Limited Liability Partnership. blg.com

X-Ray Digital & Analog YOUR SUCCESS IS OUR BUSINESS Ultrasound Committed to helping you achieve financial success ElectroSurgery & Laser in your veterinary practice Autoclave, Centrifuge & Microscope Procedure & Surgery Light Vital Sign Monitor

1480 Pemberton Avenue IV Pump & Warmer North Vancouver, BC V7P 2S1 Phone (604) 446-9099 Anesthesia & Surgery Accessories WARD & UPTIGROVE www.fmsmeds.com Stainless Steel & Veterinary Table CHARTERED PROFESSIONAL ACCOUNTANTS Email: [email protected] Dental Unit & Dental X-Ray VETERINARY BUSINESS GROUP|[email protected]|519.291.3040|wardanduptigrove.com

Providing Pet Loss Sympathy Resources for Veterinarians

Condolence Cards • Memorial Keepsakes Books on Pet Loss and Grief for Children End of Life Brochures

WWW.PAWSITIVERESOURCES.COM

Created with Care by Canadian Veterinarians

CVJ / VOL 58 / OCTOBER 2017 1125 FOR PERSONAL USE ONLY Business Directory

Practice One Consulting Reaching Canada’s Veterinarians Get your message into Practice Valuations  Practice Purchase Practice Sale  Practice Management The Canadian Veterinary Journal Dr. Frank Richardson, DVM, MBA For more information contact: Veterinary Management Consultant Laima Laffitte Advertising Manager PO Box 176 Phone: (902) 531-2617 Tel.: (613) 673-2659 Western Shore, Nova Scotia E-mail: [email protected] Fax: (613) 673-2462 B0J 3M0 Fax: (902) 531-2618 e-mail: [email protected]

1126 CVJ / VOL 58 / OCTOBER 2017 FOR PERSONAL USE ONLY FOR PERSONAL USE ONLY

SO STRONG.1

SO SAFE.1

NexGard® is the ONLY isoxazoline* product that kills fleas and ticks, including Ixodes scapularis, that is approved for puppies 8 weeks of age or older.1

* isoxazoline class of parasiticides NexGard® is a registered trademark of Merial (a member of the Boehringer Ingelheim group (afoxolaner, fluralaner, sarolaner) of companies), used under license. ©2017 Merial Canada Inc. (a member of the Boehringer 1 NexGard® Canadian product label. Ingelheim group of companies). All rights reserved. NEX-17-1055-VJA XCN281115.

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