The Canadian Veterinary Journal La Revue Vétérinaire Canadienne

October/Octobre 2020 October/Octobre The Canadian Veterinary Journal

La Revue vétérinaire canadienne Vol. 61, No. 10

October/Octobre 2020 Volume 61, No. 10 The Canadian Veterinary Journal La Revue vétérinaire canadienne A rare case of malignant vagus nerve sheath tumor presenting with multiple cranial nerve dysfunction in a dog Investigation of clinical outbreaks of American foulbrood in honey-bee operations in Saskatchewan Primary hyperlipidemia with associated ischemic strokes in a West Highland white terrier dog Factors associated with the adoption of technologies by the Canadian dairy industry Outcome following surgical stabilization of distal diaphyseal and supracondylar femoral fractures in dogs Effect of intravenous fluid warming on core body temperature during elective orthopedic procedures Incidence of incisional complications after exploratory celiotomy in equids affected with enterolithiasis Teleconsulting in the time of a global pandemic: Application to anesthesia and technological considerations Influence of abdominal elevation on radiographic measurements of the thoracolumbar interspinous spaces in asymptomatic horses Ixodes scapularis ticks and Borrelia burgdorferi on Prince Edward Island: Passive tick surveillance and canine seroprevalence Left-sided dacryostenosis in a dog FOR PERSONAL USE ONLY a bright future

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OCTOBER/OCTOBRE 2020 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

CASE REPORTS RAPPORTS DE CAS 1049 A rare case of malignant vagus nerve sheath tumor presenting with multiple cranial nerve dysfunction in a dog Lucile Giraud, Stéphane Lezmi, Eymeric Gomes, Laurent Cauzinille 1055 Investigation of clinical outbreaks of American foulbrood in honey-bee operations in Saskatchewan Michael W. Zabrodski, Geoff Wilson, Igor Moshynskyy, Alexandra Wentzell, Sarah C. Wood, Colby D. Klein, Ivanna V. Kozii, Igor Medici de Mattos, Tasha Epp, Elemir Simko REVIEW ARTICLE 1060 Primary hyperlipidemia with associated COMPTE RENDU ischemic strokes in a West Highland 1092 Teleconsulting in the time of a global white terrier dog pandemic: Application to anesthesia Stephen Everest, Gibrann Castillo, Luis Gaitero and technological considerations Daniel S.J. Pang, Jessica M. Pang, ARTICLES Opal-Jane Payne, Frazer M. Clement, Terrie Faber 1065 Factors associated with the adoption of BRIEF COMMUNICATIONS technologies by the Canadian dairy industry COMMUNICATIONS BRÈVES Murray D. Jelinski, David F. Kelton, Chris Luby, Cheryl Waldner 1101 Influence of abdominal elevation on radiographic measurements of the 1073 Outcome following surgical stabilization thoracolumbar interspinous spaces of distal diaphyseal and supracondylar in asymptomatic horses femoral fractures in dogs Charlène Pigé, Isabelle Masseau, Alvaro G. Bonilla Francisco Silveira, Isobel C. Monotti, Anna M. Cronin, Nick J. Macdonald, 1107 Ixodes scapularis ticks and Borrelia Scott Rutherford, Kornelia Tiffinger, Ian Faux, burgdorferi on Prince Edward Island: Javier Rincon-Alvarez, Elvin Kulendra, Passive tick surveillance and canine Francesca Tavola, Bruno Santos, Neil J. Burton seroprevalence 1080 Effect of intravenous fluid warming on Alexandra H. Foley-Eby, Christine Savidge, core body temperature during elective Vett K. Lloyd orthopedic procedures Robert B.E. Brady, William T. Poppell STUDENT PAPER COMMUNICATION ÉTUDIANTE 1085 Incidence of incisional complications after 1111 Left-sided dacryostenosis in a dog exploratory celiotomy in equids affected Jamey Erjavec with enterolithiasis Albert Torrent Crosa, Scott A. Katzman, 1037 QUIZ CORNER Maureen E. Kelleher, Jorge E. Nieto, Isabelle Kilcoyne, Julie E. Dechant TEST ÉCLAIR

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OCTOBER/OCTOBRE 2020 Contents Table des matières

FEATURES RUBRIQUES

EDITORIAL NOTICES ANNONCES ÉDITORIAL 1033 We are family/Nous sommes une famille 1072 New Products Carlton Gyles Nouveaux produits 1091 Index of Advertisers 1035 VETERINARY MEDICAL ETHICS Index des annonceurs DÉONTOLOGIE VÉTÉRINAIRE 1117 Classifieds THE ART OF PRIVATE Petites annonces VETERINARY PRACTICE L’ART DE LA PRATIQUE VÉTÉRINAIRE PRIVÉE NEWS | NOUVELLES 1115 Fixed and flexible practice communication Myrna Milani 1039 NEWS NOUVELLES BOOK REVIEW Heather Broughton, Sophie Perreault COMPTE RENDU DE LIVRE 1064 The Story of Lexi, and a Dream that Follows Her Michael Zigler

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net).

Les « Directives à l’intention des auteurs » sont disponibles en ligne (www.veterinairesaucanada.net).

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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 The Canadian Veterinary Medical Association holds complete copyright of all articles Telephone: 613-236-1162 within this issue. Fax: 613-236-9681 Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les E-mail: [email protected] lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de Website/Site Web: www.canadianveterinarians.net l’éditeur. www.veterinairesaucanada.net La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord avec son contenu ou qu’il l’appuie. © C anadian Veterinary Medical Association 2020 L’Association canadienne des médecins vétérinaires détient le droit d’auteur complet L’Association canadienne des médecins vétérinaires 2020 sur tous les articles contenus dans le présent numéro.

The Canadian Veterinary Journal is indexed or abstracted in: Editor-in-Chief/Rédacteur en chef La Revue vétérinaire canadienne est indexée ou ses articles sont Dr. Carlton Gyles, Guelph, Ontario résumés dans : AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Associate Editors/Rédacteurs associés Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Dr. Bruce Grahn, Saskatoon, Saskatchewan Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Dr. Wayne McDonell, Guelph, Ontario Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Dr. Murray Jelinski, Saskatoon, Saskatchewan Feature Editors/Rédacteurs des chroniques Dr. Jangi Bajwa, Burnaby, British Columbia Photo by/Photo de : Jim McLane, Battleford, Saskatchewan Dr. Bruce Grahn, Saskatoon, Saskatchewan Dr. Myrna Milani, Charlestown, New Hampshire Typesetting/Typographie Dr. Debbie Stoewen, Ayr, Ontario AN Design Communications Dr. Tim Blackwell, Fergus, Ontario Printed by/Imprimé par Assistant Editors/Rédacteurs adjoints Dollco Print Solutions Group Dr. Aylin Atilla, Calgary, Alberta Ottawa, Ontario Dr. Marcio Costa, Saint-Hyacinthe, Quebec ISSN 0008-5286 Dr. Robert Friendship, Guelph, Ontario Dr. Luis Gaitero, Guelph, Ontario Dr. Emily John, Charlottetown, Prince Edward Island Report undeliverable Canadian addresses to: Dr. Ron Johnson, Guelph, Ontario e-mail: [email protected] Dr. Shawn McKenna, Charlottetown, Prince Edward Island Dr. Shannon Martinson, Charlottetown, Prince Edward Island Subscriptions (2020). Annual: Canada $220 + applicable GST or HST; foreign Dr. Javier Sanchez, Charlottetown, Prince Edwad Island $235 US; institutional $290. Express subscriptions available. Single issue/back issue: Managing Editor/Directrice de la rédaction $25 each, institutional single issue = $50.00 + GST or HST, if applicable. (All prices Heather Broughton, Ottawa, Ontario subject to change.) Missing issues will be replaced if the Subscriptions Office is Assistant Managing Editor/Directrice adjointe de la rédaction notified within 6 months (for requests within Canada) and 1 year (for requests from Stella Wheatley, Ottawa, Ontario abroad) of the issue date. The publisher expects to supply missing issues only when Editorial Coordinator/Coordonnatrice de la rédaction losses have been sustained in transit and when the reserve stock will permit. Telephone Kelly Gray-Sabourin, Ottawa, Ontario (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 Advertising and Sponsorship Consultant/Consultante, publicité et commandites promptly. Laima Laffitte, Wendover, Ontario Abonnements (2020). Annuel : Canada 220 $ + TPS ou TVH en vigueur; pays étranger 235 $ É-U; prix d’une institution 290 $. Abonnement express disponible. Published monthly by/ Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + TPS ou TVH Publication mensuelle de en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas Canadian Veterinary Medical Association 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.

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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

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1030 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Whatever and wherever you practice, the CVMA is with you every step of your way.

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CA-NOV-190600010 FOR PERSONAL USE ONLY Editorial Éditorial

We are family Nous sommes une famille

y ideas about family were formed in my childhood days a conception de la famille s’est formée durant mon M in Jamaica. I grew up in a small village, one of 7 children M enfance en Jamaïque. J’ai grandi dans un petit village, to a mom who was an elementary school teacher and a dad who et j’étais l’un des sept enfants d’une mère enseignante à l’école was a foreman with the Public Works Department. My mom primaire et d’un père contremaître au département des travaux became qualified as a teacher by studying at home then tak- publics. Ma mère est devenue enseignante en étudiant à la mai- ing the required examinations. Her mother lived with us and son puis en passant les examens requis. Sa mère vivait avec nous was a major caregiver. My father supplemented his income by et prenait soin de nous. Mon père supplémentait son revenu mixed farming — we had a variety of animals (chickens, goats, par la polyculture – nous avions plusieurs espèces d’animaux cows, pigs, horses) in small numbers and we had various crops (poulets, chèvres, vaches, porcs, chevaux) en petits nombres et (bananas, pineapple, potatoes) — all on 10 acres of land. The divers types de cultures (bananes, ananas, pommes de terre), le children all helped on the farm and in the home. There was a tout sur 10 acres de terre. Les enfants devaient tous aider à la lot of love in the family and as children we always knew that ferme et à la maison. Il y avait beaucoup d’amour dans la famille we could express and debate our views even when those views et, en tant qu’enfants, nous savions que nous pouvions toujours were not acceptable to our parents. exprimer et justifier nos points de vue même lorsque ces derniers Later there would be important family ties that were not n’étaient pas acceptables pour nos parents. based on blood relations. There was no high school in my vil- Plus tard, j’ai tissé avec d’autres personnes des liens très forts lage and I went to high school 100 km away, where I boarded qui ne reposent pas sur la parenté de sang. Comme il n’y avait at an amazing Victorian British high school, which had been pas d’école secondaire dans mon village, j’ai dû partir étudier à founded by the Congregational Church in 1942. I remained 100 km de la maison – j’ai donc été pensionnaire dans une for- at this school for 7 years and bonded with numerous school- midable institution britannique victorienne fondée par l’Église mates — bonds which are still strong today. The school had a congrégationaliste en 1942. J’y suis resté pendant 7 ans, et j’ai unique emphasis on agriculture and all male students had to établi des relations avec de nombreux camarades de classe qui take agricultural science as a subject. The belief was that it was sont encore solides aujourd’hui. À cette école on mettait un vital to enrich agriculture with science and make it respectable accent particulier sur l’agriculture, et tous les étudiants de sexe in a country in which it was important but not popular. Past masculin devaient suivre des cours de sciences agricoles – on students get together frequently to reminisce about the good espérait ainsi enrichir l’agriculture avec la science et la rendre old days and to support one another. There remains an amazing respectable dans un pays où elle était importante mais pas amount of love in the group and we debate fiercely but lovingly. populaire. Les anciens élèves se réunissent encore souvent pour In 1959 I was fortunate to be accepted into the Ontario se remémorer le bon vieux temps et se soutenir les uns les autres. Veterinary College (OVC). This marked my entry into another Il y a beaucoup d’amour dans le groupe, ce qui ne nous empêche family. Schoolmates (classmates in particular) and faculty were pas de débattre de façon vigoureuse, mais toujours amicale. members of this new profession to which I aspired. There was En 1959, j’ai eu la chance d’être admis à l’Ontario Veterinary enormous pride in being a member of the OVC. Following College (OVC), et cela a marqué mon entrée dans une autre graduation, I pursued graduate work at OVC then postdoctoral famille. Les étudiants de l’école vétérinaire (en particulier work in England and Denmark before joining the faculty at ceux de ma cohorte) et les professeurs faisaient partie de cette

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OVC in 1969. I loved teaching and supervising students and I am proud to be part of a profession whose characteristics conducting research into animal diseases and public health, include not only high technical competence but also compassion before retiring in 2005. I have been a part of OVC, and OVC and caring for animals and people. During my travels, and at has been a part of me for some 60 years; it is still family to me. various meetings, I had the privilege of meeting veterinarians There is much for which I am thankful. I started life with from all over the world. I always felt a close kinship with them loving, caring parents and a family that was all anyone could as members of my veterinarian family. Family involves a genuine hope for. Growing up in rural Jamaica I observed that there were concern about the welfare of each other, being able to talk with so many people who had very little but lived full and happy each other about difficult subjects, to disagree without being lives. My high school years were marked by camaraderie, and hostile, and most of all being loving towards each other. Love, learning, not only academic skills, but also social and life skills. compassion, trust and support are key elements of the family ÉDITORIAL Several teachers were dedicated to helping us grow. As a student relationship and I am grateful to my profession and the numer- at OVC I was blessed with classmates who were thoughtful and ous individuals who have been kind, generous and supportive caring, teachers who were generous and dedicated, leaders who through good times and bad. If we think of each other as fam- were outstanding role models. Later, I was blessed with faculty ily this will only strengthen our profession. It is important to colleagues who were kind and caring. remember this, not only during the COVID-19 pandemic, but I took on the responsibility of Editor-in-Chief of at all times. ■ The Canadian Veterinary Journal (The CVJ) in 2008. In my work with The CVJ I became part of a small family consisting Carlton Gyles of the journal staff, the editors, and members of the editorial committee — coworkers who are not only highly competent (Opinions expressed in this column are those of the Editor.) but also caring and supportive.

nouvelle profession à laquelle j’aspirais. J’éprouvais beaucoup de de rédaction – des collaborateurs qui sont non seulement très fierté de fréquenter l’OVC. Après l’obtention de mon diplôme, compétents, mais aussi solidaires et bienveillants. j’ai poursuivi des études supérieures à l’OVC puis fait du travail Je suis fier de faire partie d’une profession dont les caractéris- postdoctoral en Angleterre et au Danemark avant de revenir tiques comprennent non seulement une très grande compétence me joindre au corps professoral de l’OVC en 1969. J’ai adoré technique, mais aussi la compassion et l’amour des animaux et enseigner, encadrer les étudiants et faire de la recherche sur les des gens. Au cours de mes voyages et lors de divers événements, maladies animales et la santé publique avant de prendre ma j’ai eu l’occasion de rencontrer des médecins vétérinaires du retraite en 2005. Je fais partie de l’OVC et l’OVC fait partie de monde entier. J’ai toujours ressenti une parenté étroite avec moi depuis plus de 60 ans; c’est toujours une famille pour moi. eux en tant que membres de ma famille vétérinaire. La famille Il y a beaucoup de choses pour lesquelles je suis reconnaissant. signifie avoir un réel souci du bien-être de l’autre, être capable de J’ai commencé ma vie avec des parents aimants et attentionnés, se parler de sujets difficiles, pouvoir exprimer son désaccord sans et une famille extraordinaire. Ayant grandi en Jamaïque rurale, être hostile, et surtout, être aimant envers les autres. L’amour, la j’ai été témoin du fait que beaucoup de gens ont très peu mais compassion, la confiance et le soutien sont des éléments clés des mènent tout de même une vie remplie et heureuse. Mes années relations familiales, et je suis reconnaissant envers ma profession d’école secondaire ont été marquées par la camaraderie et l’ap- et les nombreuses personnes qui ont été gentilles, généreuses et prentissage, non seulement de connaissances mais aussi de com- solidaires dans les bons et les moins bons moments. Se consi- pétences sociales et fondamentales. Plusieurs enseignants avaient dérer les uns les autres comme les membres d’une même famille à cœur de nous aider à nous épanouir. En tant qu’étudiant à ne fera que renforcer notre profession. Il est important de se le l’OVC, j’ai eu la chance d’avoir des pairs gentils et attentionnés, rappeler, pendant la pandémie de COVID-19 mais aussi en tout des professeurs généreux et dévoués, des leaders qui étaient des temps. ■ modèles exceptionnels. Plus tard, j’ai eu le privilège d’avoir des collègues enseignants qui étaient aimables et prévenants. Carlton Gyles Je suis devenu rédacteur en chef de La Revue vétérinaire canadienne (La RVC) en 2008. Dans mon travail à La RVC, (Les opinions exprimées dans cet article sont celles du rédacteur je suis devenu membre d’une autre petite famille composée du en chef.) personnel de la revue, des rédacteurs et des membres du Comité

1034 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — Question de déontologie du mois — July 2020 Juillet 2020 Some posit that zoos provide a unique opportunity for people Certains estiment que les zoos offrent au public une occasion to observe and appreciate wild animals. They believe that zoos unique d’observer et d’apprécier les animaux sauvages. Ils croient create a deeper appreciation of the natural world and the ani- que les zoos favorisent une meilleure compréhension du monde mals that live there. Displaying animals in zoologic parks may naturel et des animaux qui y vivent, et peuvent inspirer le public also inspire the public to work to conserve and protect wild à faire des efforts pour protéger les animaux sauvages, en parti- animals, especially those that are endangered. Others argue that culier ceux qui sont menacés d’extinction. D’autres soutiennent there can never be any justification for keeping wild animals in qu’aucune raison ne peut justifier de garder des animaux sau- captivity for public enjoyment. Do zoos provide a net benefit vages en captivité pour le simple plaisir des humains. Les zoos to wild animals as a result of their educational value or is offrent-ils un avantage net aux animaux sauvages en raison de their only benefit one of providing human entertainment at leur valeur éducative, ou leur seul avantage est-il de servir de the animals’ expense? divertissement pour les humains au détriment des animaux?

An ethicist’s commentary on the role of zoos The simple but ambivalent answer to this query is “both.” I know this from personal experience. A few years ago, I had a student who got a summer job at the National Zoo in I began to serve on the American Humane Association’s newly Washington, D.C. His primary task was to shadow visitors and formed committee for carefully accrediting zoos. There is no determine how they spent their time. Much to his surprise, question that the bad publicity generated by negative reports most visitors spent more time in the souvenir shop than read- have affected both zoo managers and the general public. ing the information signs, by a major order of magnitude, even To return to our original question, it appears that the general though the signage had recently been updated! This experience public will not tolerate small, cramped quarters for animals is replicated in the experience of many others. On the other that do nothing to respect their needs and natures. It is for hand, there are some zoologists who were first inspired to their this reason that many zoos have updated their animal facilities. careers by zoo visits. For members of the general public who increasingly care about As a young and ignorant man, I visited many zoos and was animals, learning about animals is an important component of struck by the extent to which the animals were listless and visiting zoos. On the other hand, there is still a large contingent depressed — simply lying around in their cages. I was drawn of “yahoos” who tease, bait, and make fun of the animals. One to visit zoos when I was myself depressed. Years later, I realized can fervently hope that as animal welfare occupies a greater com- that my attraction to zoos came from seeing creatures worse off ponent of public consciousness, the educational component of than I was. At one zoo I visited, the giraffes were housed in cages zoos will assume greater prominence as people realize that learn- too low for them stand up. ing about the animals is as important as watching them. This, Such deplorable situations have happily been rectified in the in turn, can provide a major boost to concern about threatened course of society developing greater concern for animal welfare. species, and lead to greater welfare and conservation thinking Outrageous roadside zoos have shrunk in number as visitors in the minds of subsequent generations. grow increasingly disgusted by the animals’ living situations. Zoological societies now accredit and rate zoos, even as televised Bernard E. Rollin, PhD nature programs provide viewers with a glimpse of the animals’ natural lives.

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Ethical question of the month — Question de déontologie du mois — October 2020 Octobre 2020 Male chicks are a by-product of the modern egg industry. Les poussins mâles sont un sous-produit de l’industrie moderne Unable to lay eggs and unsuitable for the broiler industry, male des œufs. Incapables de pondre et ne convenant pas à l’industrie layer chicks are incubated and hatched out, only to be culled as des poulets de chair, les poussins mâles sont abattus à l’âge d’un day-olds. In Canada and the United States, maceration is the jour. Au Canada et aux États-Unis, la macération est la méthode most common method of euthanasia, providing instantaneous d’euthanasie la plus courante. Bien que cette méthode entraîne death. While this may provide a humane death, the practice is une mort instantanée jugée sans cruauté, elle soulève des pré- cited as a welfare concern among animal activists, consumers, occupations en matière de bien-être animal chez les défenseurs and industry. Significant efforts have been made in Canada and des droits des animaux, parmi les consommateurs et au sein de the United States to develop commercial egg sexing technolo- l’industrie. Des efforts importants ont été faits au Canada et aux gies that would allow for the elimination of this practice, but États-Unis pour développer des technologies commerciales de none have proven economically feasible. Is it ethical to hatch sexage des œufs qui permettraient d’éliminer cette pratique, mais

DÉONTOLOGIEVÉTÉRINAIRE out chicks with the intention of euthanizing half of them? aucune ne s’est avérée économiquement réalisable. Est-il éthique If dual-purpose breeds are less efficient as both layers and de faire éclore des poussins avec l’intention d’en euthanasier broilers, is it ethical to raise these despite the associated la moitié? Si les races à double usage sont moins efficaces additional inputs/costs? pour la production d’œufs et de viande, est-il éthique de les Submitted by Megan Allore, Montreal, Quebec élever malgré les intrants et les coûts supplémentaires que cela implique? Question soumise par Megan Allore, Montréal, Québec

Responses to the case presented are welcome. Please limit your reply to Les réponses au cas présenté sont les bienvenues. Veuillez limiter votre approximately 50 words and forward along with your name and address réponse à environ 50 mots et nous la faire parvenir par la poste avec to: Ethical Choices, c/o Dr. Tim Blackwell, 6486 E. Garafraxa, vos nom et adresse à l’adresse suivante : Choix déontologiques, a/s du Townline, Belwood, Ontario N0B 1J0; telephone: 519-846-3413; Dr Tim Blackwell, 6486, E. Garafraxa, Townline, Belwood (Ontario) fax: 519-846-8178; e-mail: [email protected] N0B 1J0; téléphone : 519-846-3413; télécopieur : 519-846-8178; Suggested ethical questions of the month are also welcome! All ethical courriel : [email protected] questions or scenarios in the ethics column are based on actual events, Les propositions de questions déontologiques sont toujours bienvenues! which are changed, including names, locations, species, etc., to protect Toutes les questions et situations présentées dans cette chronique the confidentiality of the parties involved. s’inspirent d’événements réels dont nous modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.

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Quiz Corner Test éclair

1. An 8-month-old intact female German shepherd, recently 1. Une chienne berger allemand âgée de 8 mois, non stérilisée, in estrus, presents with acute weight-bearing lameness. Pain récemment en œstrus, présente une boiterie aiguë à l’appui. is elicited on palpation of the femur, and radiographs show La palpation du fémur provoque de la douleur et les radio- areas of increased density and an accentuated trabecular graphies révèlent des régions d’augmentation de la densité pattern within the medullary cavity. Which of the following osseuse et une accentuation des travées osseuses dans la is the most likely diagnosis for this patient? cavité médullaire. Lequel des diagnostics suivants est le plus A. Elbow dysplasia probable? B. Panosteitis A. Dysplasie du coude C. Hypertrophic osteodystrophy B. Panostéite D. Hypertrophic osteopathy C. Ostéodystrophie hypertrophique D. Ostéopathie hypertrophique 2. A 2-week-old puppy has acquired the L1 stage of heartworm from which of the following sources? 2. Comment un chiot âgé de 2 semaines pourrait-il avoir des A. It is not possible for a 2-week-old puppy to acquire this larves L1 du ver du cœur? stage of heartworm. A. Il n’est pas possible pour un chiot âgé de 2 semaines B. Milk transmission d’avoir des larves L1 du ver du cœur. C. Infective mosquito B. Transmission par le lait D. Flea or lice transmission C. Transmission par un moustique E. Placental transmission D. Transmission par les puces ou les poux E. Transmission par le placenta 3. A healthy, 1-year-old intact male dog is examined, and the incidental finding is made of a soft swelling in the scrotum. 3. Durant l’examen d’un chien mâle entier âgé de 1 an en The most likely diagnosis is which of the following? bonne santé, on fait la découverte imprévue d’une enflure A. Orchitis molle dans le scrotum. Lequel des diagnostics suivants est B. Testicular torsion le plus probable? C. Contact dermatitis A. Orchite D. Scrotal hernia B. Torsion testiculaire C. Dermatite de contact 4. A 15-year-old mare has intermittent fevers, severe weight D. Hernie scrotale loss, ventral edema, and regional lymphadenopathy. This leads to a high suspicion of which of the following diagnoses? 4. Une jument âgée de 15 ans présente de la fièvre intermit- A. Multicentric lymphosarcoma tente, une perte de poids importante, de l’œdème ventral B. Gastric ulceration et une lymphadénopathie régionale. Ces signes conduisent C. Abdominal abscess à une forte suspicion de laquelle des affections suivantes? D. Cecal dysfunction A. Lymphosarcome multicentrique B. Ulcération gastrique C. Abcès abdominal D. Dysfonction cæcale

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5. Which of the following does NOT explain why Johne’s 5. Lequel des énoncés suivants n’explique PAS pourquoi la disease is difficult to eradicate? maladie de Johne est difficile à éradiquer? A. Insensitivity of commercially available tests A. Insensibilité des tests disponibles sur le marché B. Long incubation time B. Longue période d’incubation C. Fecal shedding in clinically normal cattle C. Excrétion fécale chez des ruminants cliniquement normaux D. Environmental tolerance D. Tolérance environnementale E. Nonspecific clinical signs E. Signes cliniques non spécifiques

(See p. 1105 for answers./Voir les réponses à la page 1105.) TESTÉCLAIR

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).

Tips to Help your 1. Vacuum and dust regularly the key ingredient – a specific protein Clients Manage Cat It’s best to vacuum carpet at least twice sourced from eggs – binds to Fel d 1 a week and make sure to focus on spaces and safely neutralizes it. In a published Allergens at Home where cats play and lay frequently, study, the food was shown to reduce including below furniture and the the allergens in cat hair and dander by As millions of Canadians continue to furniture itself. This ensures even an average of 47%, starting in the third spend record amounts of time at home, those cozy corners get clean and don’t week of daily feeding. it also means spending unprecedented become a hot spot for allergens. amounts of time with their pets. 3. Groom and brush your cat For cat owners who have sensitivities 2. Change your cat’s diet Regularly groom or brush your cat, to cat allergens, this can create When cats groom themselves, the ma- particularly if they are prone to matted unforeseen challenges. jor cat allergen called Fel d 1 is trans- hair. The act of grooming reduces ferred to the hair and skin through loose hair and thereby reduces the Dr. Ebenezer Satyaraj, immunologist saliva. The allergen eventually lands overall allergen load. for Nestlé Purina Research and lead in the environment as the cat’s hair investigator on the research that led to and dander shed naturally. 4. Wash household items the development of Pro Plan LiveClear, Consider making a habit of washing caught up with us to provide vets and Available in Canada as of October, bedding and blankets weekly to remove clinic staff with some tips for clients vets can suggest their clients try Purina allergens from your home. Be sure who are looking to manage their cat Pro Plan LiveClear, the first and only to wash all sheets, blankets and cat food that reduces the allergens in allergens at home. pillowcases in hot water! cat hair and dander. Instead of trying Dr. Satyaraj had four tips to share to manage the allergen once it’s al- By combining these allergen manage- with our readers who are looking ready in the environment, the allergen ment strategies, cat owners can better to help their clients manage cat is neutralized at its source in the cat’s handle their current situations and be allergens at home. mouth. When cats eat the food, closer together with the cats they love.

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NEWS | NOUVELLES

Annual General Meeting (AGM) & Assemblée générale annuelle (AGA) Council Update et mise à jour du Conseil he year of the COVID-19 Pandemic: Unfortunately, the année de la pandémie de COVID-19 : Comme de nombreuses TCanadian Veterinary Medical Association (CVMA), like L’ autres organisations, l’Association canadienne des médecins many other organizations, had to cancel its 2020 Convention vétérinaires (ACMV) a malheureusement dû annuler son Congrès planned for Quebec City. However, in 2021, veterinarians from de 2020 qui devait avoir lieu à Québec. Cependant, les médecins across Canada will be gathering from July 22–25 at the CVMA vétérinaires de partout au Canada auront l’occasion de se réunir Convention in Calgary, in 2022 in Halifax, and in 2023 in l’an prochain lors du Congrès de l’ACMV qui aura lieu à Calgary Quebec City. du 22 au 25 juillet 2021. Le Congrès se tiendra ensuite à Halifax This year all meetings were held remotely, including the en 2022 et à Québec en 2023. CVMA AGM, Council and Executive meetings, meetings with Cette année, toutes les réunions ont eu lieu à distance, y com- the deans, Registered Veterinary Technologists and Technicians pris l’AGA et les réunions du Conseil et du Comité exécutif, ainsi of Canada (RVTTC), Students of the CVMA, and the National que les réunions avec les doyens, l’association des Technologues et Examining Board (NEB). Some 139 members participated vir- techniciens vétérinaires agréés du Canada (TTVAC), le Comité des tually in the CVMA’s 72nd AGM. The president, Dr. Melanie étudiants de l’ACMV et le Bureau national des examinateurs (BNE). Hicks, provided an update on the CVMA’s broad number of Au total, 139 membres ont participé virtuellement à la 72e AGA initiatives serving the profession. The complete 2019 Annual de l’ACMV. La présidente, Dre Melanie Hicks, a fait le point sur le Report can be found in the July edition of The CVJ, which can grand nombre d’initiatives de l’ACMV au service de la profession. be found on the CVMA website. Thank you and congratulations Le rapport annuel complet pour 2019 peut être consulté dans le to Dr. Hicks, Council members, all volunteers, and staff for a numéro de juillet de La RVC, accessible sur le site Web de l’ACMV. successful year including the adaptations needed to serve our Nous tenons à remercier et à féliciter la Dre Hicks, les membres du members during the novel coronavirus outbreak. Conseil, le personnel de l’ACMV et tous les bénévoles pour cette The CVMA’s new president, since July 13, 2020, is Dr. Enid année fructueuse malgré les adaptations nécessaires pour servir Stiles, a small animal practitioner from Montreal, Quebec. nos membres pendant la pandémie. Joining Dr. Stiles on Executive are Dr. Louis Kwantes, Depuis le 13 juillet 2020, la nouvelle présidente de l’ACMV est president-elect; Dr. Chris Bell, vice-president; the new execu- la Dre Enid Stiles, médecin vétérinaire en pratique des animaux de tive member, Dr. Trevor Lawson, and Dr. Melanie Hicks, compagnie à Montréal, au Québec. Se joignent à la Dre Stiles au immediate past-president. A special thank you to Dr. Terri sein du Comité exécutif le Dr Louis Kwantes, président désigné, Chotowetz, the former immediate past-president, for her many le Dr Chris Bell, vice-président, le Dr Trevor Lawson, nouveau years on Executive and Council, her dedication to the CVMA, membre exécutif, et la Dre Melanie Hicks, présidente sortante. and to the profession in general. Nous souhaitons également remercier la Dre Terri Chotowetz, Given the COVID-19 restrictions, the CVMA Award win- ancienne présidente sortante, pour les nombreuses années au sein ners were honored in a different way, by video posted through du Comité exécutif et du Conseil ainsi que pour son dévouement CVMA social media and other platforms. The 2020 CVMA à l’ACMV et à la profession en général. Awards recipients are: Compte tenu des restrictions relatives à la COVID-19, les Small Animal Practitioner Award: Dr. Suann Hosie lauréats des prix de l’ACMV ont été honorés différemment cette Merck Veterinary Award: Dr. Egan Brockhoff année, c’est-à-dire par une vidéo publiée sur les médias sociaux Humane Award: Dr. Bettina Bobsien de l’ACMV et d’autres plateformes. Voici les récipiendaires des prix Practice of the Year Award: Delaney Veterinary de l’ACMV de 2020 : Services Ltd. Prix du praticien des petits animaux : Dre Suann Hosie Industry Award: Dr. Daniel Venne Prix vétérinaire Merck : Dr Egan Brockhoff Life Membership: Dr. Eugene David Janzen Prix humanitaire : Dre Bettina Bobsien RVL Walker Award: Ms. Audrey Roy Prix de la pratique de l’année : Delaney Veterinary President’s Award: Dr. Jack Wilson Services Ltd. Prix de l’industrie : Dr Daniel Venne Membre à vie : Dr Eugene David Janzen Prix R.V.L. Walker : Mme Audrey Roy Prix de la présidente de l’ACMV : Dr Jack Wilson

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N Council meeting Réunion du Conseil he following are a few excerpts from the wealth of informa- oici quelques éléments de toute l’information communiquée Ttion shared with Council and the discussions held: Vau Conseil et des discussions qui ont eu lieu. National Issues Enjeux nationaux • COVID-19 response: From the outset, the CVMA focused • Réponse à la pandémie de COVID-19 : L’ACMV s’est effor- on providing the profession across the country with pertinent, cée de fournir aux médecins vétérinaires partout au pays de timely and credible information, particularly in the areas of l’information pertinente et fiable en temps opportun, en parti- finance, legal, veterinary wellness and COVID, and animal culier en ce qui concerne les finances, le droit, le mieux-être issues. On the latter, the CVMA has been part of the Public vétérinaire dans le contexte de la pandémie et les questions Health Agency of Canada (PHAC) led COVID Working relatives aux animaux. Sur ce dernier point, l’ACMV a fait partie Group, including federal and provincial government experts, du groupe de travail sur la COVID-19 composé d’experts des that provided one reliable voice on COVID and animal- gouvernements fédéral et provinciaux et dirigé par l’Agence related questions. The CVMA offered weekly interactive de la santé publique du Canada (ASPC) qui était chargé de Townhall Sessions on evolving issues. All the recorded webi- formuler des recommandations concernant la COVID-19 et nars and information can be found on the COVID-19 sec- les animaux. L’ACMV a offert des séances hebdomadaires tion of the CVMA’s website. Upon request of the Canadian interactives sur des questions en constante évolution. Tous les Food Inspection Agency (CFIA), the CVMA called up the webinaires enregistrés et les renseignements pertinents sont Canadian Veterinary Reserve (CVR) to assist CFIA with accessibles dans la section du site Web de l’ACMV consacrée inspection duties in slaughterhouses across Canada. à la COVID-19. À la demande de l’Agence canadienne d’ins- • National Veterinary Oversight of Antimicrobials (NVOS): pection des aliments (ACIA), l’ACMV a mobilisé la Réserve NVOS has finished its first year of a 4-year Agriculture and vétérinaire canadienne (RVC) pour appuyer l’ACIA dans ses Agri-Food Canada (AAFC)-funded project. The objectives tâches d’inspection dans les abattoirs du Canada. of this project include developing and testing a prototype • Système national de surveillance vétérinaire (SNSV) des of electronic collection and analyzing Antimicrobial Use antimicrobiens : La première année du projet de SNSV de (AMU) prescription data from the major food animal vet- quatre ans financé par Agriculture et Agroalimentaire Canada erinary practices; collecting and documenting alternatives (AAC) est terminée. Les objectifs de ce projet comprennent le to AMU; expanding the CVMA Prudent Use Guidelines développement et l’essai d’un prototype de système électro- (PUGs) with the addition of equine and aquaculture species; nique de collecte et d’analyse de données sur l’utilisation des and increasing awareness of AMU stewardship. The current antimicrobiens (UAM) à partir des ordonnances des pratiques focus of work is on establishing PUGs for the 2 additional vétérinaires pour animaux destinés à la production d’aliments, species, ameliorating access to the PUGS, and establishing la documentation de solutions de rechange aux antimicro- data-warehousing and collection requirements and options. biens, l’élargissement de la portée des lignes directrices sur This project is being developed with the involvement of a l’utilisation des antimicrobiens de l’ACMV pour inclure l’aqua- broad group of veterinary practitioners and government and culture et les chevaux, et la sensibilisation à l’usage judicieux private stakeholders. des antimicrobiens. Les travaux se concentrent actuellement • African Swine Fever (ASF): Industry groups, veterinarians sur l’élaboration de lignes directrices pour les deux catégo- and governments remain concerned about the significant ries d’espèces supplémentaires, l’amélioration de l’accès aux threat of African Swine Fever. In early 2019 and again in lignes directrices et l’établissement d’exigences et d’options en February 2020, during an in-person meeting with CFIA matière de collecte et d’entreposage des données. Ce projet officials that included the Chief Veterinary Officer (CVO), se concrétise avec la participation de beaucoup de médecins the CVMA offered the assistance of the CVR should the vétérinaires praticiens et d’intervenants du secteur privé et du need arise. gouvernement. The CVMA is also involved in the CFIA-led ASF • Peste porcine africaine (PPA) : Les groupes de l’industrie, les Communications Working Group and a Federal-Provincial- médecins vétérinaires et les gouvernements restent préoccupés Territorial Working Group, which considers depopulation- par la menace importante que représente la peste porcine afri- related issues. In addition, the CFIA worked with the CVMA caine. Au début de 2019 et de nouveau en février 2020, lors on the delivery of 2 one-hour webinars offered in September, d’une réunion en personne avec des représentants de l’ACIA and to stage a national disease outbreak exercise with a dont le vétérinaire en chef du Canada, l’ACMV a offert l’aide de broader stakeholder group. The CVMA has also worked with la RVC si le besoin s’en faisait sentir. Animal Health Emergency Management (AHEM) on the L’ACMV participe aussi à un groupe de travail sur les com- promotion of the Foreign Animal Disease (FAD)/foot-and- munications concernant la PPA dirigé par l’ACIA et à un groupe mouth disease (FMD) recognition and response training that de travail formé de représentants du gouvernement fédéral et took place from May 4, 2020 to June 1, 2020. des gouvernements des provinces et des territoires qui étu- • Importation of animals: A project entitled “Identification dient les questions liées à la dépopulation. De plus, l’ACIA et of Data Sources to Support Risk Assessment of Public Health l’ACMV ont collaboré pour offrir deux webinaires d’une heure Implications of Importation of Dogs into Canada” is under en septembre et pour organiser un exercice national d’éclosion

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way. This is a CVMA-managed and government-funded de maladie avec un groupe d’intervenants plus large. L’ACMV a N initiative, carried out by a university. The project report was également travaillé avec la Coalition canadienne pour la santé targeted to be ready in September and will form the founda- des animaux dans le cadre du Projet de gestion des urgences tion for some further work. In the meantime, the CVMA, sanitaires animales pour la promotion d’une formation sur la PHAC and the CFIA are jointly looking into regulatory détection et l’intervention en cas de maladie animale exotique means and advocacy/public education regarding the importa- ou de fièvre aphteuse offerte du 4 mai au 1er juin 2020. tion of dogs. This issue was recently brought to the attention • Importation d’animaux : Un projet visant à identifier des of the public following an importation of puppies from the sources de données pour appuyer l’évaluation des risques liés Ukraine that resulted in a large number of deaths. aux répercussions sur la santé publique de l’importation de • Lyme disease: The CVMA continues to participate in the chiens au Canada est en cours. Il s’agit d’une initiative finan- Lyme Disease Roundtable led by PHAC. This has led to a cée par le gouvernement, gérée par l’ACMV et menée par une proposed collaboration between PHAC and CVMA on rais- université. Le rapport de projet dû en septembre constituera la ing awareness of tick-borne zoonotic diseases, in addition base de certains travaux ultérieurs. L’ACMV, l’ASPC et l’ACIA to activities during the CVMA’s Annual Tick Awareness étudient conjointement la réglementation et les moyens de Month. sensibiliser et d’éduquer le public concernant l’importation de • New position statement under development: Service chiens. Cette question a été récemment portée à l’attention du animals. public à la suite d’une importation de chiots d’Ukraine durant • Position statements under review: Veterinary telemedicine; laquelle plusieurs animaux sont morts. surgical procedures performed on animals; aquatic animal • Maladie de Lyme : L’ACMV continue de participer à la table veterinary medicine; extra-label drug use; antimicrobial ronde sur la maladie de Lyme dirigée par l’Agence de la santé use in animals (being revised and reintroduced); legislation publique du Canada (ASPC). Cette participation a mené à concerning dangerous dogs; microchip animal identification. une proposition de collaboration entre l’ASPC et l’ACMV pour Animal Welfare accroître la sensibilisation aux maladies zoonotiques transmises • New initiatives: Pain Management Initiative; Extreme par les tiques, en plus des activités organisées par l’ACMV Breeding Awareness. pendant le Mois annuel de sensibilisation aux tiques. • New position statements under development: Surplus • Nouvel énoncé de position en cours d’élaboration : Un neonatal dairy calf management. nouvel énoncé de position sur les animaux d’assistance est en • Animal Welfare Issues at Auction Markets: Council cours d’élaboration. approved that the Animal Welfare Committee (AWC) develop • Énoncés de position en cours de révision : Les énoncés a position statement on Animal Welfare issues at Auction de positions sur la télémédecine vétérinaire, les interventions Markets with the proviso that relevant species groups (pro- chirurgicales effectuées sur des animaux, la médecine vétéri- duction animals) members be consulted. naire des animaux aquatiques, l’utilisation des médicaments en • Position statements under review: Pain management in dérogation des directives de l’étiquette, l’utilisation d’antimicro- animals; euthanasia of animals; humane mass depopulation biens chez les animaux, les lois concernant les chiens dange- of animals; humane slaughter of farm animals; tail docking of reux et l’identification des animaux à l’aide d’une micropuce sheep; use of animals in science; seal hunt in Atlantic Canada; sont en cours de révision. humane training methods for dogs; use of lead fishing sinkers Bien-être des animaux and lead shot in Canada; and pest control. • Nouvelles initiatives : Initiative de prise en charge de la dou- • Revisions beginning now: Induced moulting of poultry; leur, sensibilisation à la reproduction excessive. disbudding and dehorning of ruminants; and tail docking • Nouveaux énoncés de position en cours d’élaboration : of dairy cattle. Un nouvel énoncé de position sur la régie des veaux laitiers • Codes of Practice: Cattery code under review; new small nouveau-nés excédentaires est en cours d’élaboration. mammal code under development. • Questions relatives au bien-être animal dans les encans : Other Le Conseil a approuvé l’élaboration par le Comité sur le bien- CVMA Workforce Study 2020: This study provides an outlook être animal d’un énoncé de position sur les questions relatives for the current supply and demand of veterinary services in au bien-être animal dans les encans, à la condition que les Canada. The research was conducted pre-COVID by a consul- membres des groupes d’espèces concernés (animaux de pro- tant and economists and includes post-COVID forecasts. The duction) soient consultés. primary mandate for this research was to examine the equilib- • Énoncés de position en cours de révision : Les énoncés rium between supply capacity and demand for veterinary services de position sur la gestion de la douleur chez les animaux, l’eu- across the Canadian companion animal, food animal, and equine thanasie des animaux, la dépopulation de masse d’animaux de sectors now and into the future. manière non cruelle, l’abattage sans cruauté des animaux de A webinar moderated by Dr. Hicks and led by the consultant, ferme, l’amputation de la queue des moutons, l’utilisation des Colin Siren, was offered to all CVMA members on June 18. animaux à des fins scientifiques, la chasse au phoque dans la The recorded version can be found on the CVMA website. région atlantique du Canada, les méthodes de dressage sans An Executive Summary was published in the August issue of violence pour les chiens, l’utilisation des plombs pour la chasse

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N The CVJ and the full report is accessible to all CVMA members et la pêche au Canada et la lutte contre les animaux nuisibles via the website. sont en cours de révision. NEB: By mid-2020, the National Examining Board received • Énoncés dont le processus de révision s’apprête à com- 317 new applications (compared to 406 in all of 2019). mencer : On s’apprête à amorcer le processus de révision des COVID-19 largely interrupted the exam process but since mid- énoncés de position sur la mue induite de la volaille, l’enlève- June, the North American Veterinary Licensing Examination ment des bourgeons et l’écornage du bétail, et l’amputation de (NAVLE) and the Basic and Clinical Sciences Examination la queue des bovins laitiers. (BCSE) exams had resumed and by late summer, the 2 clinical • Codes de pratiques : Le Code de pratiques pour les chatte- exams, the Preliminary Surgical Assessment (PSA) and Clinical ries est en cours de révision et un nouveau Code de pratiques Proficiency Examination (CPE), were expected to resume as concernant les petits mammifères est en cours d’élaboration. well. In 2019, about 44% or 277 of the 632 Certificates of Autres Qualifications issued by the NEB were issued to internation- Étude de l’ACMV sur le marché du travail en 2020 : Cette ally trained veterinarians, about half of them to graduates from étude donne un aperçu de l’offre et de la demande actuelles de accredited veterinary colleges. services vétérinaires au Canada. La recherche a été menée avant Animal Health Week (AHW): The 2020 AHW will take la pandémie par un consultant et des économistes, et elle inclut place from October 4 to 10 with the theme “Understanding des prévisions post-COVID. L’objectif principal de l’étude était Zoonotic Diseases: Community Health — Animals and You.” d’examiner l’équilibre entre la capacité d’offre et la demande de This campaign will showcase how Canada’s veterinary profes- services vétérinaires au Canada dans les secteurs des animaux sionals occupy unique positions within the national One Health de compagnie, des animaux de consommation et des chevaux, community to support the fight against these diseases and how maintenant et à l’avenir. the protection of animal health protects everyone’s health. This Un webinaire animé par la Dre Hicks et dirigé par le consultant campaign will empower the national veterinary community through awareness, recognition, and knowledge of threats, Colin Siren a été offert à tous les membres de l’ACMV le 18 juin. thereby improving public health and animal welfare. La version enregistrée se trouve sur le site Web de l’ACMV. Un Mental Health: The CVMA’s 2020 campaign, supported by résumé a été publié dans le numéro d’août de La RVC et le rapport Merck Animal Health, ran from September 6 to 12 and featured complet est accessible à tous les membres sur le site de l’ACMV. another one-hour webinar held on World Suicide Prevention BNE : Au milieu de 2020, le Bureau national des examinateurs Day, Thursday, September 10. This webinar will help foster avait reçu 317 nouvelles candidatures (comparativement à 406 en better understanding of risk factors for suicide in veterinary 2019). La pandémie de COVID-19 a interrompu le processus medicine and increase awareness about training opportunities d’examen, mais depuis la mi-juin, les examens NAVLE (North for suicide prevention. The CVMA mental health webinars are American Veterinary Licensing Examination) et BCSE (Basic and held quarterly. Clinical Sciences Examination) ont repris, et les deux examens Tick Awareness: During March 2020, the CVMA, with sup- cliniques (PSA [Preliminary Surgical Assessment] et CPE [Clinical port of Merck Animal Health, hosted the 5th Annual National Proficiency Examination]) devaient également reprendre à la fin Tick Awareness Month. As in previous years, the CVMA pro- de l’été. En 2019, environ 44 % ou 277 des 632 certificats de duced communications material and support tools to help compétence émis par le BNE l’ont été à des médecins vétérinaires veterinary teams communicate with clients. This year’s resources formés à l’étranger, dont environ la moitié étaient diplômés d’écoles highlighted the unique seasonality of ticks, provided pet parents vétérinaires agréées. with updates regarding the expansion of ticks across Canada, and Semaine de la vie animale : La Semaine de la vie animale increased awareness of the One Health approach to tick control de 2020 sera célébrée du 4 au 10 octobre et aura pour thème and Lyme disease prevention. « Comprendre les zoonoses : Santé communautaire – Les animaux Business Management Program: The CVMA continues its et vous ». Cette campagne montrera comment les professionnels economic Benchmarking Program that includes valuable practice vétérinaires du Canada occupent des positions uniques au sein management tools and resources such as provincial suggested fee de la communauté nationale « Une santé » pour soutenir la lutte guides, compensation and benefits reports for associate veterinar- contre les zoonoses et comment la protection de la santé animale ians, non-DVM wage reports, provincial economic reports, and protège la santé de tous. Cette campagne valorisera la collectivité individual practice reports. These reports are based on CVMA’s vétérinaire nationale par la sensibilisation, la reconnaissance, et annual economic surveys. This program is financially supported la prise de conscience des menaces, et améliorera ainsi la santé by IDEXX Laboratories, Merck Animal Health, Petsecure, publique et le bien-être animal. Scotiabank, and the CVMA. Santé mentale : La campagne 2020 de l’ACMV, soutenue Diversity and Inclusion: “The Canadian Veterinary Medical par Merck Santé animale, s’est déroulée du 6 au 12 septembre Association (CVMA) commits to diversity and inclusion and rejects et a proposé un autre webinaire d’une heure lors de la Journée discrimination or harassment based on grounds such as race, color, mondiale de la prévention du suicide, le jeudi 10 septembre. Ce ancestry, ethnic origin, place of origin, age, creed, religion, sex, gen- webinaire visait à mieux comprendre les facteurs de risque de sui- der identity, family status, marital status, or disability. We affirm cide en médecine vétérinaire et à faire connaître les possibilités de that each human being is valuable and deserves to be treated with formation sur la prévention du suicide. Des webinaires sur la santé dignity and respect. mentale sont organisés par l’ACMV tous les trimestres.

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The wellbeing of our society and our profession is vital. The Sensibilisation aux tiques : En mars 2020, l’ACMV, avec le N CVMA commits to continuing to develop and make accessible its soutien de Merck Santé animale, a organisé la 5e édition du Mois services without bias and to promote diversity and inclusion. national de sensibilisation aux tiques. Comme les années précé- The CVMA also supports existing veterinary college programs dentes, l’ACMV a produit du matériel et des outils pour aider les that encourage inclusivity and diversity and allow for the equitable équipes vétérinaires à communiquer avec leurs clients. Les res- selection of students. We support continued actions taken by our sources de cette année ont mis en évidence la saisonnalité unique Canadian associations, government and educational institutions des tiques, fourni aux propriétaires d’animaux de compagnie des to make veterinary education more accessible for underrepresented mises à jour concernant l’expansion de la présence des tiques au and minority groups. Canada et accru la sensibilisation à l’approche « Une santé » pour We support the open dialogue of our membership on these issues la lutte contre les tiques et la prévention de la maladie de Lyme. and stand united with veterinarians, veterinary students and allied Programme de gestion commerciale : L’ACMV poursuit son veterinary team members who face discrimination.” programme d’analyse économique comparative qui comprend des CVMA Council is establishing a Working Group with the outils et des ressources de gestion de la pratique utiles tels que objective of making suggestions regarding the CVMA’s role in des guides provinciaux des tarifs suggérés, des rapports sur la Diversity and Inclusion with respect to veterinary medicine and rémunération et les avantages sociaux des vétérinaires salariés et to submit a report to CVMA Council, prior to its November des employés non vétérinaires, des rapports économiques provin- 2020 meeting. ciaux et des rapports sur les pratiques individuelles. Ces rapports No CVMA dues increase for 2021: Given that 2020 pre- sont fondés sur les sondages économiques annuels de l’ACMV. Ce sented many pandemic-associated challenges for the veterinary programme est soutenu financièrement par IDEXX Laboratories, profession and industry, Council has mandated that CVMA dues Merck Santé animale, Petsecure, la Banque Scotia et l’ACMV. will not be adjusted by cost of living for 2021. Diversité et inclusion : « L’Association canadienne des méde- cins vétérinaires (ACMV) appuie la diversité et l’inclusion et rejette (by Jost am Rhyn, CEO, CVMA) la discrimination et le harcèlement fondés sur des motifs tels que la race, la couleur de la peau, l’ascendance, l’origine ethnique, le lieu d’origine, l’âge, la croyance, la religion, le sexe, l’identité de genre, la situation familiale, l’état matrimonial ou un handicap. Nous affirmons que chaque être humain a de la valeur et mérite d’être traité avec dignité et respect. Le bien-être de notre société et de notre profession est vital. L’ACMV s’engage à continuer à développer ses services et à les rendre accessibles sans parti pris, et à promouvoir la diversité et l’inclusion. L’ACMV soutient également les programmes existants des écoles de médecine vétérinaire qui encouragent l’inclusivité et la diversité et permettent une sélection équitable des étudiants. Nous appuyons les mesures prises par les associations canadiennes, le gouvernement et les établissements d’enseignement pour rendre la formation vété- rinaire plus accessible aux groupes sous-représentés et minoritaires. Nous soutenons le dialogue ouvert de nos membres sur ces questions et restons unis avec les médecins vétérinaires, les étu- diants en médecine vétérinaire et les membres associés des équipes vétérinaires qui font face à la discrimination. » Le Conseil de l’ACMV met sur pied un groupe de travail res- ponsable de faire des suggestions concernant le rôle de l’ACMV pour promouvoir la diversité et l’inclusion en médecine vétérinaire et de soumettre un rapport au Conseil de l’ACMV avant sa réunion de novembre 2020. Aucune augmentation des frais d’adhésion à l’ACMV pour 2021 : Étant donné que 2020 a été difficile en raison de la pandé- mie pour la profession vétérinaire et l’industrie de la santé animale, le Conseil a décidé que les frais d’adhésion à l’ACMV ne seraient pas ajustés en fonction du coût de la vie pour 2021. (par Jost am Rhyn, président-directeur général de l’ACMV)

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N Happy Animal Health Week! Veterinary Teams Across Canada Unite to Highlight Zoonotic Diseases! Bonne Semaine de la vie animale! Des équipes vétérinaires de partout au Canada s’unissent pour parler des zoonoses! his month, we celebrate Animal Health Week from ous célébrons la Semaine de la vie animale ce mois-ci, TOctober 4 to 10, 2020. The Canadian Veterinary Medical Ndu 4 au 10 octobre 2020. L’Association canadienne des Association (CVMA) is highlighting the importance of under- médecins vétérinaires (ACMV) souligne l’importance de com- standing zoonotic diseases through the campaign slogan, prendre les maladies zoonotiques par le thème de la campagne “Understanding Zoonotic Diseases: Community Health — « Comprendre les zoonoses : Santé communautaire – Les Animals and You.” animaux et vous ». During this Animal Health Week, we are emphasizing that: Au cours de cette Semaine de la vie animale, l’ACMV met l’ac- • Regular veterinary wellness checks can help protect you, your cent sur les messages suivants : family, and your pet from zoonotic diseases. • Des examens vétérinaires préventifs réguliers peuvent aider • Zoonotic diseases may be transmitted from animals to people, à protéger votre animal et votre famille contre les maladies but they can be easily prevented. zoonotiques. • Always wash your hands after being around animals, even if • Les maladies zoonotiques peuvent être transmises des animaux you did not touch them. aux humains, mais elles peuvent aussi être facilement évitées. • Talk to your veterinary team for information on zoonotic • Lavez-vous toujours les mains après avoir été près d’animaux, diseases. même si vous ne les avez pas touchés. • Parlez à votre équipe vétérinaire pour vous renseigner sur les Social media zoonoses. The CVMA has promoted Animal Health Week for 35 years. We invite you to share your celebrations on Facebook Médias sociaux (facebook.com/CanadianVeterinaryMedicalAssociation), L’ACMV fait la promotion de la Semaine de la vie animale depuis Twitter (in English @CanVetMedAssoc and in French 35 ans. Nous vous invitons à partager vos célébrations sur @Assoccanmedvet), and Instagram (@cvma.acmv) using the Facebook (facebook.com/CanadianVeterinaryMedicalAssociation), hashtag #AnimalHealthWeek. Please also tag us in your social Twitter (@CanVetMedAssoc en anglais et @Assoccanmedvet media posts to be featured in our social media promotions. en français), et Instagram (@cvma.acmv) à l’aide des mots-clics The CVMA would not be able to carry out the important #AnimalHealthWeek et #SemaineDeLaVieAnimale. Veuillez educational campaign that Animal Health Week is without the également nous identifier dans vos publications sur les médias generous support of our sponsors and the dedication of veteri- sociaux pour figurer dans nos promotions sur les médias sociaux. nary teams throughout the country. Thank you. L’ACMV ne serait pas en mesure de mener l’importante campagne de sensibilisation que constitue la Semaine de la vie animale Sponsors sans le soutien de ses commanditaires et le dévouement des Generous support of the 2020 Animal Health Week campaign équipes vétérinaires du pays. Merci! is provided by Program Plus Sponsors, IDEXX and Merck Animal Health, and Program Sponsors, iFinance Canada Commanditaires (Petcard), Petsecure, and Virbac. La campagne de la Semaine de la vie animale 2020 est généreu- This month we highlight one of our Program Sponsors, sement appuyée par les commanditaires principaux IDEXX et Petsecure Pet Health Insurance: Merck Animal Health, et les commanditaires iFinance Canada Petsecure pet health insurance celebrates veterinary care (Petcard), Petsecure et Virbac. teams as community health champions across Canada during Ce mois-ci, nous saluons l’un de nos commanditaires de programme, Petsecure assurance maladie pour animaux. Petsecure assurance maladie pour animaux souligne l’apport des équipes de soins vétérinaires pour la santé des communau- tés partout au Canada pendant la Semaine de la vie animale. Les médecins vétérinaires ont une perspective intéressante en tant que leaders du savoir dans la lutte contre les zoonoses. Ensemble, l’expertise médicale et la compréhension de la relation entre les humains et les animaux permettent des stratégies d’action intégrées, que les zoonoses soient présentes dans la chaîne d’ap- provisionnement de la ferme à la table ou à la maison avec les animaux de compagnie. Les chats et les chiens sont de plus en plus perçus comme des membres de la famille à part entière, et cette réalité crée

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Animal Health Week. Veterinarians have valuable perspectives as un potentiel de transmission de maladies entre les humains et N knowledge leaders in the fight against zoonotic diseases. Medical leurs animaux de compagnie. Petsecure s’engage à soutenir le expertise combined with understanding the human-animal rela- personnel vétérinaire et les patients canins et félins. Les méde- tionship allows for integrated action strategies whether zoonoses cins vétérinaires et les membres de leur équipe de soins sont les are found in the chain from farm to table or in the home with mieux placés pour sensibiliser le public au potentiel zoonotique, companion animals. qu’il soit réel ou peu probable, des différentes maladies dans leurs Cats and dogs are increasingly identified as close family communautés. Les produits Petsecure permettent aux médecins members, and this reality creates the potential for illness trans- vétérinaires d’examiner les animaux, d’établir un diagnostic et de mission between people and their pets. Petsecure is committed to traiter leurs patients en fonction de leurs besoins individuels, avec supporting veterinary staff and their canine and feline patients. la tranquillité d’esprit que la protection financière apporte aux Doctors and their care teams are in the perfect position to build clients. Contrairement à certaines compagnies d’assurance pour awareness about both the real and unlikely zoonotic potential animaux de compagnie, Petsecure couvre les frais d’examen et les of different diseases in their communities. Petsecure products taxes. Petsecure offre également une couverture pour les maladies allow veterinarians to examine, diagnose, and treat pets accord- zoonotiques qu’un chien ou un chat peut développer pendant qu’il ing to individual needs with the peace of mind that financial est assuré en vertu d’une police Petsecure*. protection brings to clients. Unlike some pet insurance compa- « Le rôle de l’équipe vétérinaire est essentiel dans le concept nies, Petsecure covers examination fees and taxes. Petsecure also Une santé du bien-être collectif », déclare la Dre Colleen Fisher, provides coverage for zoonotic diseases a dog or cat may develop directrice médicale vétérinaire de Petsecure. « La prise en charge while the animal is insured under a Petsecure policy*. réussie de toute maladie zoonotique doit intégrer à la fois la “The role of the veterinary team is critical to the One Health santé des animaux et la santé des humains. Pour souligner cet concept of community wellness,” says Dr. Colleen Fisher, engagement, les régimes Petsecure incluent 1000 $ par année Petsecure’s Veterinary Medical director. “The successful approach d’assurance pour les frais de pension lorsque les propriétaires sont to any particular zoonotic disease must incorporate both the hospitalisés et ne peuvent pas prendre soin de leurs animaux de health of animals and the health of people. To highlight that compagnie*. » commitment, Petsecure plans include $1000 per policy year for Petsecure améliore l’assurance en offrant une couverture com- boarding fees where clients are hospitalized and unable to care plète contre les accidents et les maladies, y compris les problèmes for their pets*.” dentaires et les troubles du comportement, dans tous ses régimes. Petsecure makes insurance better with comprehensive acci- Le programme de bons en clinique de Petsecure est une politique dent and illness coverage, including dental and behavior benefits d’essai de 6 semaines offrant aux nouveaux propriétaires d’animaux on all plans. Petsecure’s in-clinic voucher program is a 6-week une protection financière en cas de dépenses vétérinaires impré- trial policy offering new pet owners financial protection in the vues. Renseignez-vous sur les régimes de Petsecure qui incluent event of unexpected veterinary expenses. Find out more about une couverture pour les soins préventifs tels que les vaccinations, Petsecure’s wellness plans that include coverage for routine vac- la maîtrise des parasites et les tests de santé de routine. cines, parasite control, and routine health testing. Les médecins vétérinaires sont les experts en matière de Veterinarians are the experts when it comes to identifying diagnostic et de traitement des maladies zoonotiques chez les and treating zoonotic disease in patients. Set up your clients animaux. Donnez à vos patients la possibilité de recevoir des soins for a lifetime of great pet healthcare by offering Petsecure Pet de santé optimaux durant toute leur vie en offrant à vos clients une Health Insurance. Local territory managers are available across assurance maladie pour animaux de compagnie Petsecure. Les Canada to support care teams in clinic with educational seminars représentants de Petsecure sont disponibles partout au Canada and information materials. CVMA members may contact their pour soutenir les équipes de soins en clinique avec des séminaires local territory manager or reach out to Petsecure’s Vetline at éducatifs et du matériel d’information. Les membres de l’ACMV 1-877-202-5813 for information about their products. peuvent communiquer avec leur représentant ou le personnel du service vétérinaire de Petsecure au 1-877-202-5813 pour obtenir (*Underwriting and designated waiting periods may apply. See policy de plus amples renseignements sur leurs produits. wordings for full details.) (* La souscription et des périodes d’attente peuvent s’appliquer. Voir le libellé des polices pour plus de détails.)

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N October Celebrates RVTs with Octobre célèbre les RVT/TSAc avec New RVT Month App! une nouvelle application! he Registered Veterinary Technologists and Technicians es Technologues et techniciens vétérinaires agréés du Canada Tof Canada (RVTTC) and the provincial RVT associations L(TTVAC) et les associations provinciales de techniciens vété- across Canada (BCVTA, ABVTA, SAVT, MVTA, OAVT, EVTA) rinaires du Canada (BCVTA, ABVTA, SAVT, MVTA, OAVT, EVTA) celebrate and recognize Registered Veterinary Technicians/ célèbrent et reconnaissent les techniciens/technologues vété- Technologists (RVTs) every October. This year there is even rinaires agréés (RVT) et techniciens en santé animale certifiés more reason to recognize and celebrate RVTs. (TSAc) chaque octobre. Cette année, il y a encore plus de raisons RVTs were identified as essential along with their veterinary de reconnaître et de célébrer les RVT/TSAc. team members during the COVID-19 pandemic. Veterinary Les techniciens ont été identifiés comme des travailleurs medicine came together to hold strong for all Canadian pets and essentiels avec les autres membres de l’équipe vétérinaire durant pet owners as an essential service. la pandémie de COVID-19. En effet, la médecine vétérinaire s’est Now in its 4th consecutive year, RVT Month celebrates révélée être un service essentiel pour tous les animaux canadiens approximately 10 000 RVTs across Canada throughout October. et leurs propriétaires. This year, the theme is celebrating the Heart of the RVT. Maintenant à sa 4e édition, le Mois des RVT/TSAc souligne Veterinary health care teams continued to work as the country en octobre le travail des quelque 10 000 techniciens de partout closed down to stop the spread of COVID-19; RVTs continued au Canada. Cette année, le thème salue le cœur des RVT. Les to care and advocate for animals across Canada. Whether RVTs équipes de soins vétérinaires ont continué à travailler tandis que work in an animal hospital, livestock health facility, animal le pays fermait pour arrêter la propagation de la COVID-19, et shelter, research facility, educational institution, government, les techniciens ont continué à prendre soin des animaux. Que les animal health care industry sales or in zoo animal and wildlife techniciens travaillent dans un hôpital pour animaux de compagnie, care, they all have one thing in common: the animals. Caring une pratique de grands animaux, un refuge, un centre de recherche, for animals is at the heart of being an RVT. un établissement d’enseignement ou un gouvernement ou encore This year RVT Month is going DIGITAL! The RVTTC qu’ils se consacrent aux ventes dans l’industrie de la santé animale will be providing all the same materials previously included in ou aux soins des animaux de zoo et de la faune, ils ont tous une the RVT Month Kits on a uniquely designed app just for RVT chose en commun : les animaux. Prendre soin des animaux est au Month. The app will have a special “Thank an RVT” message cœur de la vocation des techniciens.

1046 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY board for pet owners and colleagues to thank RVTs and share Cette année, le Mois des RVT/TSAc passe à l’ère N their appreciation. NUMÉRIQUE! L’association TTVAC fournira les mêmes outils qui In a joint effort between Canada’s RVT associations, this étaient inclus dans les trousses du Mois des RVT/TSAc sur une one-stop-shop for RVT Month has been created, and will allow application conçue expressément pour l’événement. L’application RVTs, employers and members of the public to take part in RVT aura un babillard spécial sur lequel les propriétaires d’animaux et Month…right at their fingertips! les collègues pourront remercier un technicien et exprimer leur Highlights of the RVT Month App include: appréciation. • Educational and marketing materials about the RVT Dans le cadre d’un effort conjoint des associations de techni- profession ciens du Canada, ce guichet unique pour le Mois des RVT/TSAc • Links to RVT merchandise, sponsor contests, RVT Month a été créé et permettra aux techniciens, aux employeurs et aux events gens du public de participer au Mois des RVT/TSAc… avec tout • “Thank an RVT” message board, for clients to thank RVTs le nécessaire à portée de main! for the work that they do L’application donnera aux utilisateurs : • The ability to share posters and videos from the app right to • un accès à du matériel pédagogique et promotionnel sur la your social media pages. profession de technicien vétérinaire; The RVT Month App is available for direct download • des liens vers la marchandise offerte, les concours des com- (rvtmonth.ca). Clinics, organizations, and businesses are asked manditaires, les événements du mois des RVT/TSAc; to help share the RVT Month App link with their clients, cus- • un babillard où afficher des messages pour remercier les tech- tomers, and colleagues to reach as wide an audience as possible. niciens pour le travail qu’ils accomplissent; The new “Proudly RVT” design is featured on a number of • la possibilité de partager des affiches et des vidéos à partir de clothing and accessory items in the RVT Month online store l’application directement sur leurs pages de réseaux sociaux. (https://urstore.ca/rvt-month). Check out the many options L’application est disponible pour téléchargement direct available for purchase. (rvtmonth.ca). Les cliniques, les organisations et les entreprises Each provincial association, as well as the RVTTC, will have sont invitées à partager le lien de l’application avec leurs clients et different things planned throughout the month of October. leurs collègues afin d’atteindre un public aussi large que possible. Check with the specific association for more information on La boutique en ligne du Mois des RVT/TSAc propose divers RVT Month in your province. vêtements et accessoires arborant la mention « Proudly RVT » (https://urstore.ca/rvt-month); visitez-la pour découvrir les diffé- Contacts rents produits offerts. British Columbia Veterinary Technologists Association Les associations provinciales et les TTVAC proposeront diffé- (BCVTA): ([email protected]) rentes choses tout au long du mois d’octobre. Vérifiez auprès de Alberta Veterinary Technologist Association (ABVTA): l’association de votre province pour en savoir plus sur les activités ([email protected]) du Mois des RVT/TSAc dans votre région. Saskatchewan Association of Veterinary Technologists (SAVT): Coordonnées ([email protected]) British Columbia Veterinary Technologists Association (BCVTA) : Manitoba Veterinary Technologists Association (MVTA): [email protected] ([email protected]) Alberta Veterinary Technologist Association (ABVTA) : Ontario Association of Veterinary Technicians (OAVT): [email protected] ([email protected]) Saskatchewan Association of Veterinary Technologists (SAVT) : Eastern Veterinary Technicians Association (EVTA): [email protected] ([email protected]) Manitoba Veterinary Technologists Association (MVTA) : Registered Veterinary Technologists and Technicians of [email protected] Canada (RVTTC): ([email protected]) Ontario Association of Veterinary Technicians (OAVT) : [email protected] Eastern Veterinary Technicians Association (EVTA) : [email protected] Technologues et techniciens vétérinaires agréés du Canada (TTVAC) : [email protected]

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N Communication Is Key: La communication est la clé : Having Difficult Conversations Avoir des conversations difficiles in the Workplace en milieu de travail Rdownloads, one of the CVMA’s valued partners, pro- Rdownloads, l’un des précieux partenaires de l’ACMV, offre Hvides advice on how to have difficult conversations in the Hdes conseils sur la façon d’aborder les conversations difficiles workplace. en milieu de travail. Having difficult, and sometimes awkward, conversations with Avoir des conversations difficiles, et parfois gênantes, avec employees is part of a manager’s role. Often these conversations les employés fait partie du travail d’un gestionnaire. Souvent, ces are about sensitive matters and are uncomfortable for both par- conversations portent sur des sujets délicats et sont inconfor- ties. Good leaders address sensitive issues rather than avoiding tables pour les deux parties. Cela dit, les bons leaders abordent them. But how you communicate an issue to an employee greatly les questions sensibles plutôt que de les éviter. Mais la façon dont affects the outcome of the situation. vous communiquez un problème à un employé peut avoir un impact Part of the challenge when having these conversations is get- important sur l’issue de la situation. ting over the fear or discomfort of having to do it. Some of the Une partie du défi lié à ces conversations difficiles est de sur- hardest conversations can be those regarding personal hygiene, monter la peur ou la gêne qu’elles génèrent. Certains des sujets performance issues, or very specific situations relating to a per- les plus délicats à aborder sont entre autres ceux qui concernent son’s habits. While these conversations can be difficult, they have l’hygiène personnelle, le rendement ou des situations très spéci- to happen for the issue to be corrected. fiques en lien avec les habitudes d’une personne. 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1048 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Case Report Rapport de cas

A rare case of malignant vagus nerve sheath tumor presenting with multiple cranial nerve dysfunction in a dog

Lucile Giraud, Stéphane Lezmi, Eymeric Gomes, Laurent Cauzinille

Abstract — A 5-year-old intact male Gascon Saintongeois dog was presented with a 6-month history of coughing, laryngeal paralysis, a deglutition disorder of gradual onset, and left-sided Horner’s syndrome. The dog was admitted as an emergency for acute central vestibular signs. Magnetic resonance images identified a left extra-axial brainstem lesion extending caudally from the medulla to the vagosympathetic trunk. Histological and immunohistological examination revealed a high grade epithelioid malignant peripheral nerve sheath tumor (MPNST). This case report is the first description of a MPNST of the vagus nerve compressing the brainstem and causing multiple cranial nerve dysfunction in a dog. Key clinical message: Nerve sheath tumors have been reported in many locations arising from spinal nerve roots and cranial nerves. Although the trigeminal nerve is the most commonly affected nerve, other cranial nerves such as the vagus can be affected.

Résumé — Un cas rare de tumeur maligne de la gaine du nerf vague à l’origine d’une dysfonction de plusieurs nerfs crâniens chez un chien. Un chien mâle entier de cinq ans de race Gascon Saintongeois a été présenté avec un historique de 6 mois de toux, paralysie laryngée, trouble de la déglutition d’évolution progressive et un syndrome de Claude Bernard Horner à gauche. Le chien a été admis en urgence pour des signes vestibulaires centraux. Une imagerie par résonnance magnétique a mis en évidence une lésion extra-axiale gauche localisée au niveau du tronc cérébral s’étendant caudalement de la medulla vers le tronc vagosympathique. Les examens histologique et immunohistologique ont révélé une tumeur épithéliale maligne des gaines nerveuses de haut grade (TMGN). Ce rapport de cas est la première description de TMGN du nerf vague comprimant le tronc cérébral et à l’origine d’une dysfonction de plusieurs nerfs crâniens chez un chien. Message clinique clé : Les tumeurs des gaines des nerfs ont été rapportées de plusieurs localisations prenant leur origine des racines des nerfs spinaux et des nerfs crâniens. Bien que le nerf trijumeau soit le nerf le plus fréquemment affecté, d’autres nerfs crâniens, tel que le vague, peuvent être affectés. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1049–1054

eripheral nerve sheath tumors (PNSTs) arise within the commonly arise from spinal nerve roots (e.g., brachial plexus, P nerve sheaths from 1 or more populations of endogenous lumbosacral plexus) and cranial nerves but have also been cells, including Schwann cells, perineurial cells, or fibroblasts. reported in the liver, spleen, adrenal gland, skin, lungs, eyes, and Based on their morphologic and biologic behavior, PNSTs are other locations (2–6). The brachial plexus is the most commonly divided into benign (Schwannoma, neurofibroma, perineu- affected site in dogs (7), while trigeminal PNST is the most rioma) and malignant forms (MPNSTs) (1). These tumors frequently encountered neoplasm of the cranial nerves (8,9). Reported cases of PNSTs of the vagus are rare in both human and veterinary medicine. A literature search identified only 3 reported canine cases (10–12). One dog with a malignant CHV Frégis, 43 Av Aristide Briand, 94110 Arcueil, France. PNST of the right proximal cervical vagosympathetic trunk Address all correspondence to Dr. Lucile Giraud; e-mail: was euthanized without treatment following confirmation of [email protected] cervical neoplasia (10). A second dog with a malignant vagus Use of this article is limited to a single copy for personal study. PNST located between the carotid artery and esophagus in the Anyone interested in obtaining reprints should contact the mid-cervical region had an 18-cm section of thickened vagus CVMA office ([email protected]) for additional nerve excised during exploratory surgery. This dog was alive copies or permission to use this material elsewhere. 19 mo after surgery at the time of the report (11). The last dog

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was diagnosed with an intrathoracic malignant PNST of the oxytoca that was isolated in culture, and polymerase chain reac- right vagus nerve at the level of the bronchus. A vagotomy was tion (PCR) testing for Mycoplasma spp. was positive. Treatment performed to excise a lesion measuring 2 cm in diameter and with prednisolone (CEVA Santé Animale, Libourne, France) at 5 cm in length, which was connected to the right vagus nerve 1 mg/kg body weight (BW) per day in conjunction with doxy- cranially. The dog was alive 710 d after surgery at the time of cycline (Boehringer Ingelheim Animal Health, Lyon, France) the report (12). Both dogs had no signs of local recurrence or at 10 mg/kg BW per day was resumed for 4 wk. Improvement metastasis. A PNST primarily involving the hypoglossal nerve was not complete, and the coughing frequency increased; in (CN XII) with secondary invasion of the vagus and accessory addition, ptyalism, gagging, and dysphagia developed. Prior nerves (CN X and XI) has also been documented (13). to admission in emergency, the owner had noticed a 1-month Peripheral nerve sheath tumors are most common in middle- history of left Horner’s syndrome (miotic pupil, prominent aged to older dogs (8,14,15). Clinical signs depend on location third eyelid, and droopy upper eyelid) and an abnormal gait RAPPORTCAS DE of the lesion. Intracranial extension is rare but compression of characterized by unsteadiness for a few days. the adjacent brainstem is described with trigeminal neoplasia On physical examination, the dog was dull and unresponsive, resulting in ipsilateral proprioceptive deficits, obtundation, tachycardic (190 beats/min), and tachypneic (60 breaths/min). and/or vestibular signs (16,17). Additionally, ipsilateral clinical The rectal temperature was 41.8°C. The dog had semi-dry signs such as reduced facial and corneal sensation and face rub- mucous membranes and a minimal loss of skin turgor. A left- bing have been reported (8). sided purulent nasal discharge and left conjunctival hyperemia Definitive diagnosis requires histopathology, but a presump- were also observed. On neurological examination, the dog was tive diagnosis can be made based on imaging findings. Magnetic non-ambulatory with left-sided postural deficits along with a resonance imaging (MRI) is the imaging modality of choice due left-sided head tilt. There was a horizontal to rotatory nystagmus to its superior soft tissue contrast resolution (18). Peripheral with a fast phase towards the right, an incomplete left palpebral nerve sheath tumors are frequently iso- to hyper-intense on closure, left Horner’s syndrome, and mild unilateral left tempo- T2-weighted images, isointense on pre-contrast T1-weighted ralis muscle atrophy. Atrophy of the lingual muscles on the left images, and display moderate to marked contrast enhance- side with deviation of the rostral third was also noticed. Based ment (19). on the abnormal neurological findings, a neuropathy involving This is the first report of a malignant vagal PNST infiltrating cranial nerves V, VII, VIII, IX, X, and XII was presumed with several other cranial nerves and causing brainstem compression. brainstem involvement. Clinical signs as well as MRI and histopathological character- Routine hematology revealed mild neutrophilic leukocyto- istics are discussed. sis (14 800 cells/mL; reference range 6000 to 13 000 cells/mL) as the sole abnormal finding; serum biochemistry was unre- Case description markable. Magnetic resonance imaging of the brain and the A 5-year-old intact male Gascon Saintongeois dog weighing neck was performed with a 0.25 T scanner (Vet-MR Grande; 25.1 kg was presented to the emergency department because Esaote, Genoa, Italy). Acquisition included transverse T1- and of an acute deterioration of his neurological status, includ- T2-weighted, dorsal FLAIR, 3D SST1, and 3D SST2 sequences. ing head tilt and an inability to stand. This active hunting Images revealed a large, rounded, extra-axial mass with sharp dog had a 6-month history of coughing. A canine infectious margins on the ventro-lateral aspect of the brainstem at the left tracheobronchitis was first suspected by his referring veterinar- cerebellopontine angle, extending as a tubular lesion through ian. None of the dogs of the pack had any respiratory signs. the left jugular foramen and the left tympano-occipital fis- The dog was initially responsive to an oral doxycycline and sure (Figure 1). The lesion appeared mildly heterogeneous on prednisolone treatment lasting 2 wk, but the cough relapsed a T1- and T2-weighted images with T1 hypo- and iso-intense few days after discontinuation. He was then treated with oral areas and a T2 hyperintense peripheral rim with a hyper- and amoxicillin-clavulanic acid and meloxicam lasting 4 wk with iso-intense center. The lesion was homogenously hyperintense partial improvement. Owing to the worsening of cough and on T2 FLAIR and showed mildly heterogenous and strong the development of exercise intolerance, the dog was referred contrast enhancement. The mass exited the cranial vault and to our internal medicine department for investigations 4 mo extended along the parapharyngeal region and formed a mass before the current presentation. At that time, routine hema- at the level of the carotid bifurcation in the area of the cranial tology and serum biochemistry were unremarkable. A test cervical ganglion. This massive round mass (22 3 25 3 33 mm) for Angiostrongylus vasorum in feces was negative. Thoracic was well-marginated, with a hypointense non-enhancing center radiographs did not show any abnormalities, while endoscopic and thick peripherally enhancing rim. Mild atrophy of the left examination of the upper respiratory tract revealed a left laryn- temporal muscles was also noted. Due to the highly invasive geal paralysis and a mild tracheal collapse (grade 1). There was nature of the lesion and the poor prognosis, the owner elected also evidence of chronic bronchitis with a non-specific mucosal to have the dog euthanized and consented to a necropsy. erythema and large amounts of mucus. Cytological analysis of Gross examination at postmortem confirmed a left extra- bronchoalveolar lavage fluid confirmed a chronic bronchitis axial brainstem mass arising from the dorsal aspect of the with signs of infection in the left cranial lobe bronchus caudal medulla oblongata. The elongated mass exited through the segment (LB1V1) characterized by degenerating neutrophils tympano-occipital fissure and emerged just caudal to the left and alveolar macrophages. Microbial testing revealed Klebsiella glossopharyngeal and vagus nerves (Figure 2). The mass further

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Figure 1. T1-weighted transverse (a–d), dorsal (e), and parasagittal (f) magnetic resonance images obtained after IV administration of gadolinium. Transverse images (a–d) from the caudal aspect of the brainstem to C1. Note the extensive mass from the ventrolateral left side of the brainstem and along the medial aspect of the tympanic bulla. The mass is exiting at the level of the jugular foramen and tympano-occipital fissure and heterogeneously contrast enhanced, with relatively defined margins.

encompassed the vagus and the accessory nerve and continued matrix (Figure 4). Neoplastic cells had a large oval vesicular caudally towards the vagosympathetic trunk through the cra- nucleus and a prominent nucleolus. The mitotic index was nial cervical ganglion. The mass appeared pinkish-white, well- up to 4 per high power field (3400). Neoplastic cells invaded circumscribed, and encapsulated and did not seem to infiltrate the proximal part of nerves but were not observed in the the neighboring tissue on gross examination. Samples of normal brainstem itself. Some nerve sections minimally infiltrated by brain tissue and of the neoplasm were fixed in 10% formalin and neoplastic cells showed a severe loss of axons (Figure 5). This routinely processed for histopathological analyses. was confirmed using BIII tubulin (Promega G7121, Madison Transverse cross sections of the lesion were stained using Wisconsin, USA) immunohistochemistry (IHC), a marker of hematoxylin and eosin (H&E). Histologically, the mass was neuronal cells and axons (Figure 6). In the tumor, cells were densely cellular with large areas of necrosis and hemorrhage strongly positive for S100 (Abcam ab11428, Cambridge, UK), (Figure 3). In some areas, neoplastic cells formed large and but GFAP (Dako Z0334, Santa Clara, California, USA) and poorly defined sheets. These cells were round, fusiform, or BIII tubulin negative. Immunohistochemical staining was per- stellate in shape with an abundant pale eosinophilic cytoplasm formed using standard avidin-biotin-peroxidase complex (ABC) (epithelioid-like) producing a variably abundant mucinous-like method. Based on the macroscopic, microscopic, and IHC

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Figure 2. Transverse section of the formalin-fixed brain at the level of the obex. Gross findings confirmed the presence of a Figure 4. Histopathology (H&E stain, tumor). Neoplastic cells non-invasive tumor (arrows) causing compression of the medulla (arrows) are poorly differentiated, round to fusiform and arranged oblongata and cerebellar hemisphere. in poorly demarcated large sheets with variable amount of extracellular myxoid material (31000).

rostrally and the cranial root of the accessory nerve (XI) arises caudally. These nerves emerge very close to each other, lateral to the myelencephalon, exit the jugular foramen and tympano- occipital fissure, and course down to supply the musculature  of the pharynx, larynx, and esophagus. These nerves cannot be  differentiated from each other on MRI (21). The dog was initially presented for coughing, inspiratory dyspnea, and exercise intolerance. A chronic bronchitis was diagnosed associated with a unilateral left laryngeal hemiplegia. The cause of the chronic bronchitis was unclear but thought likely to reflect a swallowing disorder and laryngeal tracheal mucosal irritation. All laryngeal muscles, except for the cricothyroideus, are innervated by the recurrent laryngeal nerve, which branches from the vagus nerve at the level of the heart base (on the left) or Figure 3. Histopathology (H&E stain, tumor). At low rostral to the heart base (on the right) (20). Therefore, a lesion magnification significative amount of necrosis (stars) admixed with hemorrhages (arrow) are observed (320). in the cervical vagosympathetic trunk can be expected to induce ipsilateral laryngeal hemiplegia, which could predispose the affected patient to aspiration. Radiographic evidence of aspiration pneumonia was not apparent initially, although recheck evaluations, the morphological diagnosis of a high grade, poorly radiographs were not performed. differentiated, epithelioid, malignant vagus peripheral nerve Laryngeal paralysis is usually diagnosed by examination of sheath tumor was reached. Two lymph node segments obtained the movement of arytenoid cartilages and vocal cords, either proximal to the tumor did not show any evidence of metastasis. via direct visualization when the patient is conscious or using ultrasonography or computed tomography (CT) (22). In equivo- Discussion cal cases, electromyography is helpful. Polyneuropathy complex Clinical and pathological examinations in this case revealed a and idiopathic laryngeal paralysis are the most frequent causes of tumor derived from the left vagosympathetic trunk. This case is laryngeal paralysis, but other diseases must be considered, such unique because of the unusual presentation of clinical signs, the as accidental or iatrogenic trauma to the recurrent laryngeal highly expansive nature of the tumor, and the resulting compres- nerve, toxicity (lead or organophosphates), primary neoplasia, sion causing multiple cranial nerve dysfunction. or secondary to processes such as thyroid masses or brainstem The vagus nerve provides both sensory and motor innervation inflammatory or neoplastic diseases (22). to the palate, pharynx, larynx, trachea, and esophagus, as well Over time, dysphagia became obvious in this patient. as to thoracic and abdominal organs (20). The efferent axons in Swallowing disorders can occur with mechanical (anatomical), the vagus arise from 2 nuclei located in the medulla oblongata. functional (neurological), or pain-related disorders. Functional The somatic efferent fibers have their cell bodies in the nucleus dysphagia can occur with lesions in the nucleus ambiguus of the ambiguus from which the glossopharyngeal nerve (IX) arises medulla, the glossopharyngeal (IX) and vagus (X) nerves, or the

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Figure 5. Histopathology (H&E stain, nerve section). Abnormal Figure 6. Immunohistochemistry (nerve section). BIII tubulin nerve section shows low number of infiltrating neoplastic cells IHC revealed the almost complete absence of axons in several (cells with larger nuclei) (arrows). Note the absence of axons nerve sections; only small remaining fragments of axons (arrows) in the nerve (Schwann cells only) (arrowheads) (31000). were observed (31000). pharyngeal or esophageal muscles. In this case, the dysphagia PNSTs are derived from Schwann cells or pluripotent cells of was secondary to a primary dysfunction of cranial nerves IX the neural crest and can be graded according to the WHO clas- and X. Furthermore, the characteristic combination of a miotic sification. Several distinct subtypes have been recognized includ- pupil, prolapsed third eyelid, and upper eyelid ptosis indicating “Schwannoma,” “Neurofibrosarcoma,” or “Neurosarcoma.” ing Horner’s syndrome was observed by the owner. Symptoms A malignant poorly differentiated PNST is usually defined as related to Horner’s syndrome result from dysfunction of the a tumor with nerve sheath differentiation and neoplastic cell sympathetic supply along its 3-neuron pathway. For this dog, invasion beyond the confines of the epineurium. Grossly, these a second neuron lesion in the cranial cervical vagosympathetic tumors lack an epineural tumor capsule and may aggressively trunk most likely resulted in Horner’s syndrome due to disrup- invade the surrounding structures. At microscopic examination of the sympathetic supply to the ipsilateral eye. tion, PNSTs are generally characterized by spindle-shaped cells Considering the evolution of the clinical signs and the results arranged in palisades or spiral shapes (Antoni A & B patterns or of the initial diagnostic tests, a neoplastic disorder was the main Verocay bodies) (23). In our case, these specific patterns, more hypothesis. In light of MRI sequences, anatomopathological, frequently observed in low-grade tumors, were not observed. and histological findings, a tumor originating from the left The epithelioid nature of this malignant PNST was based on vagosympathetic trunk was presumed. Over the course of a the presence of neoplastic cells with an abundant eosinophilic couple months, the tumor likely gradually infiltrated other cytoplasm and the presence of a myxoid matrix frequently cranial nerves such as glossopharyngeal and accessory nerves, described in tumors of this type in literature on humans cases and compressed the brainstem causing the more recently cen- (WHO classification) (24). Malignant PNSTs are frequently tral nervous signs observed (central vestibular syndrome, pro- S100 positive and variably positive for GFAP (1). BIII tubulin prioceptive deficits, and obtundation). A mild left temporal is a neuronal marker which allowed us to visualize the marked muscle atrophy observed on MRI was presumed to be second- loss of axons in several nerve sections present on tissue sections. ary to involvement of the mandibular branch of the trigeminal This observation was consistent with the multiple cranial nerve nerve. dysfunctions observed in this case. Intracranial PNSTs are relatively uncommon tumors in dogs. Treatment of malignant PNSTs involves the removal of The most common cranial nerve involved is the trigeminal the tumor when surgically accessible, radiation therapy, or nerve (8,14,19). Case reports describing other cranial nerve both (14,25,26). Without treatment, survival times for dogs sheath tumors are rare (10,11,13). Various diagnostic imaging with trigeminal PNST range from 5 to 21 mo and affected modalities have been reported in the diagnosis of PNSTs (8). dogs typically die as a result of tumor invasion of the adjacent Computed tomography and MRI are both appropriate options brainstem structures (8). The prognosis for PNSTs is variable for identifying affected nerves, nerve root involvement, and and mainly dependent on the treatment. Local recurrence is potential vertebral canal or intracranial extension. In this case, common, with a guarded to poor long-term prognosis. MRI was chosen as it provides excellent soft-tissue resolution Tumor removal was not considered in this case due to the and has the ability to distinguish nerve bundles from ves- highly expansive nature of the tumor and the intracranial sels (8,18,19). involvement. Indeed, intracranial nerve surgeries are rarely Histopathology findings confirmed the diagnosis of a high- performed due to the combination of a challenging approach grade epithelioid malignant PNST in this dog. Malignant and a high postoperative morbidity rate (8). If the lesion had

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been confined to the cervical region, a surgical excision might 6. Silva EO, Goiozo PFI, Pereira LG, Headley SA, Bracarense AFRL. have been proposed. Two case reports described successful Concomitant malignant pulmonary peripheral nerve sheath tumour and benign cutaneous peripheral nerve sheath tumour in a dog. J Comp vagotomies with tumors located in the mid-cervical region and Pathol 2017;157:46–50. intrathoracic location allowing resolution of the clinical signs 7. Kraft S, Ehrhart EJ, Gall D, et al. Magnetic resonance imaging charac- induced by vagal dysfunction (11,12). teristics of peripheral nerve sheath tumors of the canine brachial plexus in 18 dogs. Vet Radiol Ultrasound 2007;48:1–7. Radiation therapy is currently the preferred treatment modal- 8. Bagley RS, Wheeler SJ, Klopp L, et al. Clinical features of trigeminal ity for most patients with trigeminal PNSTs. One retrospective nerve-sheath tumor in 10 dogs. J Am Anim Hosp Assoc 1998;34:19–25. analysis demonstrated that stereotactic radiotherapy (SRT) is 9. Milodowski EJ, Amengual-Batle P, Beltran E, Gutierrez-Quintana R, De Decker S. Clinical findings and outcome of dogs with unilateral a beneficial and well-tolerated treatment option (25). In this masticatory muscle atrophy. J Vet Intern Med 2019;33:735–742. study, 8 dogs treated by stereotactic radiotherapy [3 doses of 10. Ruppert C, Hartmann K, Fischer A, Hirschberger J, Hafner A, Schmidt 8 Gray (Gy)] had a mean disease-specific survival time of 745 d P. Cervical neoplasia originating from the vagus nerve in a dog. J Small

RAPPORTCAS DE Anim Pract 2000;41:119–122. (range: 99 to 1375 d). In another study (14) including 15 dogs 11. Yap F, Pratschke K. Peripheral nerve sheath tumor of the vagus nerve treated by SRT with 3 fractions of 8 to 10 Gy megavoltage in a dog. J Am Anim Hosp Assoc 2015;52:57–62. radiation, the median survival time was 441 d. Curative intent 12. Hara Y, Tagawa M, Ejima H, et al. Regression of hypertrophic osteopathy following removal of intrathoracic neoplasia derived from vagus high dose hypofractionated frameless volumetric modulated arc nerve in a dog. J Vet Med Sci 1995;1:133–135. radiotherapy for treatment of trigeminal PNST has also been 13. Davis EG, Coates JR, Johnson GC, Cook CR, Pardo ID. What is your evaluated (27). Overall, median survival was 952 d with a 95% neurologic diagnosis? J Am Vet Med Assoc 2011;239:189–191. 14. Swift KE, McGrath S, Nolan MW, et al. Clinical and imaging findings, confidence interval of 543 to 1361 d. When considering spinal treatments, and outcomes in 27 dogs with imaging diagnosed trigemi- PNSTs, it has been described that dogs treated with SRT as a nal nerve sheath tumors: A multi-center study. Vet Radiol Ultrasound second-line treatment after tumor recurrence, following surgery 2017;58:679–689. 15. Brehm D, Vite C, Steinberg H, Haviland J, van Winkle T. A retrospec- alone or having already solely received SRT as their initial treat- tive evaluation of 51 cases of peripheral nerve sheath tumors in the dog. ment, may gain an additional 125 to 346 d survival time (26). J Am Anim Hosp Assoc 1995;31:349–359. Chemotherapy is not commonly used alone or in conjunction 16. Cizinauskas S, Lang J, Maier R, Fatzer R, Jaggy A. Paradoxical vestibular disease with trigeminal nerve-sheath tumor in a dog. Schweiz Arch with surgery or radiation for peripheral nerve sheath tumors. Tierheilkd 2001;143:419–425. Palliative care includes corticosteroids to reduce cerebral edema 17. Vandevelde M, Braund KG, Hoff EJ. Central neurofibromas in if present. two dogs. Vet Pathol 1977;14:470–478. 18. Lye RH, Ramsden RT, Stack JP, Gillespie JE. Trigeminal nerve tumor: This case report describes an uncommon presentation of a Comparison of CT and MRI. J Neurosurg 1987;67:124–127. malignant PNST in a dog. Clinical signs progressed over 6 mo, 19. Schultz RM, Tucker RL, Gavin PR, Bagley R, Saveraid TC, Berry CR. presenting initially as coughing with a suspicion of unspecific Magnetic resonance imaging of acquired trigeminal nerve disorders in six dogs. Vet Radiol Ultrasound 2007;48:101–104. bronchitis and laryngeal hemiplegia progressing with dysphagia 20. Evans H, DeLahunta A. Cranial nerves. In: Miller’s Anatomy of the and Horner’s syndrome eventually resulting in a multifocal Dog. 4th ed. St. Louis, Missouri: Saunders, 2013:726–729. brainstem dysfunction. We strongly recommend functional 21. Couturier L, Degueurce C, Ruel Y, Dennis R, Begon D. 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Immunohistochemical evaluation of 25. Hansen KS, Zwingenberger AL, Théon AP, Pfeiffer I, Kent MS. Treatment canine peripheral nerve sheath tumors and other soft tissue sarcomas. of MRI-diagnosed trigeminal peripheral nerve sheath tumors by stereo- Vet Pathol 2004;41:307–318. tactic radiotherapy in dogs. J Vet Intern Med 2016;30:1112–1120. 2. Ichikawa M, Suzuki S, Tei M, et al. Malignant peripheral nerve sheath 26. Lacassagne K, Hearon K, Berg J, et al. Canine spinal meningiomas and tumor originating from the adrenal gland in a dog. J Vet Med Sci 2018; nerve sheath tumours in 34 dogs (2008–2016): Distribution and long- 80:1572–1575. term outcome based upon histopathology and treatment modality. Vet 3. Bergmann W, Burgener IA, Roccabianca P, Rytz U, Welle M. Primary Comp Oncol 2018;16:344–351. splenic peripheral nerve sheath tumour in a dog. J Comp Pathol 2009; 27. Dolera M, Malfassi L, Marcarini S, et al. High dose hypofractionated 141:195–198. frameless volumetric modulated arc radiotherapy is a feasible method for 4. Park JW, Woo GH, Jee H, et al. Malignant peripheral nerve sheath treating canine trigeminal nerve sheath tumors. Vet Radiol Ultrasound tumour in the liver of a dog. J Comp Pathol 2011;144:223–226. 2018;59:624–631. 5. Sato T, Yamamoto A, Shibuya H, Sudo H, Shirai W, Amemori T. Intraocular peripheral nerve sheath tumor in a dog. Vet Ophthalmol 2005;8:283–286.

1054 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Case Report Rapport de cas

Investigation of clinical outbreaks of American foulbrood in honey-bee operations in Saskatchewan

Michael W. Zabrodski, Geoff Wilson, Igor Moshynskyy, Alexandra Wentzell, Sarah C. Wood, Colby D. Klein, Ivanna V. Kozii, Igor Medici de Mattos, Tasha Epp, Elemir Simko

Abstract — Four outbreaks of American foulbrood were investigated in honey-bee operations in Saskatchewan during the summer of 2019. Clinical signs were confirmed by the Saskatchewan Provincial Specialist in Apiculture and the causative agent was cultured and identified through matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS). Evaluation of management practices revealed off-label metaphylactic use of oxytetracycline in 3 of 4 operations and a discontinuation of antibiotic use in the fourth. Recent regulatory changes regarding access to medically important antimicrobials has provided an opportunity for veterinarians to promote evidence-based use of antimicrobials in apiculture while safe-guarding the health of commercial honey- bee populations and the economic viability of their producers.

Résumé — Enquête sur des poussées de cas cliniques de loque américaine dans des opérations d’abeilles mellifères en Saskatchewan. Quatre poussées de cas de loque américaine furent investiguées dans des opérations d’abeilles mellifères en Saskatchewan durant l’été 2019. Les signes cliniques furent confirmés par le Spécialiste provincial en apiculture de la Saskatchewan et l’agent causal fut cultivé et identifié par spectroscopie de masse par ionisation laser assistée par une matrice et analyse à temps de vol (MALDI-TOF MS). Une évaluation des pratiques de gestion a révélé l’utilisation métaphylactique en dérogation d’oxytétracycline dans trois des quatre opérations et un arrêt de l’utilisation d’antibiotique dans la quatrième. Des changements réglementaires récents concernant l’accès à des antimicrobiens importants médicalement ont fourni une opportunité aux vétérinaires de faire la promotion de l’utilisation factuelle des antimicrobiens en apiculture tout en conservant la santé des populations d’abeilles mellifères et la viabilité économique des apiculteurs. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1055–1059

merican foulbrood (AFB), caused by Paenibacillus larvae, is reported to maintain infectivity for decades (8). This resiliency A a highly infectious, destructive bacterial disease that affects poses significant challenges regarding the management and con- the young brood of honey-bee colonies (1,2). Newly hatched trol of disease. If clinical signs consistent with AFB infection are larvae are inadvertently fed bacterial spores, which germinate observed, burning the bees and equipment of affected colonies and replicate in the midgut causing an overwhelming septicemia or, if available, subjecting equipment to gamma irradiation or and producing over 1 billion new spores per infected larva (2,3). high velocity electron-beam irradiation are the only practical As deceased larvae are cleaned from their cells by worker caste solutions to eliminate spores (9–12). bees, spores are picked up and disseminated throughout the hive In Canada, prevention of clinical disease relies heavily on the products including honey and wax, as well as hive equipment use of biannual, metaphylactic, antibiotic treatments with oxy- including frames and boxes (4–7). Spores are resilient to envi- tetracycline in the spring and fall. Treatments are administered ronmental conditions and chemical treatments and have been as either a dusting of antibiotic mixed with powdered sugar, or as

Department of Veterinary Pathology (Zabrodski, Moshynskyy, Wentzell, Wood, Klein, Kozii, de Mattos, Simko), Department of Large Animal Clinical Sciences (Epp), Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4; Crops and Irrigation Branch, Ministry of Agriculture, Government of Saskatchewan, 800 Central Avenue, Box 3003, Prince Albert, Saskatchewan S6V 6G1 (Wilson). Address all correspondence to Dr. Michael Zabrodski; e-mail: [email protected], or Dr. Elemir Simko; 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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may also appear sunken, greasy, or perforated (Figure 1C) (2). Scattered, “shotgun” brood appearance and abnormalities in cell cappings may be suggestive for AFB, but they are not as specific as the presence of ropey brood and firmly attached larval scale (10). As infection advances, dead larvae will desiccate and form dark brown scales that adhere firmly to the ventral lateral wall A B of the brood cell (Figure 1D) and a strong, unpleasant foul odor (hence the name “foulbrood”) may be noted from affected bee frames (18). Samples of comb that contain evidence of ropey larvae and/or scales can be cultured to isolate the bacterium (6,7,20,21), or tested using molecular techniques such as poly- RAPPORTCAS DE merase chain reaction (PCR) (6,22). Clinical description C D Four suspected outbreaks of AFB were identified in com- Figure 1. Common clinical signs of American foulbrood. A — larval ropiness, representing decaying and macerated mercial honey-bee operations across central and southeastern pre-pupae (arrow); B — Scattered, ‘shotgun’ brood pattern as Saskatchewan in June, 2019. In this manuscript, outbreaks a consequence of larval/pupal mortality; C — Perforated cell are defined as an incidence of clinical disease in hives in excess cappings (arrows) and sunken cell cappings (arrowheads); D — Scale, representing dead, desiccated pre-pupae (arrows) of what is expected. All 4 operations — identified here as Operations A, B, C, and D — varied in their management prac- a direct feed within sugar syrup. If Oxysol-62.5 (DIN 00560189) tices for control of AFB, which are summarized in Table 1. All is used, each dusting treatment consists of mixing 400 g of oxy- 4 operations are large honey-producing operations with 2100 to tetracycline HCl (62.5 mg/g) with 3.5 kg of powdered sugar, 4000 honey-producing colonies. Given the use of metaphylactic and dusting 32 g of this mixture into each hive 3 times at 4- antibiotics in 3 operations and the long duration of freedom to 5-day intervals. Syrup feed is made by dissolving 400 g of from observable disease in the 4th, antibiotic-free operation, the oxytetracycline HCl (62.5 mg/g) within 300 kg of a 1:1 mixture expected incidence of clinical disease in each operation is zero. of sugar and water and feeding 2.5 kg of this solution to each hive 3 times at 4- to 5-day intervals. If Oxytet-25 (DIN 02231111) Operation A is used, then 454 g of oxytetracycline HCl (55 mg/g) is mixed Operation A had ceased using metaphylactic antibiotics and had with 3.5 kg of powdered sugar or 300 kg of 1:1 sugar syrup for last treated its colonies with oxytetracycline in the fall of 2016. dusting powder or syrup administration, respectively. Volumes can On June 10th, 2019, staff identified a single colony in 1 yard be scaled down as needed. Antibiotic use can prevent the replica- with a scattered, “shotgun” brood pattern, abnormal cell cap- tion of the vegetative state and suppress clinical manifestation, pings, larval scale, and larval ropiness. The colony was treated but it does not affect the spores present in treated colonies (13). with a single application of oxytetracycline administered over the This metaphylactic treatment is thought to have contributed frames in icing sugar, and the Provincial Specialist in Apiculture to both the development and subsequent spread of antibiotic was contacted to inspect the affected hive. A clinical diagnosis resistant strains of P. larvae and necessitated the use of alternative of AFB was confirmed based on the described clinical signs, and antibiotics such as tylosin for control (14–17). the entire hive was destroyed through burning; the remainder A definitive diagnosis of AFB requires the identification of of the yard was treated with oxytetracycline as per label direc- clinical signs consistent with disease (Figure 1) and isolation tions. Several affected frames were submitted to the laboratory of the causative agent through laboratory testing (7). As of the for bacteriological culture. fall of 2019, AFB was added to the list of provincially notifiable diseases in Saskatchewan, and laboratory-confirmed cases Operation B must be reported to the Chief Veterinary Officer within 24 h Operation B treats its colonies twice annually with oxytetracy- of confirmation. The disease is annually notifiable in Canada. cline mixed with powdered sugar in the spring and fall, but only Following infection, larvae and pupae change from pearly performs a single application of antibiotics per feed treatment white to tan to brown as they are invaded by large numbers of instead of the on-label instructions requiring 3 applications replicating vegetative bacilli (18). The large number of bacteria given 4 to 5 days apart. Brood frames are inspected frequently create a glue-like consistency to the pre-pupa/pupa that can be throughout the season and, on June 14th, 2019, a single colony macerated and strung out using a probe to test for larval ropi- within a large yard of nucleus colonies (n = 195) was marked ness. If macerated pupal tissue can be drawn out and stretched with clinical signs similar to those described in Operation A. more than 2 cm from a cell (Figure 1A), it is highly suggestive Frames and bees from the colony were destroyed by burning, of AFB infection (10). When worker bees recognize an abnor- and the remaining colony materials (i.e., super boxes, lids, and mal larval or pupal cell either before or after capping, they will bottom) had their surfaces scorched with a torch before being clean and remove the diseased or dead larva or pupa, which can re-used in circulation. The last suspected case of AFB in this produce a scattered, “shotgun” appearance to the brood pattern operation was identified 3 y ago, and a clinical diagnosis was (Figure 1B) (19). Remaining cell cappings of affected larvae made by the Provincial Specialist in Apiculture at that time.

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Table 1. Summary of management variables from 4 commercial honey-bee operations in Saskatchewan diagnosed with a clinical outbreak of American foulbrood during the summer of 2019. Operation ID Management variable A B C D Total number of honey-producing colonies 4000 2700 2800 2100 CASE REPORT CASE Total number of bee yards 125 85 45 50 Number of affected yards 1 1 1 N/Ab Total number of colonies in affected yard 40 195 44 N/Ab Number of affected colonies in affected yard 1 1 1 7 Affected colony status Alive Alive Dead Dead Metaphylactic antibiotic use No Yes Yes Yes Antibiotic used — Oxytetracycline Oxytetracycline Oxytetracycline On-label antibiotic use? — No No Noc Frequency of brood inspection Spring and Spring and Overwinter loss, Spring and whenever weak whenever weak Spring and whenever weak whenever weak Who performs brood inspection Owner and staff Owner and staff Owner and staff Owner Proportion of brood frames inspected Few Few Few All Percentage of brood frames renewed annually 10% Over 50%a 10% Less than 5% Last suspected case of American foulbrood 25 years ago 3 years ago 3 years ago 1 year ago

a Estimated frame replacement proportion for new nucleus hives, from which the affected colony originated. b All colonies were overwintered together indoors and individual yard assignments were not tracked for nucleus colonies. c Fall treatment of oxytetracycline in 2018 was given as 2 applications, not 3. N/A — Not applicable.

Operation C of all brood frames 2 to 3 times each spring. Suspect colonies Unlike operations A and B, which had identified clinical signs were initially identified due to a noticeable malodor, and subse- in living colonies, Operation C identified a suspect colony dur- quent inspection of frames revealed capping abnormalities and ing its annual inspection of dead colonies that failed to survive the presence of scale. All identified colonies and frames were overwintering. Frames contained scattered, abnormal cappings destroyed by burning. The operation reported administering and adhered scale along the ventral aspect of numerous cells. oxytetracycline twice annually and adhering to label instruc- The Provincial Specialist in Apiculture was alerted, and the tions but noted that the fall treatment in 2018 was only given entire hive was burned. Similar to Operation B, this commercial as 2 applications instead of the label-prescribed 3. outfit reported a 3-year gap between this case of AFB and its last From all operations, only those frames with either visible suspected case. The previous case was identified by clinical signs larval scale or cells identified as positive for ropiness were col- observed by the operation owner alone without visual confirma- lected for bacterial culture. Scales were collected from affected tion by the Provincial Specialist. The owner of this operation frames, vortexed in sterile water, and subjected to heat treatment also noted that a nearby hobbyist had lost their colonies to to eliminate other microbial contaminants. Samples were plated AFB in 2013 but had left the hives out instead of having them on both Columbia sheep blood agar (CSA) (BD Biosciences, destroyed. There was a high likelihood of these contaminated San Jose, California, USA) and MYPGP [prepared according to colonies being robbed out by bees belonging to Operation C, published protocols (6,7)] and incubated at 37°C with 5% CO2 a behavior whereby foraging bees from strong hives will collect for 48 h. Plates were confirmed for lawns of colony growth (steal) unprotected honey within weak and dead hives and bring consistent with the high concentration of spores expected from it back into their hives. Operation C had therefore been using contaminated larval scale and with colony morphology consis- metaphylactic oxytetracycline, but only once annually in the tent with P. larvae (7). Two serial sub-cultures were performed spring since 2010 instead of the label-prescribed twice annual from these lawns to generate a pure culture. Colony growth treatments. from the second sub-culture was submitted to Prairie Diagnostic Services, Western College of Veterinary Medicine, University Operation D of Saskatchewan, Saskatoon, Saskatchewan, and tested using Operation D identified a total of 7 deceased nucleus colonies matrix-assisted laser desorption/ionization-time of flight mass suspected to have succumbed to AFB during examination of spectrometry (MALDI-TOF MS) with a pre-existing library its overwinter mortalities. This operation overwinters all of its for Paenibacillus larvae. Bacterial isolates from all operations colonies together indoors and performs rigorous inspection were positively identified as Paenibacillus larvae. An isolate

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from Operation A was confirmed as Paenibacillus larvae using associated with clinical outbreaks of AFB in antibiotic-managed both MALDI-TOF MS and PCR with primers designed by systems, Canadian veterinarians are uniquely poised to build Dobbelaere et al (22). Independent samples collected by the effective, working veterinary-client-patient relationships with Provincial Specialist in Apiculture were submitted to the Animal hobbyist and commercial beekeepers around communicating Health Laboratory, (University of Guelph, Guelph, Ontario) for the importance of on-label use of antibiotic therapy to minimize antimicrobial susceptibility testing by Kirby Bauer disk diffu- the likelihood of clinical disease and slow the development of sion following Canadian Laboratory Standards Institute (CLSI) antimicrobial resistance within the apiculture industry. VET06 guidelines. Isolates from all operations were confirmed Conversely, if beekeepers wish to cease the use of antibiot- to be susceptible to oxytetracycline. ics for metaphylactic control of AFB, veterinarians can be Follow-up with all 4 operations was performed following relied upon to consider this decision in an evidence-based routine fall inspections. All operations confirmed that they had manner through risk assessment, the testing of hive products, RAPPORTCAS DE detected no additional clinical evidence of AFB. Operation A and the implementation of frequent brood frame examination returned to metaphylactic, on-label use of oxytetracycline and to minimize the likelihood of occurrence of clinical disease. the 3 other operations had adjusted their metaphylactic antibi- Here, Operation A had discontinued the use of oxytetracycline otic protocols to follow label instructions. due to concern about the development of antimicrobial resistance and saw an emergence of clinical disease less than 3 y after Discussion cessation of treatment in an operation that had had no clinical The current landscape of AFB in Saskatchewan remains largely disease for the previous 25 y. It is suspected that the long-term unknown due to the long-term masking of disease through viability of bacterial spores, combined with a silent accumulation antibiotic metaphylaxis; outbreaks are difficult to predict. of spores through clinical masking with chronic antimicrobial Suppression of clinical disease can lead to a high build-up of use, can create a false sense of contamination-free colony status infectious spores within contaminated colonies, unknown to (24). Removing the suppressive effects of antimicrobials in these both hobbyists and commercial beekeepers applying treat- hives without an understanding of underlying contamination ment (17,23,24). In Saskatchewan, cases of AFB are identified of P. larvae spores and relevant risk factors could potentially be through a combination of random inspections and self-reporting disastrous. If antibiotic use is discontinued, then a rigorous health by beekeepers. Four outbreaks of AFB were reported in 2018, management plan must be in place that emphasizes frequent primarily among small-scale beekeepers and hobbyists. In 2019 and thorough examination of brood frames to improve the early the number of cases increased to 8, but were mostly seen in detection of disease and prompt destruction of affected colonies to commercial operations, 4 of which were investigated here. Many reduce the spread of AFB. This approach for control of AFB has factors associated with the pathogen, host, and environment been implemented in New Zealand and many European countries are thought to play a role in determining the development of and it is being adopted successfully by a few commercial beekeep- clinical disease, including strain virulence, the hygienic behavior ers in Saskatchewan and Alberta (10,23). Veterinarians again have of worker bees within a colony (social immunity), and basic an opportunity to educate and aid in the implementation of such management practices, respectively (7,25–27). How these factors plans, and can advocate the testing of hive products such as honey interplay in the presence of chronically treated colonies remains and bees to detect the presence of spores of P. larvae and the pres- unknown. Investigations of potential risk factors for disease ence of antimicrobial resistance that may influence the decision have helped to shed light on management practices critical to use antibiotic metaphylaxis or not (23,29). to American foulbrood management and control in countries Practitioners are advised to follow the procedures listed in such as New Zealand and Belgium, but because antibiotic use suspected AFB cases: in these regions is prohibited, the applicability of the results of i) Contact the Provincial Specialist in Apiculture to establish a these investigations to Saskatchewan and Canadian beekeeping working relationship with their team. Provincial apiculture is uncertain (10,27). teams are a valuable resource in both knowledge and skills With the recent regulatory changes on December 1, 2018, concerning beekeeping practices and the detection/diagnosis requiring all medically important antimicrobials for veterinary and management of honey-bee diseases. Strong collabora- use to be sold by prescription only, the current use of antibiotics tion is necessary for efficient prevention, early detection, and in the honey-bee industry must be re-evaluated, and Canadian optimal management of AFB. Provincial apiculturists also veterinarians have an opportunity to establish themselves as lead- perform a regulatory role to implement and enact provincial ers in the judicious use of antimicrobials in this industry (28). acts related to beekeeping. Common to all operations investigated here was the variability ii) Inspect the colony frames for presence of pathognomonic of approaches taken with regard to antibiotic use. Operation A signs: ropiness and/or scales. had discontinued antibiotic metaphylaxis in their management iii) Submit suspect frame(s) to an appropriate microbiology program, and although operations B, C, and D were using laboratory to confirm the presence of P. larvae. regular antibiotic metaphylaxis, all were doing so with different, iv) If a diagnosis of AFB is confirmed and is a notifiable disease off-label protocols. It is possible that the cessation of antibiot- within your province, report to the Chief Veterinary Officer ics in operation A, or under-dosing of antibiotic in the other within 24 h of laboratory diagnosis. operations, may have contributed to the clinical appearance of v) Burn affected colonies and equipment or irradiate exposed AFB. Until there is a better understanding of the risk factors equipment if this service is available. Treat the remaining

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colonies with antibiotics or implement frequent and rigorous 12. Melathopoulos A, Nelson D, Clark K. High velocity electron-beam inspections to identify and destroy bacteria in new cases at radiation of pollen and comb for the control of Paenibacillus larvae subspecies larvae and Ascosphaera apis. Am Bee J 2004;144:714–720. early stages to prevent spread of the disease. 13. Lodesani M, Costa C. Limits of chemotherapy in beekeeping: Development of resistance and the problem of residues. Bee World Acknowledgments 2005;86:102–109. 14. Hitchcock JD, Moffett JO, Lackett JJ, Elliott JR. Tylosin for control The authors thank Sarah Barnsley, Jocelyne Chalifour, Marina of American foulbrood disease in honey bees. J Econ Entomol 1970; REPORT CASE Carla Bezerra de Silva, and Juliana Sartori Lunardi for their 63:204–207. assistance with collection and processing of samples. Additional 15. Miyagi T, Peng CYS, Chuang RY, Mussen EC, Spivak MS, Doi RH. Verification of oxytetracycline-resistant American foulbrood thanks to Patricia Wolf Veiga (National Bee Diagnostic Centre), pathogen Paenibacillus larvae in the United States. J Invertebr Pathol Dr. Durda Slavic (Animal Health Laboratory, University of 2000;75:95–96. Guelph), Dr. Musangu Ngeleka and Lilian Fernandez (Prairie 16. Evans JD. Diverse origins of tetracycline resistance in the honey bee bacterial pathogen Paenibacillus larvae. J Invertebr Pathol 2003;83:46–50. Diagnostic Services) for their assistance with the development of 17. Alippi AM, López AC, Reynaldi FJ, Grasso DH, Aguilar OM. Evidence for culture protocols and MALDI-TOF MS identification. Finally, plasmid-mediated tetracycline resistance in Paenibacillus larvae, the causal thank you to beekeepers who allowed us to use their data in agent of American Foulbrood (AFB) disease in honeybees. Vet Microbiol 2007;125:290–303. this manuscript, but who shall remain anonymous to preserve 18. Shimanuki H, Knox DA. Diagnosis of honey bee diseases. Beltsville, confidentiality. Maryland: U.S. Department of Agriculture; 2000. This research was supported by the Saskatchewan 19. Brødsgaard CJ, Hansen H, Ritter W. Progress of Paenibacillus larvae infection in individually inoculated honey bee larvae reared singly Development Agriculture Fund (20180249), Mitacs, the in vitro, in micro colonies, or in full-size colonies. J Apic Res 2000; Saskatchewan Beekeepers Development Commission, and the 39:19–27. WCVM Interprovincial Graduate Fellowship (personal support 20. Dingman DW, Stahly DP. Medium promoting sporulation of Bacillus larvae and metabolism of medium components. Appl Environ Microbiol for M.Z.). CVJ 1983;46:860–869. 21. Nordström S, Fries I. A comparison of media and cultural conditions for References identification of Bacillus larvae in honey. J Apic Res 1995;34:97–103. 22. Dobbelaere W, de Graff DC, Peeters J, Jacobs F. Development of a 1. Bamrick JF. Resistance to American foulbrood in honey bees: VI. Spore fast and reliable diagnostic method for American foulbrood disease germination in larvae of different ages. J Invertebr Pathol 1967;9:30–34. (Paenibacillus larvae subsp. larvae) using a 16S rRNA gene based PCR. 2. Pernal SF, Clay H. American foulbrood. In: Honey Bee Diseases and Apidologie 2001;32:363–370. Pests. 3rd ed. Beaverlodge, Alberta: Canadian Association of Professional 23. Von der Ohe W, Dustmann JH. Efficient prophylactic measures against Apiculturists, 2013:5–10. American foulbrood by bacteriological analysis of honey for spore con- 3. Sturtevant AP. Relation of commercial honey to the spread of American tamination. Am Bee J 1997;137:603–606. foulbrood. J Agric Res 1932;45:257–285. 24. Oldroyd BP, Goodman RD, Hornitzky MAZ, Chandler D. The effect 4. Bzdil J. Detection of Paenibacillus larvae spores in the debris and wax of on American foulbrood of standard oxytetracycline hydrochloride honey bee by the Tween 80 method. Acta Vet Brno 2007;76:643–648. treatments for the control of European foulbrood of honeybees (Apis 5. Lindström A, Korpela S, Fries I. Horizontal transmission of Paenibacillus mellifera). Aust J Agric Res 1989;40:691–697. larvae spores between honey bee (Apis mellifera) colonies through rob- 25. Genersch E, Ashiralieva A, Fries I. Strain- and genotype-specific dif- bing. Apidologie 2008;39:515–522. ferences in virulence of Paenibacillus larvae subsp. larvae, a bacterial 6. de Graaf DC, Alippi AM, Antúnez K, et al. Standard methods for pathogen causing American foulbrood disease in honeybees. Appl American foulbrood research. J Apic Res 2013;52:1–28. Environ Microbiol 2005;71:7551–7555. 7. Alippi A. American foulbrood of honey bees (infection of honey bees 26. Spivak M, Reuter GS. Resistance to American foulbrood disease by with Paenibacillus larvae). In: Manual of Diagnostic Tests and Vaccines honey bee colonies Apis mellifera bred for hygienic behavior. Apidologie for Terrestrial Animals. Paris, France: World Organisation for Animal 2001;32:555–565. Health, 2019:719–735. 27. de Graaf DC, Vandekerchove D, Dobbelaere W, Peeters JE, Jacobs FJ. 8. Hasemann L. How long can spores of American foulbrood live? Am Bee Influence of the proximity of American foulbrood cases and apicultural J 1961;101:298–299. management on the prevalence of Paenibacillus larvae spores in Belgian 9. Dobbelaere W, De Graaf DC, Reybroeck W, Desmedt E, Peeters JE, honey. Apidologie 2001;32:587–599. Jacobs FJ. Disinfection of wooden structures contaminated with 28. Government of Canada. Responsible use of Medically Important Paenibacillus larvae subsp. larvae spores. J Appl Microbiol 2001; Antimicrobials in Animals [Internet]. aem. 2017 [2019 Oct 5]. Available 91:212–216. from: https://www.canada.ca/en/public-health/services/antibiotic- 10. Goodwin M. Elimination of American foulbrood disease without the antimicrobial-resistance/animals/actions/responsible-use-antimicrobials. use of drugs. A practical manual for beekeepers. Revised. Wellington, html Last accessed July 29, 2020. New Zealand: National Beekeepers’ Association of New Zealand, 2006. 29. Pernal SF, Melathopoulos AP. Monitoring for American foulbrood spores 11. Alonso-Salces RM, Cugnata NM, Guaspari E, et al. Natural strategies from honey and bee samples in Canada. Apiacta 2006;41:99–109. for the control of Paenibacillus larvae, the causative agent of American foulbrood in honey bees: A review. Apidologie 2017;48:387–400.

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Primary hyperlipidemia with associated ischemic strokes in a West Highland white terrier dog

Stephen Everest, Gibrann Castillo, Luis Gaitero

Abstract — A 3-year-old spayed female, West Highland white terrier dog was evaluated because of a 4-month history of recurrent brain clinical signs. Magnetic resonance imaging (MRI) revealed multifocal brain lesions consistent with ischemic injuries. Blood analysis was unremarkable aside from severe hypertriglyceridemia and hypercholesterolemia with no underlying cause, suggesting primary hyperlipidemia. The patient was treated for hyperlipidemia and started on a low-fat diet and omega-3 supplementation. Clinical signs resolved over the following 12 months along with improvement in lipidemia. This represents the first reported case of MRI findings suggestive of multiple cerebrovascular injuries associated with primary hyperlipidemia in a dog, and the first primary hyperlipidemia reported in a West Highland white terrier dog.

Résumé — Hyperlipidémie primaire associée à des accidents vasculaires cérébraux ischémiques chez un chien terrier West Highland white. Une femelle stérilisée West Highland white âgée de 3 ans fut évaluée à cause d’une histoire de signes cliniques cérébraux récurrents d’une durée de 4 mois. Une imagerie par résonnance magnétique (RMI) révéla des lésions cérébrales multifocales compatibles avec des blessures ischémiques. Une analyse sanguine s’avéra peu concluante sauf pour une hypertriglycéridémie et une hypercholestérolémie sévère sans cause sous-jacente, suggérant une hyperlipidémie primaire. Le patient fut traité pour l’hyperlipidémie et débuta une diète faible en gras et une supplémentation en oméga-3. Les signes cliniques se sont résolus dans les 12 mois suivants avec une amélioration de la lipidémie. Ceci représente le premier cas rapporté de trouvailles par MRI suggestives de lésions cérébro-vasculaires multiples associées avec une hyperlipidémie primaire chez un chien, et le premier cas d’hyperlipidémie primaire rapporté chez un terrier West Highland white. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1060–1064

Case description sided head tilt, spontaneous nystagmus, and circling to the left. These signs again improved without intervention. A subsequent, 3-year-old spayed female, West Highland white terrier dog, more severe episode occurred 1 wk before presentation, which which had been in her owner’s possession since she was A prompted the owners to investigate further. On presentation, a puppy, was presented for evaluation because of a 4-month the dog showed similar clinical signs to those mentioned before; history of right-sided head tilt and circling to the left. Previous however, these were noted to be more severe by the owners. medical history included 1 episode of walking diagonally in an The owners also observed that the dog had developed ptyalism, unusual manner. The dog was also noted to have been particu- which was a novel clinical sign at this point. larly clumsy from a young age, but had otherwise been healthy. A physical examination revealed a body condition score of These clinical signs mostly resolved over the following few 7 out of 9, but was otherwise unremarkable, and no hyperten- days; however, she had a milder, persistent head tilt. A repeat sion was noted. On neurological examination the dog was quiet, episode occurred 1 mo later, with the same clinical signs: right- but responded appropriately to stimuli. No obvious ataxia or paresis was present, but there was a right-sided head tilt and left Ontario Veterinary College Health Science Centre (Everest), pleurothotonus. The dog would also stop intermittently when Department of Clinical Studies (Castillo, Gaitero), University walking and turn to the left in a tight circle. There were no of Guelph, Guelph, Ontario. cranial nerve deficits other than absent menace response on the Address all correspondence to Dr. Luis Gaitero; e-mail: right side. Postural reactions were mildly delayed in both right [email protected] limbs, but normal in both left limbs. Spinal reflexes and noci- Use of this article is limited to a single copy for personal study. ception were normal, and there was no pain response elicited on Anyone interested in obtaining reprints should contact the spinal palpation or cervical manipulation. Based on the neuro- CVMA office ([email protected]) for additional logical examination, it was determined that there were lesions copies or permission to use this material elsewhere. localized to the left forebrain and the cerebellovestibular system,

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hyperlipidemia. An ACTH stimulation test and thyroid panel were both normal, ruling out hypothyroidism and hyperadre- nocorticism. Based on this information, primary hyperlipidemia was suspected. Abdominal ultrasound was considered, but ultimately not performed due to lack of indication based on blood

analysis and physical examination. REPORT CASE The dog underwent general anesthesia and a magnetic resonance imaging (MRI) study of the brain revealed multifocal intra-axial lesions (Figure 1). One of these was a well-circumscribed oval lesion at the level of the left caudate nucleus, which was 0.65 cm  0.7 cm, mildly T2 hyperintense, with a prominent T2 hyperintense rim. There was a slightly T1 hyperintense lesion adjacent to this, extending caudally into the thalamus. The left piriform lobe showed moderate T2 hyperintense and T1 hypointense heterogenicity, with a poorly defined, slightly hypointense, wedge-shaped lesion. The last lesion was a wedge-shaped T2 hyperintense, and mildly T1 hyperintense, heterogenous lesion affecting the dorsolateral parietal cerebral cortex (Figures 1E, F). This lesion was much more prominent on the T2W sequence and could be visualized running medially from the dorsolateral border of the parietal cerebral cortex. Only the most medial aspect of this lesion could be clearly visualized on the T1W sequence. All lesions were mildly contrast enhancing. It was also noted that the lesion at the level of the caudate nucleus showed restricted diffusion (bright or hyperintense signal) on diffusion weighted imaging (DWI) and was hypointense on apparent diffusion coefficient (ADC) map Figure 1. A—T1W transverse MRI showing a mildly T1 MRI sequences, suggestive of ischemic stroke (Figures 1C, D). hyperintense lesion at the level of the caudate nucleus and a mildly hypointense lesion at the level of the left piriform lobe The appearance of the lesions suggested that they could have (indicated by arrows). B—T2W transverse MRI showing T2 been the result of multiple ischemic accidents, which could hyperintense, heterogeneous lesions at the level of the left be associated with metabolic causes (e.g., hypothyroidism, pirifom lobe and a slightly T2 hyperintense lesion surrounded by a strongly T2 hyperintense rim at the level of the caudate hypoadrenocorticism, hypercoagulable state, or protein-losing nucleus. C—DWI MRI showing a hyperintense lesion surrounded nephropathy), infectious/inflammatory causes (e.g., vasculitis by a less hyperintense rim at the level of the caudate nucleus. or septic thromboembolism), parasitic emboli, migrating para- D—ADC MRI showing a hypointense lesion surrounded by a hyperintense rim at the level of the caudate nucleus. E—T2W sites or neoplastic conditions (e.g., intravascular lymphoma or FLAIR MRI showing a heterogeneous, wedge shaped, T2 metastatic thromboembolism). Given the T1 hyperintensity hyperintense lesion at the dorsolateral aspect of the left parietal and known hyperlipidemia, it was thought lipid deposition lobe. F—T1W MRI showing a mildly T1 hyperintense lesion at the dorsolateral aspect of the left parietal lobe. within the infarcts could also be a possibility. Cerebrospinal fluid (CSF) was collected and analysis revealed a mononuclear pleocytosis with a cell count of 0.006  109/L [reference range (RR):  0.005  109/L] and a borderline elevated CSF protein level of 0.31 g/L (RR:  0.3 g/L). Thromboelastography was with differential diagnoses including cerebrovascular accidents, also performed and revealed the patient to be mildly hyperco- meningitis of unknown etiology (MUE) or, less likely, neoplasia. agulable, with a coagulation index of 3.2 (RR: 3 to 3). A complete blood (cell) count (CBC) and serum biochemis- The dog was discharged on a low-fat diet to attempt to reduce try were performed. The CBC revealed markedly elevated total her hyperlipidemia. At recheck 2 wk after initial presentation, solids (TS)/protein of 102 g/L [reference range (RR): 55 to the dog’s owners reported that her neurological clinical signs 75 g/L] but no other abnormalities. Biochemistry revealed were much improved. Blood analysis was repeated at that time a marked hypercholesterolemia of 49.95 mmol/L (RR: 3.60 and revealed that the patient was still markedly hyperlipid- to 10.20 mmol/L). The rest of the biochemistry profile was emic, with a blood cholesterol of 42.09 mmol/L (RR: 3.60 unremarkable. A thyroid panel, fasting cholesterol/triglyceride to 10.20 mmol/L) and triglycerides of 4.3 mmol/L (RR: 0.2 panel and an adrenocorticotropic hormone (ACTH) stimula- to 1.3 mmol/L). The dog was continued on the low-fat diet. tion test were performed to determine whether the hypercho- Since it was noted that transitioning to this diet had not had lesterolemia was primary, or secondary to an underlying cause. a significant impact on the dog’s hyperlipidemia, the dog was Fasting cholesterol/triglyceride panel confirmed hypercholester- started on omega-3 fatty acids supplementation. olemia (41.07 mmol/L) and also revealed hypertriglyceridemia By her following recheck, 8 mo after initial presentation, the (3.4 mmol/L, RR: 0.2 to 1.3 mmol/L) indicating a general dog’s clinical signs had almost completely resolved, with only

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a mild head tilt noted on occasion. Omega-3 fatty acids supple- suggesting primary hyperlipidemia. In humans, familial hyper- mentation was continued. cholesterolemia is attributed to approximately 2% of cases Cholesterol and triglyceride levels were rechecked approxi- of hypercholesterolemia in the population, with 15% being mately 1 y after initial development of clinical signs. Both attributed to primary hypercholesterolemia in general (5). were still elevated; however, there had been a marked decrease Three main mechanisms are suspected to be responsible for in the dog’s hypercholesterolemia, with a blood cholesterol of the remaining cases: hepatic overproduction of lipoproteins, 18.34 mmol/L (RR: 3.60 to 10.20 mmol/L). Triglycerides, how- reduced affinity of LDL for their receptors, and reduced LDL ever, had increased, with a reading of 5.5 mmol/L (RR: 0.2 to receptor activity (5,6). 1.3 mmol/L). The dog was to be continued on her low-fat diet Although primary hyperlipidemia is relatively common in and was prescribed bezafibrate [50 mg; approximately 6 mg/kg humans, it is very rare in dogs. There is a familial component, body weight (BW) q24h] to help control her hyperlipidemia. with miniature schnauzers first being implicated as a predis- RAPPORTCAS DE She was discharged, with regular monitoring of her cholesterol posed breed by Rogers et al (7) who noted hypertriglyceridemia and triglyceride concentrations to continue at the hospital. in 6 dogs, 5 of which were miniature schnauzers. Since then, Neurological examination at time of discharge confirmed that numerous studies have found hypertriglyceridemia with or her clinical signs had completely resolved. without concurrent hypercholesterolemia to be overrepresented in this breed (8–10). Although there have been associations Discussion noted with other breeds (beagles, Labradors, Shetland sheep- The case of a dog which developed recurrent neurological signs dogs, Briards, rough collies, and poodles) (11–13), a familial with concurrent severe hypercholesterolemia and hypertriglyceri- predisposition in West Highland white terriers has not been demia is described in this report. However, no underlying cause noted in the literature. for this hyperlipidemia could be identified. The thyroid panel As in humans, there appears to be an increased incidence of ruled out hypothyroidism and an ACTH stimulation test ruled cerebrovascular events in dogs with hyperlipidemia; however, in out hypoadrenocorticism. Serum biochemistry did not reveal previous case reports and studies this has either been secondary, any evidence of hepatic damage, insufficiency, or cholestasis and or due to familial hyperlipidemia. Patterson et al (14) reported there was no evidence of pancreatitis or other pancreatic issues. on a 6-year-old, obese, spayed doberman pinscher which was Abdominal ultrasound was not performed as there was no indi- presented because of a 1-day history of seizures. The dog also cation for further diagnostics at the time. Retrospectively, this had a long history of intermittent bouts of ataxia, circling, may have been valuable to confirm the absence of gross changes and head tilt. This dog had multifocal lesion localization, and to the patient’s liver and pancreas. There was also no history of died 2 d after presentation despite adequate control of seizures urinary abnormalities and no evidence of renal disease on blood using phenobarbital. On necropsy, generalized atherosclerosis analysis. The dog was not on any medications at the time of was noted, along with cortical laminar necrosis, acute vasculitis presentation. Diabetes mellitus and recent ingestion of a high-fat within the cerebrum, and congestive heart failure. This was meal were considered as other potential causes of hyperlipidemia. consistent with severe hypoxic, ischemic injuries to the cerebrum Diabetes mellitus was ruled out because the dog never showed (strokes), most likely secondary to vascular occlusion as a result any evidence of hyperglycemia or other clinical signs suggestive of cerebrovascular atherosclerosis. Severe follicular atrophy of the of this. Additionally, the patient was fasted for at least 12 h before thyroid gland supported hypothyroidism as the primary disease blood sampling on each occasion, ruling out recent ingestion of process. This case had many similarities to one reported by Blois a high-fat meal. On this basis, all known causes of secondary et al (15), who described an obese, 2-year-old male, castrated hyperlipidemia were ruled out, suggesting a primary hyperlip- Australian shepherd dog which was presented with multifocal idemia as the underlying etiology for the patient’s clinical signs. neurological deficits. Blood analysis revealed a marked hyper- West Highland white terriers have no known familial predisposi- cholesterolemia of 25.38 mmol/L (RR: 3.6 to 10.2 mmol/L), tion to hyperlipidemia, making this the first report of such a case. as well as a mild non-regenerative anemia. The dog was ulti- The dog in this case had neurological signs and MRI findings mately euthanized due to multiple neurological deficits, with consistent with multiple ischemic strokes and blood analysis necropsy revealing marked atrophy of both lobes of the thyroid revealing a severe hypercholesterolemia, with levels 4 to 5 times gland and generalized atherosclerosis of vasculature supplying the upper end of the reference range. This correlates with the the cerebrum, brainstem, and cervical spinal cord. literature in human medicine, in which it has long been demon- Vitale and Olby (16) also noted neurological signs secondary strated that there is a strong positive correlation between stroke to severe hyperlipidemia associated with primary hyperlipid- incidence and hypercholesterolemia. In particular, it has been emia. Vitale and Olby (16) studied the medical records of 4 dogs, shown that a reduction in low-density lipoprotein (LDL) cho- 3 of which were Labrador retrievers, and another a Labrador lesterol of 1 mmol/L can reduce the incidence of major coronary cross. Each had severe hypertriglyceridemia with concurrent events, coronary revascularization, and stroke by approximately severe hypercholesterolemia and neurological signs. Two of these 20% over a 5-year period (1). An association has also been noted dogs exhibited chronic neurological signs, whereas the other between total cholesterol (TC)/high-density lipoprotein (HDL-C) 2 had more acute onset signs, which resolved. Each showed dif- ratio and recurrence of embolic stroke (2–4). ferent clinical signs and lesion localizations, with the 1 common The patient in this case was presented with severe hyperlip- clinical sign being lethargy. Interestingly, in these 4 cases, idemia, with no underlying cause found on diagnostic tests, hypercholesterolemia was more severe than in previous studies,

1062 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY with mean serum cholesterol concentration of 1568 mg/dL with recurrent neurological signs localizing to multifocal regions (40.55 mmol/L) (14) compared to 417 mg/dL (10.78 mmol/L) in the brain, similar to the dogs mentioned in case reports by (17), and 11.4 mmol/L (18) in other studies. Chikamune et al Patterson et al (14), Vitale and Olby (16), and Blois et al (15) as (17) and Dixon et al (18) studied the association between well as the study conducted by Liu et al (19). Unlike the dogs in obesity and hyperlipidemia in dogs, and hypothyroidism and these previous studies, the patient discussed in this study had no hyperlipidemia in dogs, respectively. Both studies compared known breed predisposition to hypothyroidism. The MRI and REPORT CASE serum triglyceride concentrations and clinical signs among clinical signs were in accordance with ischemic vascular injury to populations. Neurological signs were not noted in either of these the brain and clinical signs reported in case reports and studies studies; however, the mean serum cholesterol levels in reports of neurological issues in dogs with secondary hyperlipidemia. were much lower than in the study performed by Vitale and In conclusion, this appears to be the first reported case of Olby (16). Interestingly, the dog herein had a serum cholesterol MRI findings suggestive of multiple cerebrovascular injuries concentration of 41.07 mmol/L, which was similar in severity to associated with primary hyperlipidemia in a dog and the first the cases in Vitale and Olby’s study (16). This suggests that, as primary hyperlipidemia reported in a West Highland white in humans, the severity of hyperlipidemia positively correlates terrier dog. Cholesterol and triglyceride blood levels should be with incidence of vascular injury as these neurological signs only evaluated in cases of suspected cerebrovascular ischemic injury appear to be described in dogs with severe hyperlipidemia, but since, despite being much less common, primary hyperlipidemia not in milder cases. can be associated with cerebrovascular incidents in dogs as well Finally, a study carried out by Liu et al (19) looked at nec- as humans. CVJ ropsies of 21 dogs from 1970 to 1983, all of which had ath- References erosclerosis, and most of which had had hypercholesterolemia, 1. Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol- hypertriglyceridemia, and hypothyroidism noted on ante-mortem lowering treatment: Prospective meta-analysis of data from 90,056 par- blood analysis. Among the most common clinical signs seen across ticipants in 14 randomised trials of statins. Lancet 2005;8:1267–1278. these dogs was collapse, due to neurological or cardiopulmonary 2. De la Riva P, Zubikarai M, Sarasqueta C, et al. Nontraditional lipid variables predict recurrent brain ischemia in embolic stroke of undeter- pathology. On necropsy, atherosclerosis was seen to have affected mined source. J Stroke Cerebrovasc Dis 2017;26:1670–1677. arteries in multiple locations, including cerebral arteries. This 3. Pikula A, Beiser AS, Wang J, et al. Lipid and lipoprotein measurements study also suggests that neurological signs, or at least neurological and the risk of ischemic vascular events: Framingham Study. Neurology 2015;84:472–479. pathology, are associated with hyperlipidemia and atherosclerosis. 4. Liu X, Yan L, Xue F. The associations of lipids and lipid ratios with Although atherosclerosis could not be confirmed in the patient stroke: A prospective cohort study. J Clin Hypertens 2018;21:127–135. in this report, MRI images revealed multifocal lesions consistent 5. Vega DL, Grundy SM. Mechanisms of primary hypercholesterolemia in humans. Am Heart J 1987;113:493. with ischemic stroke within the telencephalon and diencepha- 6. Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction lon. This was associated with marked hypercholesterolemia and of atherosclerotic disease. New perspectives in the Framingham study. hypertriglyceridemia confirmed on blood analysis, similar to the Ann Intern Med 1979;90:85. 7. Rogers WA, Donovan EF, Kociba GJ. Idiopathic hyperlipoproteinemia dogs mentioned in the study by Liu et al (19). in dogs. J Am Vet Med Assoc 1975;166:1087–1091. The neurological examination localized multifocal intra-axial 8. Ford RB. Idiopathic hyperchylomicronemia in miniature schnauzers. forebrain lesions, which were confirmed on MRI. It was noted J Small Anim Pract 1993;34:488–492. 9. Whitney MS. Evaluation of hyperlipidemias in dogs and cats. Semin that there were no brain stem or cerebellar lesions, which could Vet Med Surg (Small Anim) 1992;7:292–300. have accounted for the head tilt and nystagmus that were noted. 10. Whitney MS, Boon GD, Rebar AH, Story JA, Bottoms GD. Ultracentrifugal and electrophoretic characteristics of the plasma Vestibulocerebellar signs such as these, however, have been previ- lipoproteins of miniature schnauzer dogs with idiopathic hyperlipo- ously reported in association with thalamic or midbrain lesions proteinemia. J Vet Intern Med 1993;7:253–260. such as those described in this case (20). It has been inferred 11. Jeusette I, Grauwels M, Cuvelier C, Tonglet C, Istasse L, Diez M. Hypercholesterolaemia in a family of rough collie dogs. J Small Anim by Wijesinghe et al (21) that the thalamus plays a key role in Pract 2006;4:319–324. processing of vestibular information, and integration of other 12. Watson P, Simpson KW, Bedford PGC. Hypercholesterolaemia in sensory inputs. A study performed by Kirsch et al (22) describ- briards in the United Kingdom. Vet Sci 1993;54:80-85. 13. Sato K, Agoh H, Kaneshige T, Hikasa W, Kagota K. Hypercholes- ing multiple projections, which course from the vestibular nuclei terolemia in Shetland sheepdogs. J Vet Med Sci 2000;60:1297–1301. to the thalamus, support this theory. Given the close association 14. Patterson JS, Rusley MS, Zachary JF. Neurologic manifestations between the thalamus and vestibulocerebellar system, it makes of cerebrovascular atherosclerosis associated with primary hypothyroidism in a dog. J Am Vet Med Assoc 1985;186:499–503. sense that thalamic lesions could present with vestibulocerebellar 15. Blois SL, Poma R, Stalker MJ, Allen DG. A case of primary hypo- signs, as has previously been described in human patients. Saiki thyroidism causing central nervous system atherosclerosis in a dog. et al (23) described 2 patients, both of whom presented with Can Vet J 2008;49:789–792. 16. Vitale CL, Olby NJ. Neurologic dysfunction in hypothyroid, hyper- loss of balance and astasia, amongst other neurological signs. lipidemic Labrador retrievers. J Vet Intern Med 2007;21:1316–1322. Magnetic resonance imaging in these cases revealed lesions in 17. Chikamune T, Katamoto H, Ohashi F, Shimada Y. Serum-lipid and the ventrolateral thalamus, which had terminated fibers from lipoprotein concentrations in obese dogs. J Vet Med Sci 1995;60: 413–421. the vestibulocerebellum. Despite these being human cases, 18. Dixon RM, Reid SWJ, Mooney CT. Epidemiological, clinical, haema- it could be inferred that a similar mechanism was responsible tological and biochemical characteristics of canine hypothyroidism. for the clinical signs shown by the dog reported in this case. Vet Rec 1999;145:481–487. 19. Liu SK, Tilley LP, Tappe JP, Fox PR. Clinical and pathologic findings in The appearance of these lesions on MRI was suggestive of dogs with atherosclerosis: 21 cases (1970–1983). J Am Vet Med Assoc ischemic vascular injuries (i.e., stroke). This dog was presented 1986;189:227–232.

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20. Garosi L, McConnell JF, Platt SR, et al. Clinical and topographic mag- 22. Kirsch V, Keeser D, Hergenroeder T, et al. Structural and functional netic resonance characteristics of suspected brain infarction in 40 dogs. connectivity mapping of the vestibular circuitry from human brainstem J Vet Intern Med 2008;2:311–321. to cortex. Brain Struct Funct 2016;221:1291–1308. 21. Wijesinghe R, Protti DA, Camp AJ. Vestibular interactions in the thala- 23. Saiki S, Yoshioka A, Yamaya Y, Kanemoto M, Hirose G. Two cases mus. Front Neural Circuits 2015;9:79. of thalamic infarction presenting with “thalamic astasia.” Rinsho Shinkeigaku 2000;40:383–387.

Book Review RAPPORTCAS DE Compte rendu de livre

The Story of Lexi, and a Dream that Following Trish’s passing, and without overdoing the anthro- Follows Her pomorphism we learn that Lexi is saddened by the loss of her “mom,” and she has difficulty dealing with the move from the Wild M. Tellwell Talent. Victoria, British Columbia. 2018. 66 pp. northern prairie to the northwest rainforest with her new family. ISBN: 9781-7737-0772-3 (Hardcover), 9781-7737-0771-6 Soon enough Lexi becomes well integrated into her new com- (paperback). munity of family, friends, and other pets. When Lexi is 10 years of age, she begins to cough and wheeze he Story of Lexi, and a Dream that Follows Her, is a and become lethargic. She rallies for a few days, but then the T book for children dealing with the mutual love between symptoms return, and soon after Lexi and Aunty-Mom arrive people and their pets and the sense of loss when one of them at the animal hospital Lexi dies. dies. Around the time that Trish dies and again the morning that We are first introduced to Lexi, a miniature schnauzer, with Lexi dies, Rico has dreams in which he sees his mom as a form- her photograph on the cover of the book where she sits quietly less deity surrounded by fog. Although he can’t see clearly, he in a field of white and pink clover. There are a few other photos knows that he is seeing Trish and Lexi reunited, and he is com- of Lexi in the book but most of the time she is represented by forted by this. The book is dedicated to Lexi and Trish, and to adorable illustrations drawn by Paul Grignon. This animation all those beloved ones we have lost — 2 legged and 4 legged — technique allows Lexi to “come alive” on the page. as they disappeared into the “Greater Mystery.” We are also introduced to Lexi’s human companions Trish This is a lovely and comforting book that can be appreciated by and her son Rico, who adopted Lexi as a puppy, and Maureen children and adults. My only hesitation about recommending this (the author) who is called “Aunty-Mom” who adopts Lexi when book as supportive material in your veterinary clinic is the appar- sadly, Trish dies. ent lack of veterinary follow-up after Lexi was diagnosed with a When Lexi is 7 years old Trish discovers that Lexi has dental significant heart murmur at 7 years of age to what presented as an disease and needs 20 extractions. Trish notes that dogs have acute cardiovascular collapse and sudden death at 10 years of age. 42 teeth and following the extractions Lexi still has 22 teeth… lucky for her!! We also discover that Lexi has a loud heart Reviewed by Dr. Michael Zigler, DVM, MScIAH, RCVS Adv. murmur, and that she may need heart medicine in the future. Pract. Vet. Ophth., Toronto, Ontario.

1064 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Article

Factors associated with the adoption of technologies by the Canadian dairy industry

Murray D. Jelinski, David F. Kelton, Chris Luby, Cheryl Waldner

Abstract — Data generated from Statistics Canada’s 2016 Census of Agriculture and Census of Population were used to describe the adoption of 8 technologies by the Canadian dairy industry: computer/laptop, smartphone/ tablet, auto-steering, auto-feeding, auto-environment, robotic milking, global positioning systems (GPS), and geographical information systems (GIS). Logistic regression was used to analyze the adoption of each technology by geographical region, operators’ gender, operators’ age, herd size, and number of operators per farm. Gender and age were marginally related to the level of adoption of each technology, whereas the number of operators per dairy farm and farm size were associated with increased adoption of most technologies. Quebec had the smallest average farm size, but the highest levels of adoption for 5 of 8 technologies.

Résumé — Facteurs associés avec l’adoption des technologies par l’industrie laitière canadienne. Les données générées par le Recensement de la population et le Recensement de l’agriculture de 2016 de Statistiques Canada furent utilisées pour décrire l’adoption de huit technologies par l’industrie laitière canadienne : ordinateur/portable, téléphone intelligent/tablette, assistant à la navigation, alimentation automatique, environnement automatisé, traite robotisée, système de positionnement global (GPS), et système d’information géographique (GIS). Une régression logistique fut utilisée pour analyser l’adoption de chaque technologie par région géographique, sexe de l’opérateur, l’âge de l’opérateur, taille du troupeau, et nombre d’opérateurs par ferme. Le sexe et l’âge étaient reliés de manière marginale au degré d’adoption de chaque technologie, alors que le nombre d’opérateurs par ferme et la taille de la ferme étaient associés avec une augmentation de l’adoption de la plupart des technologies. Le Québec avait la taille moyenne des fermes la plus petite, mais le niveau d’adoption le plus élevé pour cinq des huit technologies. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1065–1072

Introduction technologies. On this point, several terms such as precision agriculture, precision farming, and smart farming have entered the he dairy industry has a long history of supporting research agricultural lexicon to describe the use of technologies. One pro- dedicated to nutrition, management practices, and tech- T posed definition of precision dairy farming is “the use of informa- nologies. Exemplars are the Journal of Dairy Science, a journal tion and communication technologies for improved control of fine- that has been in existence for more than 100 years (1), and the scale animal and physical resource variability to optimise economic, Society of Dairy Technology, which has been publishing on social and environmental dairy farm performance” (3). Regardless advances in dairy technologies since 1943 (2). Furthermore, of the definitions or the terminology used, precision or smart agricultural conferences on precision livestock farming fre- agricultural technologies are comprised of both information quently have sessions dedicated to new and innovative dairy and communication technology (ICT) and decision support systems (DSSs). The ICT component includes data acquisition (sensors), recording, and the communication of information, Department of Large Animal Clinical Sciences, Western College while the DSSs are software systems that interface with operators of Veterinary Medicine, University of Saskatchewan, Saskatoon, to inform management’s decision-making process (3,4). While Saskatchewan S7N 5B4 (Jelinski, Luby, Waldner); Department precision dairy farming is frequently categorized as the utiliza- of Population Medicine, University of Guelph, Guelph, Ontario tion of “Big Data,” these terms are not synonymous because N1G 2W1 (Kelton). precision dairy farming lacks some of the central components Address all correspondence to Dr. Murray Jelinski; e-mail: for fulfilling the definition of Big Data, namely the volume, [email protected] variety, and velocity of the data (5). Currently, much of the Use of this article is limited to a single copy for personal study. data are generated from individual animals; however, to fulfill Anyone interested in obtaining reprints should contact the the volume and variety criteria more data must be generated CVMA office ([email protected]) for additional and integrated across a broad population of animals, farms, as copies or permission to use this material elsewhere. well as milk processors, retailers, and consumers. This will be

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Table 1. Proportion and 95% confidence interval (95% CI) of producers who were using computers and/or laptops, stratified by region, number of operators/herd, gender, age, and herd size (breeding heifers and cows) and absolute differences in proportions among groups. 95% CI 95% CI Difference from Mean Lower Upper reference group Lower Upper P-value Region , 0.001 Atlantic 0.69 0.66 0.73 20.04 20.04 20.03 , 0.001 Ontario 0.68 0.63 0.73 20.05 20.07 20.03 , 0.001 Quebec 0.74 0.69 0.79 0.01 0.00 0.03 0.121 Western Canada 0.73 0.69 0.77 Reference ARTICLE Operators 1 Operator 0.64 0.58 0.71 20.13 20.17 20.09 , 0.001 $ 2 Operators 0.77 0.74 0.80 Reference Gender Female 0.70 0.65 0.75 20.02 20.05 0.00 0.080 Male 0.72 0.68 0.76 Reference Operator age (years) , 0.001 # 30 0.69 0.63 0.75 0.05 20.06 0.15 0.397 31 to 40 0.75 0.73 0.77 0.11 0.04 0.17 0.002 41 to 50 0.73 0.70 0.77 0.09 0.04 0.14 , 0.001 51 to 60 0.73 0.64 0.81 0.08 0.07 0.09 , 0.001 $ 61 0.65 0.56 0.72 Reference Herd size # 50 0.50 0.46 0.54 20.19 20.30 20.08 0.001 51 to 100 0.72 0.68 0.75 0.03 20.08 0.13 0.617 101 to 200 0.83 0.79 0.86 0.14 0.07 0.21 , 0.001 201 to 300 0.79 0.75 0.83 0.10 0.04 0.16 0.001 301 to 500 0.70 0.50 0.84 0.01 20.12 0.13 0.932 $ 501 0.69 0.60 0.77 Reference

challenging since it requires the integration and sharing of data review article on precision agricultural (PA) practices reported across different acquisition and processing systems, which are that increasing farm size, producers’ level of education, familiar- frequently provided by different manufacturers and suppliers. ity with computers, and the perception that the adoption of PA The other component that is missing is velocity, which refers will lead to improved competitiveness and greater profitability to how frequently the data are generated with the ultimate goal were all associated with adopting PA practices (13). being for the decision-making processes to be made in real time. In North America, the relationship between herd size and Like other facets of agriculture, Canada’s dairy industry has adoption of technologies appears to be confounded by other been consolidating, resulting in fewer but larger operations (6), factors. Barkema et al (8) reported that the adoption of auto- which is also a global phenomenon (7,8). A main driver of con- mated milking systems (AMSs) was higher in Canada than in solidation has been the ability for larger operations to capture the United States, even though US dairies tend to be larger than economies of scale. For instance, a US study found that costs Canadian dairies. These authors surmised that lower US milk per hundredweight of milk sold were twice as high for the prices and lower labor costs deterred the adoption of AMSs by smaller (, 50 head) versus larger dairies (. 500 head), with US producers. Other researchers have posited that the slower per unit costs continuing to decline as herd size increased (9). uptake of the use of AMSs by US dairies may be related to the Consolidation in American dairies is also being driven by lack of service providers and that the initial AMSs were better improvements in individual animal milk production; from 1991 suited for smaller dairies (14). However, several factors may to 2010 individual animal production increased by 42%, while accelerate the adoption of AMSs in the US. First, the introduc- the number of dairy farms decreased by 66% (10). A similar tion of AMS parlors has led to an increase in the adoption of trend has occurred in Canada with individual animal production these units by larger dairies. Secondly, changing immigration increasing by 9.7% between 2011 and 2016 (11). policies are projected to exacerbate labor shortages in agricul- A number of demographic factors are associated with the tural sectors that are intensive users of labor (15), which will adoption of technologies and increased milk production. A US have ramifications for the US dairy industry since immigrant study found that increasing farm size as well as dairy operators labor accounts for more than half of the labor force (16). In gen- having a college education were 2 factors associated with the eral, labor shortages in both Canada and the US will undoubt- adoption of productivity-influencing technologies, management edly lead to increased adoption of AMSs in North America. practices, and production systems (TMPPS) (10). This is sup- Both the Census of Agriculture and Census of Population ported by an Australian study reporting that larger operations are administered concurrently every 5 y, providing data that (. 500 head) were 2 to 5 times more likely to adopt precision describe the socioeconomic traits of Canada’s agricultural dairy farming technologies than smaller dairies (12). And a operators. Historically, the Census of Agriculture’s technology

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Table 2. Proportion and 95% confidence interval (95% CI) of producers who were using smartphones and/or tablets, stratified by region, number of operators/herd, gender, age, and herd size (breeding heifers and cows) and absolute differences in proportions among groups. 95% CI 95% CI Difference from Mean Lower Upper reference group Lower Upper P-value Region , 0.001

Atlantic 0.54 0.51 0.57 20.09 20.10 20.07 , 0.001 ARTICLE Ontario 0.56 0.53 0.60 20.06 20.07 20.05 , 0.001 Quebec 0.62 0.59 0.66 0.00 20.01 0.02 0.780 Western Canada 0.62 0.60 0.65 Reference Operators 1 Operator 0.55 0.52 0.58 20.08 20.10 20.06 , 0.001 $ 2 Operators 0.62 0.59 0.66 Reference Gender Female 0.58 0.55 0.61 20.01 20.01 0.02 0.277 Male 0.59 0.56 0.63 Reference Operator age (years) , 0.001 # 30 0.66 0.60 0.71 0.16 0.10 0.23 , 0.001 31 to 40 0.65 0.62 0.68 0.16 0.10 0.22 , 0.001 41 to 50 0.60 0.57 0.63 0.11 0.05 0.17 , 0.001 51 to 60 0.53 0.49 0.57 0.04 0.00 0.08 0.038 $ 61 0.49 0.45 0.54 Reference Herd size , 0.001 # 50 0.33 0.30 0.37 20.35 20.48 20.22 , 0.001 51 to 100 0.50 0.47 0.53 20.19 20.34 20.03 0.021 101 to 200 0.63 0.58 0.68 20.05 20.23 0.12 0.556 201 to 300 0.67 0.61 0.73 20.01 20.16 0.13 0.870 301 to 500 0.68 0.59 0.76 0.00 20.12 0.11 0.939 $ 501 0.69 0.53 0.81 Reference

section was restricted to a few questions relating to computer ing, auto-environment, GPS, and GIS. Robotic milking is used usage (17). The 2016 Census, however, was the first to inquire synonymously with automated milking systems (AMSs). about the adoption of technologies by all the commodity Statistics Canada defined a farm operator as any person who, groups (18). The timing of this change is somewhat fortuitous as of May 10, 2016, was responsible for the management deci- since it provides a baseline for the adoption of dairy technologies sions in controlling the function of an agricultural operation, before the implementation of both the Canada-European Union including owners, tenants, or hired managers (20). While dairy Comprehensive Economic and Trade Agreement (CETA) and operators were defined as producers who reported having dairy the Canada-United States-Mexico Agreement (CUSMA). These cows and dairy replacement heifers. Statistics Canada’s custom- agreements will increase foreign access to Canada’s domestic ized data extraction resulted in a cross-tabulation of the adop- market, thereby encouraging Canadian dairy producers to adopt tion of the 8 technologies by 5 operator/farm characteristics: more technology in order to become more competitive. operators’ gender (female and male); number of dairy operators The objective of this study was to examine the relationship per farm (1 and $ 2); operator age (, 26 y, 26 to 30 y, 31 to between operator/farm characteristics and the adoption of 35 y, 36 to 40 y, 41 to 45 y, 46 to 50 y, 51 to 55 y, 56 to 60 y, 8 technologies. and . 60 y); herd size (# 50, 51 to 100, 101 to 200, 201 to 300, 301 to 500, and . 500 dairy cows and replacement heifers Materials and methods . 1 y old); and geographical region (Canada, Atlantic provinces, Data were generated from Statistic’s Canada (StatsCan) 2016 Quebec, Ontario, and western Canada). Census of Agriculture (18), with a customized data extraction The extracted data were provided in a commercial spreadsheet of the answers to the following question: “In 2015, which of (Microsoft Excel v. 12; Microsoft Corporation, Redmond, the following TECHNOLOGIES were used on this operation? Washington, USA) and then imported into a statistical program Computers/laptops for farm management, Smartphones/tablets for for analyses (IBM SPSS Statistics Ver 25; IBM Corporation, farm management, automated steering (auto-steer), GPS technology, Armonk, New York, USA). Descriptive statistics were used to GIS mapping (e.g., soil mapping), greenhouse automation, robotic assess the adoption of each technology by each of the 5 opera- milking, automated environmental controls for animal housing, tor/farm characteristics. The mean adoption of each technology automated animal feeding, Other technologies (specify), and None was calculated by dividing the total number of operators using of the above.” Greenhouse automation and “other technologies” each technology (numerator) by the total number of operators were excluded because of very low adoption, 0.8% and 0.6%, reporting to the census in each category (denominator). The respectively (19). The following 8 technologies were analyzed: operators’ ages were reduced from 9 to 5 age groups: (, 31, computer/laptop, smartphone/tablet, auto-steering, auto-feed- 31 to 40, 41 to 50, 51 to 60, $ 61 y). Univariate analyses were

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Table 3. Proportion and 95% confidence interval (95% CI) of producers who were using global positioning systems (GPS), stratified by region, number of operators/herd, gender, age, and herd size (breeding heifers and cows) and absolute differences in proportions among groups. 95% CI 95% CI Difference from Mean Lower Upper reference group Lower Upper P-value Region , 0.001 Atlantic 0.26 0.24 0.29 20.20 20.21 20.19 , 0.001 Ontario 0.42 0.39 0.46 20.04 20.05 20.02 , 0.001 Quebec 0.28 0.24 0.32 20.18 20.20 20.17 , 0.001 Western Canada 0.46 0.43 0.49 Reference ARTICLE Operators 1 Operator 0.32 0.28 0.36 20.07 20.09 20.05 , 0.001 $ 2 Operators 0.39 0.36 0.42 Reference Gender Female 0.32 0.26 0.38 20.07 20.12 20.02 0.010 Male 0.39 0.37 0.40 Reference Operator age (years) , 0.001 # 30 0.34 0.30 0.37 0.01 20.04 0.01 0.329 31 to 40 0.40 0.34 0.45 0.07 0.03 0.12 0.001 41 to 50 0.36 0.32 0.39 0.04 0.02 0.05 , 0.001 51 to 60 0.35 0.31 0.39 0.03 0.01 0.05 0.012 $ 61 0.32 0.30 0.35 Reference Herd size , 0.001 # 50 0.13 0.11 0.15 20.32 20.43 20.21 , 0.001 51 to 100 0.26 0.25 0.26 20.19 20.31 20.06 0.003 101 to 200 0.40 0.39 0.42 20.04 20.17 0.08 0.481 201 to 300 0.46 0.39 0.54 0.02 20.11 0.14 0.783 301 to 500 0.51 0.48 0.54 0.07 20.03 0.16 0.181 $ 501 0.45 0.33 0.57 Reference

performed for each technology by operator/farm characteristic. with $ 1 male operator(s). The greatest number of operators A generalized estimating equation (GEE) with a logit link (n = 5500; 20%) were in the oldest age cohort ($ 61 y), 26% function and binomial distribution was used to examine factors (n = 1415) of which were single operators. Conversely, the young- associated with the adoption of each of the 8 technologies, cor- est cohort, # 30 y of age, represented only 9% (n = 2315) of all recting for clustering associated with herds within a geographical operators, 19% (n = 450) of which were single operators. region (Atlantic provinces, Ontario, Quebec, western provinces). While a GEE was generated for each of the 8 technolo- All 5 operator/farm characteristics were included in all 8 mul- gies, only the results from 5 technologies are provided in tivariable models. Data were excluded when the denominator Tables 1 to 5. The 3 technologies not shown (auto-environment, was 0 or was rounded off as 0 by Statistics Canada, or in a auto-steer, and GIS) either had low adoption and/or there was few instances in which the rounding procedure resulted in a minimal variation by geographical region, gender, age of opera- numerator greater than the denominator. The number of valid tor, number of operators/farm, or herd size. combinations of data for each analysis are reported. There were several trends across the 8 technologies. Quebec The GEE analyses provided statistically significant differences dairy operators had the highest adoption for 5 of the 8 tech- among groups with common operator/farm characteristics as nologies. Quebec operators were the least likely to be using GPS well as the measure of effect (difference between estimates of technology, while western Canadian and Ontario producers were the mean). Complete census data were available for the analysis; the highest adopters of this technology. Increasing farm size was therefore, the GEE model was used to generate predicted prob- generally associated with increasing adoption and farms with abilities of adopting the management tool for each category $ 2 operators were consistently more likely to be adopters of with 95% confidence interval (CI). The absolute differences all technologies compared to single operator farms. There was in the probabilities of those adopting and those not adopting little to no association between gender and the adoption of each management tool were determined for each factor with most technologies. While there were significant differences in 95% CI. Residuals were examined for outliers. No interac- adoption by operator age, the measure of effect was often small. tions were evaluated for any model. Level of significance was More specifically, the adoption of AMS (robotic milking) P , 0.05 (2-tailed). was consistently low (6% to 11%) by region, herd size, number of operators/farm, and operator age (Table 5). The highest esti- Results mated mean adoption rate was in western Canada (11%), which Statistics Canada reported 26 935 dairy operators on 12 895 dair- was greater than both Ontario (8%) and Atlantic Canada (8%) ies in 2016 with most (n = 20 180; 75%) co-managing with (P # 0.001), but not different from Quebec (10%) (P = 0.302). another operator. Only 505 (7%) of the single dairy operators Although there were significance differences in adoption by were female; therefore, most (93%; n = 6650) were co-managing region, the measures of effect were very small. Unlike most

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Table 4. Proportion and 95% confidence interval (95% CI) of producers who were using auto-feeding technology, stratified by region, number of operators/herd, gender, age, and herd size (breeding heifers and cows) and absolute differences in proportions among groups. 95% CI 95% CI Difference from Mean Lower Upper reference group Lower Upper P-value Region , 0.001

Atlantic 0.28 0.25 0.30 0.02 0.00 0.04 0.011 ARTICLE Ontario 0.20 0.17 0.22 20.06 20.07 20.04 , 0.001 Quebec 0.47 0.43 0.52 0.22 0.18 0.25 , 0.001 Western Canada 0.26 0.24 0.27 Reference Operators 1 Operator 0.27 0.25 0.30 20.03 20.06 20.01 0.004 $ 2 Operators 0.31 0.27 0.34 Reference Gender Female 0.29 0.26 0.32 20.01 20.03 0.01 0.252 Male 0.30 0.27 0.32 Reference 0.27 0.32 Operator age (years) , 0.001 # 30 0.30 0.26 0.35 0.03 20.03 0.10 0.335 31 to 40 0.28 0.24 0.32 0.01 20.04 0.06 0.697 41 to 50 0.32 0.29 0.35 0.05 0.00 0.10 0.056 51 to 60 0.28 0.26 0.31 0.01 20.01 0.04 0.267 $ 61 0.27 0.23 0.31 Reference Herd size , 0.001 # 50 0.10 0.07 0.12 20.30 20.38 20.23 0.000 51 to 100 0.29 0.24 0.33 20.11 20.23 0.01 0.072 101 to 200 0.40 0.37 0.43 0.00 20.11 0.11 0.995 201 to 300 0.38 0.36 0.40 20.02 20.11 0.08 0.732 301 to 500 0.29 0.20 0.40 20.10 20.16 20.05 , 0.001 $ 501 0.40 0.31 0.49 Reference

other technologies, the adoption of AMS was not related to the Although the list of technologies provided by the Census of number of operators per operation (P = 0.147), nor to gender Agriculture was short and non-specific to the dairy industry, the (P = 0.070). The adoption of AMS by age was steady at 9%, 8 technologies serve as a proxy for the adoption of technology except for the 31 to 40 y cohort, which had higher adoption at by Canadian dairy operators. 11% (P , 0.013). Herd size had an effect on the adoption of In describing the factors influencing the adoption of preci- AMS (P , 0.001), with the smallest herds (# 50 head) having sion agriculture for dry-land farming, Pierce et al (21) coined the lowest adoption at 1%, while 21% of herds with 201 to the phrase “do the right thing, in the right place, at the right time, 300 head had adopted this technology. and in the right way.” However, there are a number of steps For the 3 technologies not shown, 20% to 30% of operators needed before arriving at the point of adoption. The first step used auto-environment technology. Adoption was lowest in is rooted in the diffusion theory, which explains how innovative western Canada and highest in Quebec (P , 0.001). The oldest technologies are first communicated amongst operators before operators (. 60 y) were less likely to use environmental technol- being adopted (22). This well-recognized theory is supported ogy compared to all other age cohorts (P , 0.001). Generally, by a European study that found that access to information adoption of auto-environment increased with increasing herd from extension services, service providers, and those selling size. Auto-steer was more commonly used in western Canada the technology (vendors) was a determinant for the adoption than in all other regions (P , 0.001) and there was a clear trend of precision agricultural (PA) technologies (13). Thus, there is for increasing adoption with increasing herd size. Although a need for intermediaries or “translators” such as nutritionists, younger operators were more likely to use auto-steer technology veterinarians, technicians, and vendors to participate in the dif- than the . 60 y cohort, the differences in the measures of effect fusion of information. Although awareness of the technology is were very small. The adoption for GIS across all regions ranged important, other factors such as return on investment, total cost from 12% to 15%; however, the largest farms (. 500 head) had of the investment, and ease of use must also be factored into the the highest adoption rate (36%; P , 0.001). decision (23). The last point is salient because the installation of precision dairy farming technologies often results in a steep Discussion learning curve (3). The 2016 Census was the first time Statistics Canada included As previously discussed, there is a strong correlation between a section dedicated to technologies. This section, however, was increasing farm size and the adoption of PA technologies. designed to capture data on all commodities, not just dairy. Therefore, it is paradoxical that Quebec producers, whose Thus, some technologies such as auto-steer, GIS, and GPS average herd size is the smallest in Canada (24), led the nation were not particularly relevant, while reproductive technologies in adoption of computers/laptops, smartphones/tablets, auto- such as estrus detection and sexed semen were not included. feeding, auto-environment, and auto-milking technologies.

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Table 5. Proportion and 95% confidence interval (95% CI) of producers who were using automated milking systems, stratified by region, number of operators/herd, gender, age, and herd size (breeding heifers and cows) and absolute differences in proportions among groups. 95% CI 95% CI Difference from Mean Lower Upper reference group Lower Upper P-value Region , 0.001 Atlantic 0.08 0.07 0.09 20.03 20.03 20.02 , 0.001 Ontario 0.08 0.07 0.09 20.03 20.03 20.02 , 0.001 Quebec 0.10 0.08 0.12 0.01 20.02 20.01 0.302 Western Canada 0.11 0.10 0.12 Reference ARTICLE Operators 1 Operator 0.09 0.08 0.10 20.01 20.03 0.00 0.147 $ 2 Operators 0.10 0.08 0.12 Reference Gender Female 0.10 0.08 0.11 0.01 0.00 0.01 0.070 Male 0.09 0.08 0.10 Reference Operator age (years) , 0.013 # 30 0.09 0.06 0.12 0.00 20.02 0.02 0.901 31 to 40 0.11 0.09 0.14 0.02 0.01 0.04 0.000 41 to 50 0.09 0.08 0.10 0.00 20.03 0.02 0.679 51 to 60 0.09 0.08 0.10 0.00 20.02 0.02 0.812 $ 61 0.09 0.08 0.10 Reference Herd size , 0.000 # 50 0.01 0.01 0.01 20.14 20.21 20.08 0.003 51 to 100 0.07 0.05 0.09 20.08 20.18 0.02 0.102 101 to 200 0.15 0.14 0.17 0.00 20.09 0.10 0.918 201 to 300 0.21 0.17 0.26 0.06 20.05 0.17 0.264 301 to 500 0.18 0.11 0.28 0.03 20.11 0.17 0.699 $ 501 0.15 0.08 0.27 Reference

This may be explained by the diffusion of information within than single operator farms, which is likely confounded by herd the Quebec dairy industry. Consider that 10 700 dairies in size. It was also common to find no difference in adoption by Canada ship milk, 48% of which are in Quebec (25). This gender; however, this finding requires some explanation. Farms concentration of dairies presumably results in more interactions were not segregated by those operated solely by females or males; between dairy producers as well as more vendors and technicians rather, 93% of female operators were managing alongside male servicing the industry. Furthermore, the province subsidizes both operators; therefore, it is difficult to parse the effect of gender. veterinary and dairy extension services, resulting in a relatively Similarly, operator age also had a marginal effect on the adop- high number of dairy veterinarians and consultants. And while tion of most technologies with the exception being smartphones/ many provinces have moved away from providing extension ser- tablets and computers/laptops. This lack of age effect is likely vices, Quebec has created a knowledge translation service within related to 75% of dairies having multiple operators, who by their milk recording program (Valacta). With the 2019 launch Statistics Canada’s definition are responsible for farm manage- of Lactanet (a partnership between Valacta, Canwest DHI, and ment decisions. Farming in Canada is still very much a family the Canadian Dairy Network), some of these services may be enterprise; therefore, the operators undoubtedly represent offered nationally in the future, although when and how this multiple generations, which conceals the effect of age on the will happen has yet to be determined. The density of dairy farms adoption of technologies. Regarding the use of smartphones/ coupled with the number of translators has created an ideal tablets, there was a clear trend for younger operators to be more environment for the diffusion of technology. intensive users of these devices; however, this may be related Of the 8 technologies analyzed, the 3 most closely aligned to these devices being personal use items. Overall, adoption of with the dairy industry were auto-feeding, auto-environmental smartphones/tablets and computers/laptops was higher in the control, and automated milking systems (AMSs). However, dairy industry compared to the Canadian cow-calf industry (26), auto-feeding was not defined by Statistics Canada, hence it which may reflect dairy operators being more comfortable with could have been interpreted as feed mixing, feed delivery, or computers and software applications. pushing up the feed to the cattle. Similarly, auto-environment While there were statistical differences in the estimates of the did not specify whether it applied to cow housing or calf hous- mean for each AMS parameter, the measure of effects was neg- ing. Furthermore, the census asked about the use of robotic ligible for gender, number of operators per farm, and operators’ milking, whereas AMS is perhaps a more encompassing term. age. The only determinants of significance were geographical That said, dairy producers should appreciate the clear delinea- region and herd size. The estimates of the means by geographical tion between using and not using robotic milkers. Despite these region show that dairies in western Canada and Quebec had the limitations, a common finding to most of the 8 technologies highest adoption of AMS compared to Ontario and the Atlantic was that farms with $ 2 operators had a higher rate of adoption region. These relationships, however, are probably confounded

1070 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY by other management practices, such as housing. Automated References milking systems are not used in tie-stall (pipeline) systems, a 1. Lucy MC, McNamara JP. Journal of Dairy Science Volume 100 Special housing practice that is much more common in Quebec (41%) Issue: Summary. J Dairy Sci 2017;100:10445–10446. and Ontario (31%) and rarely used in the Atlantic region (3%) 2. Society of Dairy Technology, Homepage: https://www.sdt.org/pages/ Last accessed August 5, 2020. or western Canada (2%) (27). Furthermore, only 7% of 3. Eastwood CR, Chapman DF, Paine MS. Networks of practice for Canadian herds milked . 80 cows using a pipeline system and co-construction of agricultural decision support systems: Case studies of precision dairy farms in Australia. Agric Syst 2012;108:10–18. average herd size is greatest in western Canada (27). There are ARTICLE 4. Cox S. 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Outcome following surgical stabilization of distal diaphyseal and supracondylar femoral fractures in dogs

Francisco Silveira, Isobel C. Monotti, Anna M. Cronin, Nick J. Macdonald, Scott Rutherford, Kornelia Tiffinger, Ian Faux, Javier Rincon-Alvarez, Elvin Kulendra, Francesca Tavola, Bruno Santos, Neil J. Burton

Abstract — Signalment, clinical features, fixation techniques, complications, and outcome for dogs presenting with distal diaphyseal and supracondylar femoral fractures were retrospectively reviewed. A total of 45 dogs with unilateral femoral fractures were included. Supracondylar femoral plates were the most popular method of fixation. However, various fixation techniques resulted in favorable outcomes in most dogs with 19/45 cases achieving full function and 22/45 achieving acceptable function. Degree of fracture comminution did not appear to affect complication rate or be a surrogate for worse clinical outcome.

Résumé — Résultats de stabilisation chirurgicale de fractures fémorales diaphysaires distales et supracondylaires chez le chien. Une étude rétrospective portant sur le signalement, la présentation clinique, les techniques de réduction de fracture, les complications et les résultats de chiens atteints de fractures fémorales supracondyliennes et diaphysaires distales a été réalisée. Quarante-cinq chiens présentant une fracture fémorale unilatérale ont été inclus au total. Les plaques fémorales supracondyliennes représentaient la méthode d’ostéosynthèse la plus courante. Diverses techniques de fixation ont abouti à des résultats favorables dans la majorité des cas, avec 19/45 cas récupérant une fonction complète et 22/45 une fonction considérée acceptable. Le degré de comminution de la fracture n’apparaissait pas comme étant un facteur de risque de complication ou étant associé à des résultats défavorables. (Traduit par Emilie Fauchon et Emilie Hanot) Can Vet J 2020;61:1073–1079

Introduction chondrodystrophic breeds appears to predispose these breeds anine femoral fractures are the most common appendicular to this type of fracture (2,4). Limited bone stock of the distal C fracture, comprising 45% of all long-bone fractures and femur, proximity of a high motion joint (i.e., stifle), fracture 20% to 25% of all fractures seen in small animals (1,2). Of comminution and procurvatum offsetting the distal femur these, distal femoral extra-articular fractures can be described caudal to the diaphysis may cumulatively present challenges for as either supracondylar (6% of femoral fractures) (i.e., non- internal fixation (2,4,5). physeal fractures of the distal metaphyseal region) or distal Canine distal femoral diaphyseal and supracondylar fractures physeal (18% to 21% of femoral fractures) (2,3). Supracondylar have a low incidence of occurrence (3). Multiple fixation strate- femoral fractures are most commonly reported in skeletally gies are suggested for these fractures (2,6) including the use of mature dogs (4,5). The topography of the canine femur with bone plates (7), interlocking nails (8), Kirschner wires, Rush distal femoral procurvatum in concert with a naturally occur- pinning, lag screw fixation, intramedullary rods (9), and exter- ring isthmus at the level of the distal femoral metaphysis in nal skeletal fixation (10). However, a distinction is not made

Dick White Referrals, Six Mile Bottom, Cambridgeshire, UK (Silveira); School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia (Monotti); Queen’s Veterinary School Hospital, Madingley Road, Cambridge, UK (Cronin); Northwest Veterinary Specialists, Sutton Weaver, Cheshire, UK (Macdonald); Frank. Pet Surgeons, Leeds, Yorkshire, UK (Rutherford); The Grove Referrals, Fakenham, Norfolk, UK (Tiffinger); Hospital for Small Animals, The Royal (Dick) School of Veterinary Studies, Midlothian, UK (Faux); Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, UK (Rincon-Alvarez); North Downs Specialist Referrals, Bletchingley, Surrey, UK (Kulendra, Santos); AniCura Albano, Danderyd, Stockholm, Sweden (Tavola); Wear Referrals, Bradbury, Stockton-on-Tees, County Durham, UK (Burton). Address all correspondence to Dr. Francisco Silveira; 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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Figure 1. a — Supra-condylar plate (SCP). Plate designs from top to bottom: 3.5-mm broad long left plate, 3.5-mm narrow long left plate, 2.7-mm left plate, 2.4-mm left plate, 2.0-mm long left plate, 2.0-mm left plate. b — Supra-condylar osteotomy plate (SCOP). Plate designs from top to bottom: 3.5-mm left plate, 2.7-mm left plate, 2.4-mm left plate, 2.0-mm left plate.

between supracondylar or physeal (i.e., Salter-Harris) fractures femoral metaphysis, which cannot be outlined using anatomic in some reports, making interpretation of the outcome and landmarks. In our study, fractures were first classified as distal any complications as a function of exact fracture configuration femoral (1). Of these, fractures were defined as supracondylar challenging (9). Furthermore, a case series reviewing the use if they were found to be proximal to the distal femoral physis of supracondylar femoral plates (Veterinary instrumentation, (in skeletally immature animals) and/or extra-articular (in skele- Sheffield, UK) in the context of distal femoral fracture stabili- tally mature animals) but still within the distal femoral segment. zation is lacking. Roch and Gemmill (11) reported use of these The quadrate method as described by Unger et al (1) whereby a plates for stabilization after distal femoral wedge ostectomy, in square representing the widest portion of the distal femur was the context of medial patellar luxation. Supracondylar plates templated onto each radiograph, was used to define the distal have been designed with the assistance of finite element analysis femoral segment. Fractures were classified as distal diaphyseal to be used as bridging plates across comminuted fractures, with if proximal to the distal femoral segment but still within the the aim of minimal contouring and maximizing the number of distal third of the femur, according to the measurements made cortices engaged within the distal femoral fragment, which is on pre-operative radiographs (Figure 2). The middle of oblique offset caudally relative to the distal femoral shaft (12). Two plate and transverse fractures, the broadest part of the wedge for designs have evolved (Veterinary instrumentation, Sheffield, wedge fractures and the center of the area of comminution for UK); the supra-condylar plate (SCP), which has screw holes comminuted fractures were used to define fractures as either distributed throughout the whole length of the plate (Figure 1a), supracondylar or distal diaphyseal (1). Physeal (Salter-Harris) and the supra-condylar osteotomy plate (SCOP), which incor- fractures were not included in the study. porates a bridging plate segment without screw holes (to be laid Complications were classified using Cook et al (13) proposed over the fracture/osteotomy site), increasing the area moment of criteria in terms of the timescale of their occurrence as periop- inertia of the implant in that segment (Figure 1b). erative (before surgery, during surgery, and up to 3 mo after The purpose of this retrospective multicenter case series was surgery), short-term (between 3 and 6 mo after surgery), mid- to describe the signalment, clinical features, fixation techniques, term (6 to 12 mo after surgery), or long-term (more than12 mo complications, and outcomes for dogs presenting with distal after surgery). Complications were further classified as either diaphyseal or supracondylar femoral fractures. catastrophic (when a complication or associated morbidity had caused permanent unacceptable function, was directly related Materials and methods to death, or was the cause for euthanasia), major (when a Medical records of dogs presented between 2007 and 2018 complication or associated morbidity required further surgical for surgical treatment of distal femoral and supracondylar or medical treatment, based on current standards of care, to fractures at 12 referral centers in the UK and 2 referral centers resolve), or minor (when not requiring additional surgical or in Australia were obtained for review. Cases were included in medical treatment to resolve). Clinical outcome was evaluated the study if complete clinical records, pre-operative and post- based on the data recorded by the attending surgeon at the last operative radiographic imaging, and clinical and radiographic revisit or based on information gathered from the owners at follow-up were available for review. The term supracondylar has the time of data collection. Clinical outcome was classified in been used previously to define the distal metaphyseal region of terms of time frame as perioperative (pre-, intra- and up to 3 mo the femur (2). The authors are unaware of a methodology that post-surgery), short-term (. 3 to 6 mo post-surgery), mid- can be used to confidently identify the boundaries of the distal term (. 6 to 12 mo post-surgery), and long-term (. 12 mo

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(range: 1 to 6) was collected from each referral center. The median age of the study population at the time of surgery was 2 y 3 mo (range 0 y 3 mo to 9 y 10 mo). Median body weight (BW) was 9.1 kg (range: 2.15 to 50 kg). Twenty-nine dogs were male (13 of which were neutered) and 16 were female (7 of which were neutered). Breeds represented in the study popula-

tion were: cross-breed (n = 6), cocker spaniel (n = 4), 3 each of ARTICLE Staffordshire bull terrier, Jack Russell terrier, Chihuahua, border terrier, bichon frise, 2 each of pug, Maltese terrier, border collie, distal diaphyseal fractures and 1 each of the shih tzu cross Maltese, Rottweiler, Pomeranian cross, lhasa apso, Labrador retriever, Jack Russell terrier cross, husky, greyhound, dachshund, cockapoo, boxer, Belgian shepherd, working cocker, and beagle. Fracture etiologies were supracondylar fractures recorded in 39/45 cases (Appendix 1, available from the cor- x responding author) and included road-traffic accident (20/45), fall from height (11/45), and leg entrapment (3/45). Thirty- two dogs had right femoral fractures and 13 had left femoral fractures. Eighteen dogs were diagnosed with supracondylar femoral fractures and 27 with distal diaphyseal fractures. Fracture configuration comprised 15 comminuted, 15 transverse, and 15 oblique. Twenty-one of the 45 dogs suffered adjunctive orthopedic and/or soft tissue injuries (Table 1). Fixation methods employed for fracture stabilization comprised x/3 a predominance of lateral plating, used in 27 dogs. Of those, femoral supracondylar plates were used in 18/27 dogs, locking- compression plates (LCP; Synthes, West Chester, Pennsylvania, y USA) in 4/27 dogs, dynamic-compression plates (DCP) in 2/27 dogs, a locking reconstruction plate (VetLOX Titanium plate; Freelance Veterinary, Somerset, UK) in 1/27 dogs, a notched locking T-plate (Synthes) in 1/27 dogs and a broad lock- y ing TPLO plate (Synthes) in 1/27 dogs. Plate-rod fixation was used in 9 dogs, with LCP plates used in 4/9 dogs, DCP plates in 3/9 dogs, a supracondylar plate in 1/9 dogs, and a string-of-pearls Figure 2. Illustration of fracture classification scheme used. plate (Orthomed UK, Halifax, West Yorkshire, UK) in 1/9 dogs. Fractures of the distal third of the femur (x/3) were considered for analysis. Fractures were classified as supracondylar using the Crossed-arthrodesis wires were employed as the main method of quadrate method described by Unger et al (1). The width of the fixation in 4/45 dogs, external skeletal fixation was employed in widest point of the distal femoral epiphysis (y) was used to draw 3/45 dogs, and bilateral plating (with either 2 string-of-pearls a square over the distal epiphysis, within which non-physeal, nonarticular fractures were classified as supracondylar. Fractures plates in 1 dog or with an LCP medially and supracondylar plate were classified as distal diaphyseal when proximal to the square laterally in another dog) in 2/45 dogs (Figure 3). Further details drawn using the quadrate method but still within the distal third are presented in Appendix 1. of the femur. In the 20 dogs in which a supracondylar plate was employed (either in isolation or in combination with other implants), 2.0-, 2.7-, or 3.5-mm plates were used. In 12 cases a supra- post-surgery). Clinical outcome was subsequently subjectively condylar plate (SCP) and in 8 cases a supra-condylar osteotomy classified as dogs having achieved full function (restoration to, plate (SCOP) were used. Supracondylar plates were used as the or maintenance of, full intended level and duration of activities primary method of fixation in 18/45 dogs (excluding a case in and performance from pre-injury or pre-disease status, without which a supracondylar plate was combined with an IM pin, medication), acceptable function (restoration to, or maintenance and a case in which a contralateral LCP plate was added). Of of, intended activities and performance from pre-injury or pre- these 18 cases, 3 comminuted fractures, 6 oblique fractures, and disease status that is limited in level or duration and/or requires 9 transverse fractures were recorded; 10 being supracondylar medication to achieve) or unacceptable function (all other and 8 distal diaphyseal. In 3 of these 18 cases, a single intra- outcomes) (13). fragmentary arthrodesis wire was also placed, and in 1 case crossed arthrodesis wires were also placed, either to maintain Results fracture reduction during surgery or as adjunctive fixation Forty-five dogs with unilateral femoral fractures were eli- (Appendix 1). Supracondylar femoral plates were used without gible for inclusion in the study. A median number of 4 cases any adjunctive fixation in 14 cases (Figure 3a).

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Table 1. Concurrent injuries listed by dog. Trauma Fracture location Age Sex Breed type Other injuries and configuration 1 y 5 mo FN Springer spaniel RTA Pneumothorax Left, distal diaphyseal, comminuted

1 y 11 mo FN Beagle RTA Vertebral subluxation of T8-T9, with suspected Right, distal diaphyseal, transverse compression fracture of the body of T9. Damage to the articular facets and dorsal spinous process was not seen and no neurological deficits were apparent. Subluxation of the 9th right rib head. ARTICLE 11 mo MN Jack Russell terrier Hit by falling log Fracture of left acetabulum, left ischium, and Left distal, diaphyseal, comminuted left pubis. 1 y 1 mo F Cockapoo RTA Right coxofemoral luxation, bilateral sacroiliac Right, distal diaphyseal, comminuted luxation, right ilial body fracture, left ischiatic fracture, and pubic symphysis separation. 3 y 4 mo M Chihuahua RTA Comminuted fracture/avulsion of the right Right, distal diaphyseal, transverse calcaneus, loss of viability of skin over dorsal aspect of the right pes. 9 mo MN Crossbreed RTA Laceration between digits IV and V. Right, distal diaphyseal, oblique 3 mo M Boxer Fall from height Fracture of the right femoral head capital physis Right, supracondylar, oblique with minimal displacement or apparent instability. 1 y M Pomeranian-cross RTA Bladder rupture. Right ischial fracture, multiple Left, distal diaphyseal, transverse pubic fractures, right ilial body fracture. 2 y 11 mo FN Crossbreed RTA Left sacroiliac luxation, bilateral pubic fractures, Right, supracondylar, transverse left ischial fracture. 4 mo F Pug Mild unknown Suspected Salter-Harris type V of the ipsilateral Right, supracondylar, oblique trauma distal femoral physis. 9 mo M Bichon frise RTA Mid-diaphyseal, oblique, right tibial fracture, Right, supracondylar, transverse right coxofemoral luxation, bilateral right sacroiliac luxation and multiple pelvic floor fractures. 3 y 1 mo MN Crossbreed Fell from height Pulmonary contusions and mild pneumothorax. Right, supracondylar, oblique

4 y 1 mo MN Border terrier Hit by metal rod Small puncture wound on the right hock. Right, distal diaphyseal, comminuted

4 y 1 mo MN Dachshund RTA Multiple pelvic floor fractures, right ischiatic Right, supracondylar, oblique tuberosity fracture, left cranial ischiatic fracture. 3 y M Crossbreed RTA Right ischial fracture, pelvic floor fractures, Right, supracondylar, oblique left ilial body fracture. 3 y 10 mo FN Maltese terrier RTA Right coxofemoral luxation, right sacroiliac Left, distal diaphyseal, oblique luxation, bilateral pubic fractures and right ischiatic fracture. 7 y MN Maltese RTA Left trochanteric fracture, laceration left inguinal Right, supracondylar, comminuted region. 3 y 6 mo MN Rottweiler Fell out of Non-displaced right ischial fracture, incidental Right, distal diaphyseal, comminuted moving vehicle OCD lesion of medial femoral condyle seen at surgery. 8 mo MN Border terrier RTA Laceration lateral aspect of the right thigh. Right, distal diaphyseal, comminuted

M — male; MN — male neutered; F — female; FN — female neutered; RTA — road-traffic accident; OCD — osteochondritis dissecans.

Outcome in 9 cases, medium-term in 3 cases, and long-term in 1 case. All cases had at least 1 post-operative consultation and radio- Nineteen of the 45 cases were deemed to have achieved full graphs with a veterinary surgeon. Radiographic follow-up had function at their last recorded follow-up, 22 had achieved a median duration of 7 wk (range: 2 to 28 wk) and clinical acceptable function, and 4 unacceptable function. Of those dogs follow-up for a median duration of 8 wk (range: 4 to 208 wk). in which SCP/SCOP was employed, 9/20 cases were deemed to Clinical and radiographic follow-up data allowed for attribution have achieved full function, 10 had achieved acceptable func- of a perioperative outcome in all cases, short-term outcome tion, and 1 had unacceptable function at their last recorded

1076 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY ARTICLE

Figure 3. Post-operative cranio-caudal and mediolateral radiographic views of multiple fixation methods employed. a — Crossed arthrodesis wires with intramedullary pin countersunk at intercondylar notch. b — Intramedullary pin used in combination with supracondylar 3.5-mm plate. c — Intramedullary pin used in combination with 9-hole SOP 3.5-mm plate. d — Type IIb modified ‘tie-in’ configuration external skeletal fixator. e) Bilateral 2.7-mm SOP plates. f — Supracondylar plate.

follow-up. Among cases in which supracondylar plates were used Of the 20 dogs in which SCP/SCOP was employed, 4 post- as the primary method of fixation, 9/18 dogs achieved full and operative complications occurred; 1 catastrophic (quadriceps 9/18 achieved acceptable function. contracture and IM pin migration), 2 major (patella luxation A total of 16 postoperative complications were recorded in and screw loosening requiring removal), and 1 minor (screw 14 dogs. Catastrophic complications were recorded in 4 dogs, loosening as an incidental finding not requiring removal). An 2 of which were diagnosed with quadriceps contracture, defined SCP plate was used in both cases in which screw loosening as an inability to flex the stifle with concurrent tarsal extension occurred. In total, 2 of the 14 dogs that had a SCP/SCOP plate and flexed digits on the operated limb. The third dog with a applied as sole method of fixation had recorded complications, recorded catastrophic complication suffered failure of the initial accounting for a rate of complications of 2/14 (14.3%). fixation with 4 crossed arthrodesis wires (later revised with a supracondylar plate). A fourth dog had proximal migration of Discussion the intramedullary pin, inserted as part of a plate-rod construct To the authors’ knowledge, this multicenter study describes the and was still severely lame at the last recorded follow-up (19 wk largest case series of canine distal diaphyseal/supracondylar frac- after surgery). Major complications were recorded in 6 cases. tures to date and the only series evaluating the use of the SCP/ These included worsening of pre-existing medial patellar luxa- SCOP in the context of femoral fracture repair. No complication requiring corrective surgery (in 2 cases), surgical site infections were recorded in the 3 cases of comminuted fractures in tion with ipsilateral septic arthritis of the stifle (in 1 case), exter- which SCPs were used in bridging mode, suggesting the implant nal skeletal fixator pin discharge (in 1 case), patellar desmitis (in performs adequately in a scenario of comminution, as did other 1 case) and screw loosening requiring removal (in 1 case). Minor fixation strategies reported in this manuscript. Single screw loos- complications were recorded in 6 cases and included pin tract ening was recorded in 2 cases and although both fractures healed discharge without the need for any intervention (in 3 cases), uneventfully, 1 screw did require surgical removal. A recent ex edema in the operated limb (in 1 case), limb shortening due to vivo biomechanical study on the effect of bicortical or mono- premature closure of the distal femoral physis without associated cortical locking screws on a mid-diaphyseal femoral fracture lameness (in 1 case) and screw loosening that did not require gap model (14), reported no screw loosening or screw pull-out surgical removal (in 1 case). All recorded complications were with locking screws compared to a 70% incidence of screw pull classified as “perioperative” with regard to the time frame of out when cortical screws were used (15). Distal femoral locking their occurrence, with the exception of the case in which screw plates are also available (New Generation Devices, Glen Rock, migration requiring screw removal was detected. The latter was New Jersey, USA) and it is plausible that the use of a locking classed as “long-term,” having occurred 13 mo after surgery. plate and screws could have reduced the risk of screw loosening.

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Our case series has an overall rate of complications of 31.1%. neither did whether the fracture was distal diaphyseal or supra- Previously published case series documenting the use of internal condylar. Complication rates when SCP/SCOP plate fixation fixation for non-articular fractures in dogs reported complication was used were comparable to those for other fixation strategies. rates that varied between 5% and 37% (16–20). Pin migration occurred in 2/9 plate-rod cases in our series, in both instances Acknowledgments necessitating pin removal. Pin associated complications (with We acknowledge Veterinary Instrumentation, Sheffield, UK, for pin migration being the most frequently reported), requiring the assistance given towards the acquisition of the supracondylar a form of intervention have been reported in 9% to 19% of osteotomy plate photographs. CVJ plate-rod repairs (16–18).

ARTICLE Quadriceps contracture was reported in 2 cases in this case References series. Young dogs with distal femoral fractures appear to be 1. Unger M, Montavon PM, Heim UF. Classification of fractures of the long bones in the dog and cat: Introduction and clinical application. predisposed (21). However, both cases reported herein were Vet Comp Orthop Traumatol 1990;3:41–50. adult dogs with comminuted fractures. The presence of com- 2. Guiot LP, Déjardin LM. Fractures of the femur. In: Tobias KE, Johnston minution, and as such, due to a higher energy injury, more SA, eds. Veterinary Surgery: Small Animal. St. Louis, Missouri: Elsevier Saunders, 2017:1019–1071. adjunctive soft tissue damage and more callus formation rather 3. Braden TD, Eicker SW, Abdinoor D, Prieur WD. Characteristics of than age could have been a predisposing facture to contracture 1000 femur fractures in the dog and cat. Vet Comp Orthop Traumatol development in our cases. 1995;8:203–209. 4. Lewis DD, Van Ee RT, Oakes MG, Elkins AD. Use of reconstruc- Linear LCP or DCP plates were used to repair 13 fractures. tion plates for stabilization of fractures and osteotomies involving the Given the limited 3-dimensional contouring that such plates supracondylar region of the femur. J Am Anim Hosp Assoc 1993;29: can tolerate, the use of this fixation strategy may involve either 171–178. 5. Lidbetter DA, Glyde R. Supracondylar femoral fractures in adult ani- over-reducing the distal fracture to increase the bone stock mals. Compend Contin Educ Pract Vet 2000;22:1041–1053. available for screw placement distally (2) or helical plating (22). 6. Brinker WO, Piermattei D, Flo G. Fractures of the femur and patella. Over-reduction of the distal fragment could predispose to In: Handbook of Small Animal Orthopedics and Fracture Repair. 4th ed. St. Louis, Missouri: Elsevier, 2016:518–597. misalignment of the patellar and quadriceps mechanism (2,5). 7. Voss K, Hull MA, Haessig M, Montavon PM. Repair of long-bone Interestingly, in our series, iatrogenic de novo patellar luxation fractures in cats and small dogs with the Unilock mandible locking plate was not a recorded complication. However, worsening of pre- system. Vet Comp Orthop Traumatol 2009;22:398–405. 8. Scotti S, Klein A, Pink J, Hidalgo A, Moissonnier P, Fayolle P. existing medial patellar luxation, requiring surgical interven- Retrograde placement of a novel 3.5 mm titanium interlocking nail tion, was recorded in 2 cases. Possible etiologies to explain this for supracondylar and diaphyseal femoral fractures in cats. Vet Comp complication could include lateral distal femoral soft tissue dis- Orthop Traumatol 2007;20:211–218. 9. Stigen O. Supracondylar femoral fractures in 159 dogs and cats treated section at the time of fracture repair, malreduction of the distal using a normograde intramedullary pinning technique. J Small Anim femoral fragment, or postoperative quadriceps muscle atrophy Pract 1999;40:519–523. affecting either the magnitude or direction of force through the 10. Farese JP, Lewis DD, Cross AR, Collins KE, Anderson GM, Halling KB. Use of IMEX SK-circular external fixator hybrid constructs for patellofemoral joint. fracture stabilization in dogs and cats. J Am Anim Hosp Assoc 2002; Our study has limitations inherent in its retrospective nature. 38:279–289. 11. Roch S, Gemmill J. Treatment of medial patellar luxation by femoral When assessing outcome, we opted for the “last observation car- closing wedge ostectomy using a distal femoral plate in four dogs. ried forward” method, which has limitations in interpretation J Small Anim Pract 2008;49:152–158. of outcome (23,24). Given the short duration of follow-up in 12. Glyde M, Fitzpatrick D, Fitzpatrick C. Use of finite element analysis for design of a 2.7 mm and 3.5 mm broad supracondylar femoral bone some of the cases it is plausible that some could have devel- plate. British Veterinary Orthopaedic Association Spring Meeting. oped undocumented mid- to long-term complications that April 6, Birmingham, UK. 2005:32–36. could have significantly affected outcome (25,26). It is equally 13. Cook JL, Evans R, Conzemius MG, et al. Proposed definitions and criteria for reporting time frame, outcome, and complications for clinical plausible that, should there have been short-, mid- and long- orthopedic studies in veterinary medicine. Vet Surg 201;39:905–908. term follow-up available for all cases, some of the cases with 14. Field EJ, Parsons K, Etches JA, Hamilton K, Burton N.J. Effect of “acceptable” outcome could have been allowed the necessary monocortical and bicortical screw numbers on the properties of a locking plate-intramedullary rod configuration. Vet Comp Orthop Traumatol time to recover full function and as such, outcome in our series 2016;29:459–465. could be negatively biased. Similarly, the presence of adjunc- 15. Delisser PJ, McCombe GP, Trask RS, et al. Ex vivo evaluation of the tive polytrauma in our case series (21/45) makes it difficult to biomechanical effect of varying monocortical screw numbers on a plate- rod canine femoral gap model. Vet Comp Orthop Traumatol 2013;26: discern the precise contribution of each individual injury to the 177–185. final outcome recorded. The short duration of follow-up also 16. Reems MR, Beale BS, Hulse DA. Use of a plate-rod construct and precluded a radiological analysis of the time to complete fracture principles of biological osteosynthesis for repair of diaphyseal fractures in dogs and cats: 47 cases (1994–2001). J Am Vet Med Assoc 2003;223: healing in all cases. Contribution of case material from multiple 330–335. referral hospitals treated by multiple surgeons also introduced 17. Haaland P, Sjöström L, Devor M, Haug A. Appendicular fracture repair variation in surgeon experience and postoperative management in dogs using the Locking Compression Plate system: 47 cases. Vet Comp Orthop Traumatol 2009;22:309–315. between cases. 18. Guiot LP, Déjardin LM. Prospective evaluation of minimally invasive In summary, this case series documents the use of multiple plate osteosynthesis in 36 nonarticular tibial fractures in dogs and cats. fixation strategies for the management of supracondylar and dis- Vet Surg 2011;40:171–182. 19. Gibert S, Ragetly GR, Boudrieau RJ. Locking compression plate stabili- tal diaphyseal femoral fractures in dogs. Comminution was often zation of 20 distal radial and ulnar fractures in toy and miniature breed present, but this did not appear to result in a poorer outcome, dogs. Vet Comp Orthop Traumatol 2015;28:441–447.

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20. Tan CJ, Johnson KA. Stabilisation of periarticular fractures and osteoto- 24. Lachin JM. Fallacies of last observation carried forward analyses. Clin mies with a notched head locking T-plate. Aust Vet J 2016;94:377–383. Trials 2016;13:161–168. 21. Taylor J, Tangner CH. Acquired muscle contractures in the dog and cat. 25. Aiken MJ, Hughes TK, Abercromby RH, Holmes MA, Anderson AA. A review of the literature and case report. Vet Comp Orthop Traumatol Prospective, randomized comparison of the effect of two antimicrobial 2007;20:79–85. regimes on surgical site infection rate in dogs undergoing orthopedic 22. Kowaleski MP. Minimally invasive osteosynthesis techniques of the implant surgery. Vet Surg 2015;44:661–667. femur. Vet Clin North Am Small Anim Pract 2012;42:997–1022. 26. Pratesi A, Moores AP, Downes C, Grierson J, Maddox TW. Efficacy of 23. Wood A, White IR, Thompson SG. Are missing outcome data ade- postoperative antimicrobial use for clean orthopedic implant surgery

quately handled? A review of published randomized controlled trials in in dogs: A prospective randomized study in 100 consecutive cases. Vet ARTICLE major medical journals. Clin Trials 2004;1:368–376. Surg 2015;44:653–660.

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Effect of intravenous fluid warming on core body temperature during elective orthopedic procedures

Robert B.E. Brady, William T. Poppell

Abstract — The effects of intravenous (IV) fluid warming on core body temperature in a group of dogs undergoing an elective orthopedic procedure was studied. An IV fluid warmer was used alone or in conjunction with forced warmed air to determine the individual or additive effects of IV fluid warming. These effects were compared to those in dogs with no heat support or those with only forced warmed air in a randomized prospective study design. The conclusion was that IV fluid warming had no effect on the maintenance or preservation of core body temperature in this population of dogs, and that, as previous reports have shown, forced warmed air decreased the rate of heat loss during anesthetic procedures. One possible explanation for the lack of benefit is the location of the fluid warmer in relation to the patient. To our knowledge, this is the first study to examine the effects of IV fluid warming on core body temperature in dogs undergoing an elective orthopedic procedure.

Résumé — Effet du réchauffement du liquide intraveineux sur la température corporelle centrale durant des procédures orthopédiques électives. Les effets du réchauffement du liquide intraveineux (IV) sur la température corporelle centrale dans un groupe de chiens soumis à une procédure orthopédique élective fut étudiée. Un réchaud à fluide IV était utilisé seul ou conjointement avec de l’air chaud forcé afin de déterminer les effets individuels ou additifs du réchauffement du liquide IV. Ces effets furent comparés à ceux de chiens sans support de chaleur ou ceux avec uniquement de l’air chaud forcé dans une étude prospective randomisée. La conclusion était à l’effet que le réchauffement du liquide IV n’avait aucun effet sur le maintien ou la préservation de la température corporelle centrale dans cette population de chiens, et que, tel que démontré par des études antérieures, de l’air chaud forcé diminuait le taux de perte de chaleur durant les procédures anesthésiques. Une explication possible pour l’absence de bénéfice serait la localisation du chauffe liquide relativement au patient. À notre connaissance, ceci constitue la première étude à examiner les effets du réchauffement du liquide IV sur la température corporelle centrale chez des chiens soumis à une procédure orthopédique élective. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1080–1084

Introduction below 36.5°C to 37.5°C (5,6). Inadvertent perioperative hypothermia (IPH) is a well-known complication of both general ypothermia associated with anesthesia occurs in an esti- and neuraxial anesthesia and is associated with increased risk mated 83% of veterinary patients (1). Body heat is lost H of infection, cardiac arrhythmias, prolonged recovery times, during anesthesia as a result of conduction, convection, radia- coagulopathy, morbidity, and increased length of hospitalization, decreased vasomotor tone and thermoregulatory function, tion (7–9). Anesthesia depresses thermoregulatory mechanisms inhalation of cold anesthetic gases, and evaporation through which are responsible for maintaining body temperature within application of skin disinfectants (2). Core body temperature is a certain window, termed the “interthreshold range.” A widen- a fundamental vital sign and is to be monitored closely in all ing of the interthreshold range, as occurs under anesthesia, anesthesia patients (3,4). Hypothermia in the canine patient alters the body’s activation point for corrective mechanisms is ill-defined and ranges from a core body temperature at or which maintain body temperature within its set range (6–10). For example, if an animal’s interthreshold range is 38.0°C to Memphis Veterinary Specialists, 555 Trinity Creek Cove, 39.0°C, this will widen to approximately 36.0°C to 41.0°C Cordova, Tennessee 38018, USA. under general anesthesia. Should hypothermia occur, thermo- Address all correspondence to Dr. Robert B.E. Brady; e-mail: regulatory mechanisms would not be activated until core body [email protected] temperature falls below 36.0°C. Risk factors for development Use of this article is limited to a single copy for personal study. of hypothermia under anesthesia include reduced body fat, Anyone interested in obtaining reprints should contact the increased surface area:body mass ratio (e.g., puppies), underlying CVMA office ([email protected]) for additional systemic disease, age (geriatric or neonatal), and multiple anes- copies or permission to use this material elsewhere. thetic drugs that contribute to vasodilation and or hypothalamic

1080 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY depression (5,11,12). Anesthetic drugs can predispose patients of healthy, skeletally mature dogs, 2- to 8-years of age, of good to IPH by disruption of hypothalamic thermoregulatory centers body condition, BCS 4/9 to 6/9, which were undergoing an as well as blockade of efferent neurons involved in homeostatic elective orthopedic procedure. These procedures included tibial reflexes, such as shivering (10,13,14). A body temperature of plateau leveling osteotomy (n = 42), medial patellar luxation less than 34.4°C leads to loss of thermoregulatory function, repair (n = 1), primary fracture repair (n = 2), open reduction decreased shivering, and reduced hypothalamic activity, further of lateral elbow luxation (n = 1), hip toggle placement (n = 1), exacerbating heat loss (15). and a corrective osteotomy (n = 1). Exclusion criteria included ARTICLE During the induction phase of anesthesia, vasodilation facili- patients with any known underlying chronic or metabolic dis- tates the flow of large volumes of blood to the periphery, where ease, preoperative temperatures . 39.5°C or , 37.5°C, patients heat is lost to the surrounding environment through conduction, requiring significant intraoperative treatment for anesthetic convection, and radiation. This accounts for up to 80% of heat complication leading to additional drug administration or loss during the first hour of anesthesia (2,16–19). Maintaining repeated fluid bolus administration, and dogs with abnormali- normothermia during the perioperative period is critical for ties on pre-operative blood analysis consistent with chronic or ensuring fast recovery from anesthesia and avoiding the deleteri- metabolic disease. Of the 48 dogs which met eligibility criteria ous effects of hypothermia. The greatest reduction in core body for the study none were excluded and all patient data were temperature occurs during the first hour of anesthesia (2,20). reported up to 105 min under anesthesia, with 47 patients’ data This suggests that early intervention in the perioperative period reported to 120 min. may be key in preventing perioperative hypothermia. Forced warmed air is the most effective method of reduc- Experimental design ing the rate of core body temperature loss in humans (21,22) This investigation was a prospective randomized study. A power and in veterinary patients (23–25) and will be used as the analysis indicated that 8 subjects per group were needed to reach gold standard in this study. The most accurate, albeit invasive, 90% power with an effect size of 1.0°C. A research randomizer assessments of core body temperature in veterinary patients are (www.randomizer.org) was used to assign each patient number obtained via thermistors placed in the esophagus, urinary blad- to its respective treatment group at the onset of the trial. A der, and caudal vena cava, while in human medicine, core body single investigator was responsible for all patient data collection. temperature measurement within the pulmonary artery is the All patients received the same anesthesia protocol, consisting gold standard (26–28). In addition, both rectal and auricular of IV catheter placement followed by famotidine (West-Ward, thermometry are reliable methods for evaluating core body Eatontown, New Jersey, USA), 1 mg/kg body weight (BW), IV, temperature (29). However, 1 study showed greater variability then diazepam (Hospira, Lake Forest, Illinois, USA), 0.25 mg/kg between auricular temperature readings compared to rectal BW, IV and propofol (Zoetis, Kalamazoo, Michigan, USA), thermometry which provided temperature readings within 0.5°C 4 mg/kg BW, IV, to effect for induction of anesthesia. The of the pulmonary artery temperature (30). Rectal temperature patients were then connected to an isoflurane vaporizer with closely correlates with more invasive core body temperature an O2 flow rate of 2 L/min. Lactated Ringer’s solution (Baxter, measurements, and its noninvasive nature makes it a convenient Deerfield, Illinois, USA) was started at a rate of 5 mL/kg BW method of monitoring body temperature during surgery (29,30). per hour. In all pelvic limb procedures, epidural morphine Several methods of intraoperative warming have been evalu- (West-Ward), 0.1 mg/kg BW, was administered followed by a ated including heating pads, warmed blankets, warm water fentanyl (Hospira) CRI of 7 mg/kg BW per hour for the dura- bottles/rice bags, and forced warmed air (23–25). However, tion of anesthesia. Cefazolin (Hikma Farmaceutica, Eatontown, no previous studies have evaluated the effectiveness of IV New Jersey, USA), 22 mg/kg BW, IV, was given 30 min before fluid warming. Active heating devices carry the risk of thermal initial incision and every 90 min thereafter. Patients were then injury. Some techniques, such as warmed fluid bags/rice bags, transported to the radiology suite for pre-operative radiographs increase conductive loss of heat once they cool thereby wors- followed by sterile preparation, surgery, post-operative radio- ening hypothermia (33). As with many facets of anesthesia, a graphs, and recovery. All heating interventions were paused dur- multi-modal approach may be warranted to support core body ing transport for all patients due to a lack of mobile electricity temperature preservation while decreasing the risk for thermal sources for the active warming devices used. injury and/or hyperthermia in patients. In light of all this, we Animals were randomized to 1 of 4 treatment groups: hypothesized that intravenous fluid warming, as instructed by Group 1 — control group with no heat support; Group 2 — the manufacturer, will be ineffective in reducing the rate of IV fluid warmer only (Midmark i-warm Fluid warmer, Dayton, heat loss, while forced warmed air will slow the rate of heat loss Ohio, USA) at 40.5°C, 170 cm from fluid warmer to patient during anesthesia. (as per manufacturer recommendations); Group 3 — forced warmed air (Cocoon blanket, Care Essentials, North Geelong, Materials and methods Australia) at 43.9°C; and Group 4 — IV fluid warmer and Animals forced warmed air. At the time of induction, a baseline rectal Forty-eight client-owned adult large breed dogs were included temperature was obtained via a rectal thermometer; this was in the study, which ran from September 2018 to June 2019. followed by rectal temperature recordings every 15 min there-

All owners provided written informed consent at the time of after. Heart rate (HR), respiratory rate (RR), ETCO2, SPO2, surgery to be included in the study. Inclusion criteria consisted Gas %, O2 flow rate, ECG, fluid boluses, and anesthetic plane

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Table 1. Mean (SD) values for patient characteristics and fluid rates. Group 1 2 3 4 Variable Control Warmed IV Forced Warmed Air Both F P-value Age (years) 6.17 (2.3) 5.50 (2.4) 5.08 (2.2) 4.92 (2.2) 0.72 0.544 Weight (kg) 37.02 (7.7) 32.55 (5.7) 33.41 (7.9) 34.10 (8.7) 0.79 0.509 Body condition scorea 5.17 (0.6) 4.83 (0.4) 4.67 (0.7) 4.42 (0.5) 4.05 0.213 Fluid rateb 177.17 (49.8) 162.25 (28.3) 166.50 (39.5) 169.67 (43.6) 0.28 0.838

a Scale of 1 to 9. b mL/h. ARTICLE F = F-value.

Table 2. Group by time repeated measures analysis of covariance on body temperature during surgery. Group Time Group 3 Time F df P-value F df P-value F df P-value All groups 2.55 3, 38 0.070 1.31 3, 114 0.276 2.38 9, 114 0.017 Post-hoc control versus Warmed IV 0.15 1, 18 1.000 1.46 3.67, 66.02 0.687 0.48 3.67, 66.02 1.000 Forced warmed air 4.63 1, 19 0.132 0.80 4.17, 79.17 1.000 8.55 4.17, 79.17 , 0.001 Both treatments 1.85 1, 17 0.576 0.81 2.69, 45.71 1.000 3.52 2.69, 45.71 0.012

Note: Huynh-Feldt correction was applied to the ANCOVA; Bonferroni adjustment was applied to post-hoc significance levels. F — F-value. df — Degrees of freedom.

were also monitored. If a patient’s core body temperature in Control either the control group or the warmed IV fluids only groups Warmed IV fell below 36.1°C, forced warmed air was added. Monitoring Forced Warmed Air of temperature and active warming were discontinued during Both transport to recovery. The ambient temperature in the hospital and operating room suite was maintained at 21.1°C.

Statistical analysis A commercial statistical package (SPSS Version 21; IBM, Armonk, New York, USA) was used for all statistical analyses. An analysis of variance (ANOVA) was used to compare the 4 treatment groups’ signalment along with Chi-square analysis on gender of patients. Z-scores were used to ensure normality of Figure 1. Body temperatures during surgery for the 4 groups. data in the progression of body temperature over time. A group by time repeated measures analysis of covariance (ANCOVA) with a Huynh-Feldt correction was conducted to determine statistics for body temperatures are provided in Table 2. All difference in treatment groups cumulatively over time in regard patients were monitored for a total of 120 min, with the excep- to change in body temperature at all time points. Dunnett’s tion of a single patient which was monitored for 105 min. The post-hoc analysis of covariance was then used to determine the interaction effect shown in Table 2 for all groups indicates that statistical significance of each treatment group compared to body temperatures varied differently over time depending on the the control and adjusted using Bonferroni corrections with a type of heat support provided [F (9, 114) = 2.38, P = 0.017]. statistical significance of P , 0.05. Polynomial contrasts were Our results suggest that forced warmed air is the most effective also utilized to test the linear trends across time for each group heat support [F (4.17, 79.17) = 8.55, P , 0.001] with or with- compared to control. out being combined with warmed IV fluids. Figure 1 displays the slower drop in body temperature among patients which received Results forced warmed air support. The slope of the control group was Patient characteristics and fluid rate were compared among 20.03 compared to the slope of the warmed air group (20.01) the 4 groups (Table 1). Fluid rate, age, BCS, and BW were not illustrating a slower rate of core body temperature loss in the significantly different among the 4 groups. warmed air group. The clinical significance of this is unknown The groups did not differ significantly with respect to the at this time and further investigation is warranted. number of intact patients (x2 = 4.24; P = 0.237) nor with respect to gender (x2 = 4.67; P = 0.198). Discussion Body temperatures were recorded at baseline and at Our study results are consistent with previous reports, suggesting 15-minute intervals during the surgical procedure. Summary that forced warmed air is superior to other warming methods in

1082 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY reducing the rate of loss of core body temperature during sur- and peripheral vasodilation (10,11). For our investigation, all gery. While the current study did not investigate other warming patients were subject to the same anesthetic protocol in an effort methods, such as water blankets, heating pads, or warm water to keep these known anesthetic effects constant throughout the bottles, the literature is consistent that the gold standard for data collection process. warmth support is forced warmed air. This allowed us to have a Monitoring body temperature is imperative during anesthetic control of no heat support and the gold standard treatment of procedures, as low body temperatures decrease the effective- forced warmed air (21–25). As hypothesized, the current study ness of commonly used drugs during anesthesia including ARTICLE shows no benefit in using warmed intravenous fluids as directed fluid boluses, glycopyrrolate, dopamine, dobutamine, and by the manufacturer, who recommends placing the warmer norepinephrine (31–33). Hypothermia also reduces the dose directly downstream from the fluid pump. requirement of anesthetic gas and decreases solubility of said The biggest limitation in the current study is the 170 cm gases, leading to longer recovery from anesthesia after inhalants of fluid line between the warmer and the patient, leading to are discontinued (33). Maintenance of core body temperature possible loss of heat through convection and radiation as the becomes more difficult as patient size decreases, in part due to fluids move through the line. Further investigation into varying an increase in body surface area to weight ratio. These smaller locations of the fluid warmer device in relation to the patient patients lose more heat per unit body weight through conduc- are warranted, as placement of the fluid warmer closer to the tion, convection, and radiation as a result of peripheral vasodila- patient may lead to greater retention of warmth within the fluid tion caused by anesthetic and peri-anesthetic drugs. These effects line, thereby increasing the benefit to the patient. However, a are compounded when the thoracic or abdominal cavities are location too close to the patient may lead to thermal injury to opened. Investigating modalities to aid in the maintenance of the vasculature and care must be taken to avoid this potential patient’s core body temperature in larger dogs will also benefit complication during study design. Another limitation is the smaller dogs, which are more prone to complications arising variance in thermometer depth and lack of consistent control from hypothermia. Even in the face of active heating, a large over insertion depth. The current study was able to control for proportion of anesthetized animals experience hypothermia to multiple variables to create as homogeneous a population as some degree, including 75% of patients in this study recording possible by controlling age, weight, BCS, length of anesthesia, at least 1 temperature , 37°C. It may be necessary to incor- ambient temperature, O2 flow rate, and procedure type being porate a multi-modal approach to active warming of patients elective orthopedic procedures. Other limitations to the current in hopes of preserving core body temperature and associated study include a slightly lower starting body temperature for the physiologic function without increasing the risks of thermal warmed fluids only group compared with the other 3 groups. injury. A key to this approach would be earlier intervention, The percent difference between the starting temperatures was including more research on pre-warming of patients via various 0.5%, and likely played no role in the outcome. Other limita- warming devices or possibly starting warmed intravenous fluids tions include periods of interruption in active warming support, some time before anesthetic induction coupled with avoiding such as during transport when these interventions were not drugs such as acepromazine whenever possible. By incorporat- feasible. While these periods were consistent among all study ing a multi-modal approach to active warming, we may also be patients, these interruptions may have played a role in tempera- able to reduce the amount of thermal injury to patients by not ture loss as 3 of the 4 occur within the first hour of anesthesia, relying on a single warming modality, such as warmed blankets, further illustrating the need for a warming method that may be pads, forced warmed air at higher heat settings. instituted early and without interruption such as warming of In conclusion, the current study showed no improvement in intravenous fluids. patients’ ability to maintain core body temperature with the addi- Core body temperature maintenance is vital to patient health tion of an IV fluid warmer device in large breed dogs undergoing during the perioperative and intraoperative period, especially elective orthopedic procedures. The most common procedure during the first hour of anesthesia as this is the period of great- performed in our study population was the TPLO (89%). est heat loss. Fluctuations in body temperature can affect many Patients in which forced warmed air was used showed a statisti- autonomous body systems including metabolism, peripheral cally significant ability to reduce loss of core body temperature vascular resistance, respiratory centers, interthreshold widen- compared with both the negative control and fluid warmer only ing, leading to anesthetic complications such as hypotension, groups, although 75% of patients experienced a drop in body perpetuation of hypothermia, drug metabolism/effectiveness, temperature below 37°C. Further investigation into the optimal and prolonged recovery. Early intervention may be a key factor location of the fluid warming device in relation to the patient, we are missing, as many veterinary patients undergo a period as well as possibly initiating warmed IV fluids before induction of time without heat support before and during the induc- is warranted. Future studies should include other subject pools tion and surgical preparation phase as well in some cases until including open cavity surgeries and smaller patients. CVJ sterile draping has been completed. This initial phase of heat loss is mostly attributed to anesthetic drugs and gases that References suppress the hypothalamus and, in turn, inhibit the patient’s . 1 Redondo JI, Suesta P, Serra I, et al. Retrospective study of the prevalence inherent temperature regulatory mechanisms (3,5,7). Other of postanaesthetic hypothermia in dogs. Vet Rec 2012;171:374. 2. Tan C, Govendir M, Zaki S, Miyake Y, Packiarajah P, Malik R. Evalu causes include decreases in heat as a byproduct of metabolism, ation of four warming procedures to minimise heat loss induced by muscle contraction/tone, widening of the interthreshold range, anaesthesia and surgery in dogs. Aust Vet J 2004;82:65–68.

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. 3 Torossian A. Thermal management during anaesthesia and thermo- 20. Rigotti CF, Jolliffe CT, Leece EA. Effect of prewarming on the body regulation standards for the prevention of inadvertent perioperative temperature of small dogs undergoing inhalation anesthesia. J Am Vet hypothermia. Best Pract Res Clin Anaesthesiol 2009;22:659–668. Med Assoc 2015;247:765–770. 4. Bednarski R, Grimm K, Harvey R, et al. AAHA Anesthesia Guidelines 21. Ng S-F, Oo C-S, Loh K-H, Lim P-Y, Chan Y-H, Ong B-C. A com- for Dogs and Cats. J Am Anim Hosp Assoc 2011;47:377–385. parative study of three warming interventions to determine the most 5. Oncken A, Kirby R, Rudloff E. Hypothermia in critically ill dogs and effective in maintaining perioperative normothermia. Anesth Analg cats. Compend Contin Educ Pract Vet 2001;23:506–520. 2003;96:171–176. 6. Rose N, Kwong GPS, Pang DSJ. A clinical audit cycle of post-operative 22. Negishi C, Hasegawa K, Mukai S, Nakagawa F, Ozaki M, Sessler DI. hypothermia in dogs. J Small Anim Pract 2016;57:447–452. Resistive-heating and force-air warming are comparably effective. Anesth 7. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce Analg 2003;96:1683–1687. the incidence of surgical-wound infection and shorten hospitalization. 23. Sessler DI. Temperature regulation and monitoring. In: Miller RD, Study of Wound Infection and Temperature Group. N Engl J Med Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish J, Young WL,

ARTICLE 1996;334:1209–1215. eds. Miller’s Anesthesia. 8th ed. St. Louis, Missouri: Saunders Elsevier, 8. Todd J, Powell LL. Hypothermia. In: Silverstein DC, Hopper K, eds. 2015:1622–1646. Small Animal Critical Care Medicine. St. Louis, Missouri: Saunders, 24. Clark-Price SC, Dossin O, Jones KR, Otto AN, Weng H-Y. Comparison 2009:720–722. of three different methods to prevent heat loss in healthy dogs under- 9. Sessler DI. Temperature regulation and monitoring. In: Miller RD, going 90 minutes of general anesthesia. Vet Anaesth Analg 2013;40: Erikson LI, Fleisher LA, Wiener-Kronish JP, Young WL, eds. Miller’s 280–284. Anesthesia. 7th ed. St. Louis, Missouri: Saunders Elsevier, 2015: 25. Machon RG, Raffe MR, Robinson EP. Warming with a forced air warm- 1622–1646. ing blanket minimizes anesthetic-induced hypothermia in cats. Vet Surg 10. Sessler DI. Mild Perioperative Hypothermia. N Engl J Med 1997;336: 1999;28:301–310. 1730–1737. 26. Koyama K, Ochiai R, Takahashi J, Takeda J, Sekiguchi H, Fukushima K. 11. Sessler DI. Temperature regulation and monitoring. In: Miller RD, Evaluation of gastric tube with esophageal thermistor (Thermosump). Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish J, Young WL, J Anesth 1992;6:372–375. eds. Miller’s Anesthesia. 8th ed. St. Louis, Missouri: Saunders Elsevier, 27. Maxton FJ, Justin L, Gillies D. Estimating core temperature in infants 2015:1533–1556. and children after cardiac surgery: A comparison of six methods. J Adv 12. Mallet M. Pathophysiology of accidental hypothermia. QJM 2002;95: Nurs 2004;45:214–222. 775–785. 28. Nierman DM. Core temperature measurement in the intensive care 13. Clark-Price S. Inadvertent perianesthetic hypothermia in small animal unit. Crit Care Med 1991;19:818–823. patients. Vet Clin North Am Small Anim Pract 2015;45:983–994. 29. Southward ES, Mann FA, Dodam J, Wagner-Mann CC. A com- 14. Ikeda T, Kim J-S, Sessler DI, Negishi C, Turakhia M, Jeffrey R. parison of auricular, rectal and pulmonary artery thermometry in Isoflurane alters shivering patterns and reduces maximum shivering dogs with anesthesia-induced hypothermia. J Vet Emerg Crit Care intensity. Anesthesiology 1998;88:866–873. 2006;16:172–175. 15. Stepaniuk K, Brock N. Hypothermia and thermoregulation during 30. Greer R, Cohn L, Dodam J, Wagner-Mann CC, Mann FA. Com anesthesia for the dental and oral surgery patient. J Vet Dent 2008;25: parison of three methods of temperature measurement in hypothermic, 279–283. euthermic, and hyperthermic dogs. J Am Vet Med Assoc 2007;230: 16. Bernard J-M, Wouters PF, Doursout M-F, Florence B, Chelly JE, Merin 1841–1848. RG. Effects of sevoflurane and isoflurane on cardiac and coronary 31. Haskins SC. Hypothermia and its prevention during general anaesthesia dynamics in chronically instrumented dogs. Anesthesiology 1990;72: in cats. Am J Vet Res 1981;42:856–861. 659–662. 32. Zhou J, Poloyac SM. The effect of therapeutic hypothermia on drug 17. Malan Jr. TP, DiNardo JA, Isner RJ, et al. Cardiovascular effects of sevo- metabolism and response: Cellular mechanisms to organ function. flurane compared with those of isoflurane in volunteers. Anesthesiology Expert Opin Drug Metab Toxicol 2011;7:803–816. 1995;83:918–928. 33. Pottie R, Dart C, Perkins N, Hodgson D. Effect of hypothermia on 18. Mutoh T, Nishimura R, Kim HY, et al. Rapid inhalation induction of recovery from general anaesthesia in the dog. Aust Vet J 2007;85: anesthesia by halothane, enflurane, isoflurane and sevoflurane and their 158–162. cardiopulmonary effects in dogs. J Vet Med Sci 1995;57:1007–1013. 19. Mutoh T, Nishimura R, Kim HY, Matsunaga S, Sasaki N. Cardiopulmonary effects of sevoflurane, compared with halothane, enflurane, and isoflurane, in dogs. Am J Vet Res 1997;58:885–890.

1084 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Article

Incidence of incisional complications after exploratory celiotomy in equids affected with enterolithiasis

Albert Torrent Crosa, Scott A. Katzman, Maureen E. Kelleher, Jorge E. Nieto, Isabelle Kilcoyne, Julie E. Dechant

Abstract — This study reports the prevalence of and risk factors for incisional complications in equids after ventral midline celiotomy for enterolithiasis. This study covered the years 2008 to 2015 and included 72 equids. Enteroliths were removed from the ascending or descending colon through 1 or more enterotomies. Complications were defined as surgical site infection and/or incisional hernia formation. Follow-up by telephone questionnaire or medical records determined that 10/72 (13.9%) equids experienced complications, with 6/72 (8.3%) developing a surgical site infection and 5/72 (6.9%) a hernia. Seven of ten were presented for chronic abdominal discomfort ( 24 hours), and 8/10 had right dorsal colon and pelvic flexure enterotomies. All equids that developed an incisional hernia and 4 with surgical site infection had enteroliths  15 cm diameter removed from the right dorsal colon. Antimicrobial powder applied to the ventral midline incision during closure significantly reduced incisional complications. Removal of  15 cm diameter enteroliths from the right dorsal colon may predispose to postoperative incisional complications.

Résumé — Incidence des complications incisionnelles après une céliotomie exploratoire chez des équidés atteints d’entérolithiase. Cette étude rapporte la prévalence et les facteurs de risque des complications incisionnelles chez les équidés opérés pour l’entérolithiase en utilisant une celiotomie médiane ventrale de 2008 à 2015. Soixante- douze équidés ont été inclus. Les entérolithes ont été retirés du côlon ascendant ou descendant par  1 entérotomies. Les complications étaient définies comme une infection du site opératoire et/ou la formation d’une hernie incisionnelle. Le suivi a été obtenu par questionnaire téléphonique ou par dossiers médicaux. Dix des 72 (13,9 %) des équidés ont eu des complications, dont 6/72 (8,3 %) ont développé une infection du site opératoire et 5/72 (6,9 %) une hernie. Sept sur 10 ont été présentés pour un malaise abdominal chronique ( 24 heures) et 8/10 avaient des entérotomies du côlon dorsal droit et de la flexion pelvienne. Tous les équidés ayant développé une hernie incisionnelle et quatre avec une infection du site opératoire avaient des entérolithes  15 cm de diamètre prélevés du côlon dorsal droit. La poudre antimicrobienne appliquée sur l’incision médiane ventrale lors de la fermeture réduisait significativement les complications incisionnelles. Le retrait d’entolithes de  15 cm de diamètre du côlon dorsal droit peut prédisposer aux complications incisionnelles postopératoires. (Traduit par les auteurs) Can Vet J 2020;61:1085–1091

Introduction in certain geographical regions of the United States, particularly nterolithiasis is a significant cause of abdominal pain in in California, Florida, and Texas, and occurs sporadically in E equids, with abdominal pain developing secondary to other parts of the world (1–4). Most often, horses are presented partial or complete obstruction of the ascending colon (AC) for mild to moderate intermittent abdominal discomfort (5–7) descending colon (DC), or transverse colon (TC). Prevalence of or a history of recurrent colic (4), but others are presented with enterolithiasis has been reported to range from 1.7% to 15.1% signs of acute, severe abdominal pain (8). Surgical removal

William R. Pritchard Veterinary Medical Teaching Hospital (Torrent), Department of Surgical and Radiological Sciences (Katzman, Nieto, Kilcoyne, Dechant), School of Veterinary Medicine, University of California, Davis, California 95616, USA; Virginia- Maryland College of Veterinary Medicine, Marion duPont Scott Equine Medical Center, Leesburg, Virginia, USA (Kelleher). Address all correspondence to Dr. Albert Torrent Crosa; e-mail: [email protected] Dr. Torrent Crosa’s current address is Département de sciences cliniques, Faculté de médecine vétérinaire, Université de Montréal, St-Hyacinthe, Québec. 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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through ventral midline incision with subsequent enterotomy for removal of enteroliths would be associated with an increased is the treatment of choice, and successful removal was reported rate of incisional complications. as early as 1877 (8,9). Success rates following surgical removal of enteroliths are Materials and methods good to excellent (2,10), with short-term survival ranging from Case selection 94% to 96.2% (4,11), and long-term survival from 85% to Medical records from the William R. Pritchard Veterinary Medical 92.5% (4,10,11). Nevertheless, exploratory celiotomy in equids Teaching Hospital at the University of California-Davis were is not without risk for potential complications, with incisional reviewed to identify equids that underwent exploratory celiotomy complications being one of the most commonly reported prob- for enterolithiasis affecting the AC, DC, and/or TC between

ARTICLE lems following ventral midline celiotomy (12). January 1, 2008, and June 30, 2015. A tentative diagnosis of Several studies have reported incisional infection as a com- enterolithiasis was made if 1 or more radiopaque spherical struc- plication following exploratory celiotomy, with an incidence tures were identified on a complete abdominal radiographic study, ranging from 2.7% to 42% (13,14). Pre- and peri-operative with definitive diagnosis made following identification of 1 or factors identified as predisposing factors for postoperativ e more enteroliths during exploratory celiotomy. incisional complications include anamnesis, signalment, Equids were included in the study if they recovered from and several pre-, intra-, and postoperative variables (12,13, anesthesia, survived  4 mo after surgery, and follow-up infor- 15–30). Incisional infection, dehiscence, and hernia formation mation was available. have been reported to be of particular concern following enterotomy (12). However, other studies did not support the find- Medical records review ing that enterotomy influenced the development of incisional Pre-operative data collected included signalment, body weight, complications (11,15,17,18,31). physical examination findings, results of complete blood cell Several studies reported that ventral abdominal hernia count, serum biochemistry and peritoneal fluid analysis, and formation was most common in equids that had developed results of abdominal radiography. Duration of colic signs was postoperative incision drainage or infection (18,22,32). In recorded and considered acute for equids displaying signs of 1 study, equids that experienced an incisional infection were abdominal discomfort of  24 h and chronic for cases display- 17.8 times more likely to develop a hernia compared to equids ing signs for  24 h. that did not develop infection (18). In another study, purulent Intra-operative data collected included duration of surgery, incisional drainage preceded development of a hernia in 48% of length of ventral midline incision, location of enteroliths (AC, cases (33). Furthermore, the odds of incisional hernia formation DC, and/or TC), additional lesions discovered at surgery, hypox-  were 62.5 times greater for horses that had incisional drainage emia (PaO2 65 mmHg), or hypotension during anesthesia after surgery, and incisional drainage and herniation negatively (MAP  65 mmHg for  15 min), and quality of recovery. influenced survival (34). Additional intra-operative data collected included suture mate- Regarding enterolithiasis, incisional complications following rial used for subcutaneous closure, topical administration of exploratory celiotomy have been reported, with a prevalence an antimicrobial following closure of the linea alba and type between 12.9% and 44.1% (4,35). However, investigating of incisional protection applied for recovery from anesthesia. specific risk factors associated with incisional complications was Postoperative data collected included duration of hospi- not the focus of these studies. One study found no statistical sig- talization and administration of systemic antimicrobial and nificance between location of enteroliths (AC or DC) and inci- anti-inflammatory medications, development of colic, fever, dence of incisional complications, although more complications and results of hematologic evaluation when available. Incisional developed when enteroliths were removed from the DC (11). complications were defined as persistent incisional drainage To our knowledge, specific pre-, intra-, and postoperative fac- with or without positive bacterial culture which was considered tors contributing to incisional complications following entero- indicative of surgical site infection, and hernia formation. lith removal have not been investigated. The objectives of this study were to report the prevalence of incisional complications Surgical technique following enterolith removal through ventral midline celiotomy, Prior to surgery, an IV catheter was inserted into the left jugu- determine if there is increased risk for incisional complications lar vein using aseptic technique. All equids were administered following AC enterotomy compared to DC enterotomy per- parenteral broad-spectrum antimicrobials and tetanus prophy- formed for enterolith removal, d etermine whether the risk for laxis 30 min before induction of general anesthesia. Flunixin incisional complications increased with increased number of meglumine (Intervet, Madison, New Jersey, USA), 1.1 mg/kg enterotomies, and determine if enterolith size and location of body weight (BW) IV, was administered unless the horse had enterotomy influenced the incidence of incisional complications already received an NSAID 6 to 8 h before surgery. in equids following enterolith removal. We hypothesized that Following induction of anesthesia and orotracheal intubation, the overall rate of incisional complications would be low for equids were mechanically ventilated, and anesthesia was main- horses with enteroliths removed via ventral midline celiotomy, tained using isoflurane in 100% oxygen. Equids were placed that the incidence of incisional complications would be similar in dorsal recumbency and hair was removed from the ventral when enteroliths were removed from either the AC or DC, and abdomen using electric clippers. For intact males and geldings, that increasing the size and number of enterotomies necessary the prepuce was cleaned, packed with gauze and sutured closed

1086 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY or closed with towel clamps. Preparation of the skin for each tered IV for a minimum of 8 h. At the discretion of the attending member of the surgical team consisted of a 5-minute scrub of clinician, some equids received a constant rate infusion (CRI) of the hands and forearms with a scrub brush using 4% chlorhexi- 2% lidocaine (VetOne), 0.05 mg/kg BW per min IV, for 12 to dine gluconate (BD E-Z Scrub 107; Becton, Dickinson and 24 h. Parenteral administration of broad-spectrum antimicrobi- Company, Franklin Lakes, New Jersey, USA) followed by als was continued for 1 to 5 d after surgery based on the clinical application of an 85% ethyl alcohol-based rub (Sterillium Rub; case progression of each individual equid. Flunixin meglumine

Medline Industries, Northfield, Illinois, USA). (Intervet), 0.75 mg/kg BW, IV, q8h was initially administered for ARTICLE Following aseptic preparation of the ventral abdomen, 3 d, followed by transition to oral flunixin meglumine (Intervet), an iodine impregnated adhesive drape (Ioban; 3M Health Care, 0.5 mg/kg BW, q12h with this dose gradually reduced. St. Paul, Minnesota, USA) was applied and the surgical site Feed was gradually reintroduced, with frequent feedings of draped routinely. A ventral midline incision was created using small amounts of grass hay starting 6 to 12 h after surgery. The a #10 scalpel blade, beginning at the umbilicus and extending amount of feed was then gradually increased, and frequency of cranially. The incision was carried through the subcutaneous feeding was decreased during the postoperative hospitalization tissues and was lavaged with sterile 0.9% irrigation saline. A new period. #10 scalpel blade was used to incise the linea alba. The surgical site was monitored daily. Incisional bandages The large colon was exteriorized and placed on a colon tray placed at the completion of surgery were removed immediately (Colon Tray; Kimsey Welding Works, Woodland, California, after recovery from anesthesia or within the first 24 h after sur- USA). An enterotomy was created at the pelvic flexure (PF) gery. During the hospitalization period, incisions were cleaned and contents of the AC were evacuated. When size permitted, twice daily using gauze soaked in isopropyl alcohol or dilute enteroliths within the TC or right dorsal colon (RDC) were chlorhexidine solution to remove any debris from the surgical mobilized to the PF enterotomy and removed. Larger enteroliths incision and identify any abnormalities indicative of developing located in either the RDC or TC were mobilized as far orad incisional complications such as tenderness or discharge from as possible and removed through a second enterotomy created the surgical site. at the antimesenteric border of either the RDC or left dorsal Restricted exercise was recommended for 12 wk, with con- colon (LDC). Enteroliths located within the DC were removed finement to a box stall (3.7  3.7 m) for the first 4 wk followed through an enterotomy created through the antimesenteric by small paddock (6.1  6.1 m) turnout for 4 wk and finally band. All enterotomies were closed in 2 layers using #2-0 USP unrestricted turnout for the final 4 wk. Daily monitoring of the polydioxanone (PDS; Ethicon, Somerville, New Jersey, USA). surgical site was recommended, with follow-up examination A full thickness simple continuous pattern was placed and performed by the referring veterinarian at 2 wk after surgery oversewn in a Cushing pattern. The colon was replaced in the for skin staple removal, and at each monthly increase in exercise abdomen and intra-abdominal lavage performed using sterile during this initial 12-week period. 0.9% irrigation saline prior to abdominal closure. The linea alba Postoperative incisional complications were defined as the was closed in a simple continuous pattern using #3 USP polyglac- presence of surgical site infection (SSI), and/or development of tin 910 (Vicryl; Ethicon) followed by lavage with 0.9% irrigation hernia formation. Surgical site infection was defined as devel- saline. In most cases, 1 g of cefazolin (Cefazolin; Apotex, Weston, opment of spontaneous serosanguinous or purulent incisional Florida, USA) powder was applied topically to the incision before drainage persisting for  24 h, and/or positive bacterial culture closure of the subcutaneous tissue and skin based on surgeon of incisional drainage. Improved drainage was facilitated by preference. The subcutaneous tissues were closed in a simple selective removal of staples in these cases. Incisional complica- continuous pattern using #2-0 USP polydioxanone (Ethicon) tions that developed during hospitalization were identified from or #2-0 USP poliglecaprone acid (Ethicon). The skin was closed the medical record. Incisional complications that developed fol- with nonabsorbable stainless steel staples (Vet One, MWI Animal lowing discharge from the hospital were identified by telephone Health, Boise, Idaho, USA). The incisions were measured using questionnaire with owners or referring veterinarians. the metric measurement markings on the scalpel blade handle at the end of surgery. A sterile bandage was placed over the inci- Statistical analysis sion and consisted of either a 50  30 cm rolled cotton sterile Data were divided into continuous (age, body weight, pre- disposable surgical towel (Medline) or antimicrobial impregnated operative physical examination and clinicopathological findings, roll gauze (AMD Kerlix, Covidien, Plymouth, Minnesota, USA) enterolith size and number, incision length, duration of surgery, secured with #2 USP polypropylene (Ethicon) or gauze placed days of hospitalization) and categorical variables [colic dura tion over the incision and secured using an iodine impregnated adhe- (acute, chronic) year and month of presentation, breed, gender, sive drape (Ioban; 3M Health Care). Recovery from anesthesia number of enterotomies, location of enterotomies, application of was assisted using a head and tail rope in all but 2 cases. topical antibiotics in the incision during closure, recovery quality, type of suture material used for subcutaneous inci- Postoperative care sional closure, type of postoperative incision protection, Following recovery from anesthesia, equids were admitted to the signs of postoperative colic, presence of postoperative fever]. intensive care unit for monitoring and treatment. Equids were Continuous variables were evaluated for normality using immediately allowed free access to water, with food withheld for Q-Q plots and comparisons between equids with and without 6 to 12 h. Crystalloids (2 to 4 mL/kg BW per hour) were adminis- incisional complication were made using Student’s t-tests,

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if the data were normally distributed, and Wilcoxon rank- TC (n = 3), LDC and RDC (n = 2), and LDC, RDC, and sum test, if the data were not normally distributed. Similarly, DC (n = 1). The location of enteroliths was not recorded in categorical variables were compared between equids with and 2 equids. Nine equids were presented with a concurrent right without incisional complications using 2 test or a Fisher’s exact dorsal displacement of the large colon and 1 with a concurrent test, as appropriate. Significance was set at P  0.05 for all tests. large colon sand impaction. No ischemic lesions were observed Statistical analyses were performed using commercially available in any of the equids included in this study. statistical analysis software (SAS 9.4, SAS Institute, Cary, North Among 72 equids, 71 had PF enterotomy performed to empty Carolina, USA). Descriptive statistics are reported as range the colon and facilitate mobilization of enteroliths to a portion [mean  standard deviation (SD)]. of the colon safer for removal. Specifics regarding enterotomies

ARTICLE performed for enterolith removal were recorded in 69 cases. In Results 9 equids, a solitary enterolith was removed through a single Seventy-two equids met the inclusion criteria. There were enterotomy. In 8 of these cases the enterolith was manipulated 29 Quarter Horses, 12 Arabians, 10 American Paint Horses, from the RDC to the PF enterotomy. In 1 equid PF enterotomy 4 Appaloosas, 4 Thoroughbreds, 2 each of Aztecas, Morgans, was not performed and the enterolith was removed through an Tennessee Walking Horses, Friesians, and 1 each of Warmblood, enterotomy performed in the DC. A second enterotomy was cre- Peruvian Paso, National Show Horse, American Miniature Horse, ated for enterolith removal in 57 equids following PF enterotomy. and miniature donkey. Ages ranged from 4 to 33 y old (mean: Of these, 38 enterotomies were performed in the RDC, 15 were 13.89  7.5 y). There were 32 geldings (44%), 30 mares (42%), performed in the DC, and 4 were performed in the LDC. Three and 10 intact males (14%). Body weight ranged from 87 to equids with multiple enteroliths required a total of 3 enteroto- 658 kg (mean: 486.2  90.6 kg). mies. Two had enterotomies performed in the PF, RDC, and DC, Thirty (41.7%) equids were presented for evaluation of acute and 1 had enterotomies performed in the PF, LDC, and DC. The abdominal pain and 37 (51.4%) for chronic abdominal pain. Five number of enterotomies was not reported for 3 equids. equids (6.9%) were presented for elective abdominal radiographs The duration of postoperative hospitalization ranged from and were not exhibiting signs of abdominal discomfort on admis- 2 to 13 d (mean: 4.7  1.9 d). Ten equids (13.9%) developed sion but were presented with a history suggestive of enterolithia- 1 or more incisional complication and all weighed  400 kg. sis including episodic abdominal discomfort, anorexia, passage of Seven of ten were presented for evaluation of chronic abdominal soft feces, or passage of small enteroliths in manure. pain. Postoperative incisional complications occurred in 6 equids Seventy equids had a complete digital radiographic study of (8.3%) diagnosed with SSI and 5 equids (6.9%) that developed the abdomen performed at hospital admission and 1 horse was incisional hernias. One equid with confirmed SSI also had an presented with abdominal radiographs taken by the referring vet- incisional hernia. Three equids had SSI definitively diagnosed on erinarian. The other equid was not radiographed and exploratory microbial culture performed during postoperative hospitalization celiotomy was performed immediately following initial evaluation and in the remaining 3 a presumptive diagnosis of SSI was based due to intractable abdominal pain. In this case, enterolithiasis was on persistent serosanguinous or purulent incisional drainage diagnosed during abdominal exploration. which began after hospital discharge. For the 3 horses that had A single or multiple enteroliths were identified radiographi- microbial culture performed, bacterial isolates included colonies cally in 65 equids (65/71, 91.6%). Radiography failed to identify of Staphylococcus sp., Enterococcus faecium, Escherichia coli, and enteroliths in the remaining 6. For the 64 equids that had evidence Bacteroides fragilis. In each of these cases treatment included of enterolithiasis on radiographs obtained at our institution, the establishment of adequate incisional drainage, continued local approximate diameters of enteroliths were measured in 61 using wound care, and administration of systemic antimicrobials until dedicated medical imaging software (SAS 9.4; SAS Institute). incisional drainage resolved. For the 3 cases with presumed SSI The diameters of enteroliths ranged from 4.5 to 27.8 cm (mean: diagnosed after hospital discharge, administration of systemic 17.2  4.7 cm). The diameter of enteroliths could not be mea- antimicrobials prescribed by referring veterinarians and local sured in the remaining 3 equids due to indistinct margins. wound care resulted in resolution of clinical signs. Length of the ventral midline incision was recorded for For the 5 equids that developed incisional hernias, the defect 68 equids, and ranged from 15 to 40 cm (mean: 28.1  in the body wall was detected between 1 and 5 mo following 5.9 cm). Nine equids were hypotensive during general anesthesia hospital discharge. More Quarter Horses (n = 3) developed an (MAP  65 mmHg) for  15 min. Two of these equids devel- incisional hernia than did other breeds, but Quarter Horses were oped incisional complications. Total surgery time was recorded initially overrepresented in this population and this finding was in 71 cases and ranged from 70 to 200 min (mean: 127.6  not statistically significant. In 2 equids, hernias were managed 30.5 min). Surgical time was  120 min in 38 of these cases successfully using an abdominal support bandage, and no treat- and included 8 equids that developed 1 or more incisional ment was deemed necessary in 2 equids. For the remaining equid, complication. Forty-four equids had a single enterolith located surgical repair was recommended due to the size of the hernia. in either the RDC (n = 19), TC (n = 12), or DC (n = 13). Eight of ten equids with incisional complications had an Fourteen equids had multiple enteroliths located in the RDC enterotomy performed in the RDC following PF enterotomy and 1 had 3 enteroliths located in the TC. In 11 equids the for removal of an enterolith measuring  15 cm in diameter. enteroliths were identified in multiple locations throughout the Of these, 4 developed an incisional hernia as a sole complica- AC, TC, and DC including RDC and DC (n = 5), RDC and tion, 3 developed an SSI as a sole complication (2 confirmed,

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1 presumptive) and 1 developed a hernia following SSI followed by application of an 85% ethyl alcohol-based rub (confirmed). The remaining 2 with SSI (presumptive) had entero- before exploratory celiotomy. A recent study evaluated pre- liths removed through DC enterotomy following PF enterotomy. operative hand preparation using chlorhexidine applied using Cefazolin powder (Cefazolin; Apotex, Weston, Florida, USA) either the scrub side or sponge side of a disposable sponge/scrub was applied topically to the incision following closure of the brush, a chlorhexidine/alcohol based rub, or an alcohol based linea alba in 39 of 72 cases. Eight of ten equids that developed rub alone (36). The authors of that study concluded that while

incisional complications did not have a topical antibiotic applied all 4 preparations adequately reduced bacterial counts on the ARTICLE during closure of the ventral midline incision. Topical application skin, an alcohol based rub alone was less effective than products of an antimicrobial powder (Cefazolin; Apotex) to the incision containing chlorhexidine. Furthermore, given the residual effects following closure of the linea alba was significantly associated of chlorhexidine, these findings may be of further significance (P = 0.02) with a reduced occurrence of incisional complications. when performing exploratory celiotomy and extended surgical A statistically significant association was not found for any other times may be encountered. pre-, intra-, or postoperative continuous or categorical variables In the current study, the only factor significantly associ- evaluated in the study. ated with a reduced occurrence of incisional complications Thirty-one equids recovered with the incision protected using a was the topical application of an antimicrobial to the incision stent bandage. Twenty-three had a sterile blue towel sutured over following closure of the linea alba and before closure of the the incision, 5 had an antibiotic impregnated dressing sutured subcutis and skin (P = 0.02). Cefazolin is a broad-spectrum first- over the incision, and in 3 the type of stent bandage was not generation cephalosporin with activity against Gram-positive recorded. Thirty-one equids recovered with the incision protected and Gram-negative bacteria that have been commonly isolated using sterile gauze and an iodine impregnated adhesive drape from ventral midline incisional infections in horses, including placed over the incision. Type of incisional protection employed Staphylococcus spp., Streptococcus spp. and E. coli (34). Thirty- for recovery from anesthesia was not recorded in the remaining nine equids had cefazolin powder applied topically following 10 equids. closure of the linea alba and 33 did not. Eight of the 33 cases that did not have cefazolin powder applied subsequently devel- Discussion oped 1 or more incisional complication. Based on these results, In the current study, horses undergoing exploratory celiotomy the authors recommend application of cefazolin powder during for removal of enteroliths had an overall incisional complica- closure of ventral midline celiotomy incisions. tion rate of 13.9%, with 8.3% SSI and 6.9% hernia formation A recent study reported that the development of SSI does rates respectively. Pre-operative reported factors that have not appear to be solely related to bacterial contamination of the been associated with increased risk of SSI include body weight incision peri-operatively, and that various bacterial isolates will  300 kg (12); longer duration of colic signs ( 8 to 24 h) be cultured pre-, intra-, and post-surgery without the develop- before presentation at a referral center (24); and the nature of ment of an SSI (37). Also, the authors of that report state that the emergency surgical procedure (12). Intra-operative variables the development of an SSI is multifactorial and influenced by such as hypovolemia, hypoxemia, poor tissue perfusion (12,27), other factors including hematogenous spread of bacteria. In increased duration of surgery (19) and anesthesia (24,25), the current study, ventral midline incisions were only cultured creation of an enterotomy and draping technique to isolate the if evidence of SSI was present which is standard practice at our enterotomy site (23), contamination of the abdominal cavity institution. This is because development of SSI is not necessar- during surgery (12,15), length of the incision (29), quality of ily related to bacterial isolates present without concurrent signs recovery from general anesthesia (17), and administration of of an SSI. Based on this recent study (36), a positive bacterial a topical antibiotic during closure of the abdominal incision (23) culture obtained during or after surgery should be interpreted have all been shown to influence the occurrence of incisional cautiously if no overt signs of SSI are present. complications. In the current study, the rate of SSI was low and incisional In the current study, no statistically significant increase in hernia formation was similar to previous reports (4,11,18,35). incisional complications was identified when comparing the It is difficult to make comparisons between the current study different locations or number of enterotomies (AC compared and previous reports on SSI and hernia formation, due to to DC) created for enterolith removal. Furthermore, size of temporal and spatial differences, pre-, intra-, and postoperative enteroliths was not significantly associated with an increased variables, and indications for exploratory celiotomy. This study risk for incisional complications. However, 8 of the equids that specifically evaluated a relatively systemically healthy subset of developed incisional complications had an enterolith  15 cm equids requiring exploratory celiotomy for correction of a non- removed through an enterotomy performed in the RDC. strangulating gastrointestinal lesion. All equids that developed incisional complications weighed A recent study reported that a 3-layer closure of a ventral mid-  400 kg, in 8/10 surgical time was  2 h, in 8/10 a topical line incision was protective compared to a 2-layer closure (28). antimicrobial was not applied to the incision during wound clo- Closure of the skin incision with staples was associated with sure and 7/10 were presented for a chronic episode of abdominal increased incisional complications in 1 study (25), whereas other discomfort ( 24 h). authors were unable to demonstrate a significant effect of the At our institution, it is standard for surgeons to prepare the use of skin staples on the incidence of incisional drainage (31). skin with a 5-minute scrub using 4% chlorhexidine gluconate In the current study, all ventral midline incisions were closed in

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3 layers (linea alba, subcutaneous tissues, and skin). The linea barrier against incisional contamination during recovery from alba was closed with #3 USP polyglactin 910e, and in the 67 cases anesthesia. In the current study the type of incisional protection for which it was reported, the subcutaneous tissues were closed applied was not found to be significantly associated with the with either #2-0 USP poliglecaprone acid (n = 46) or #2-0 USP development of incisional complications. polydioxanone (n = 21) and skin with nonabsorbable stainless Limitations of the current study include its retrospective steel staples. No association was identified between incisional nature, the limited total number of equids that met the inclu- complications and suture material used for closure of the subcutis. sion criteria with even fewer of those that went on to develop An additional risk factor associated with the development incisional complications, and that follow-up was dependent on of incisional complications following exploratory celiotomy is owner information in most of the cases. While application of a

ARTICLE trauma to the incisional edges while manipulating the gastro- topical antimicrobial during closure of ventral midline celiotomy intestinal tract (15,16,20). Manipulation and mobilization of was the only factor found to be statistically significant regarding enteroliths from the point of obstruction to a suitable location for a reduced risk for incisional complications in the current study, removal may cause iatrogenic trauma to the edges of the incision. the specific reason for application in each case was not inves- Incisional infection and subsequent hernia formation are of tigated. Therefore, factors which may have contributed to the concern after enterotomy (12,15), in particular when enteroliths decision to apply a topical antimicrobial such as surgical time, cannot be mobilized to a location distant from the ventral mid- length of incision, number and location of enterotomies and line incision before enterotomy (7). This can be due to the size surgeon preference, among others, may have been confounders of the enterolith exceeding the diameter of the colon through as they were not included in analysis. which mobilization is being attempted, and can be compounded Additional limitations include lack of standardization by anatomic restrictions limiting mobility of certain segments (i.e., different suture materials used to close the subcutaneous of colon. One study found an association between enterotomy tissues and different methods used to protect the incisions for and an increased risk of incisional infection (20), and another recovery related to surgeon preference), presence of multiple study reported a 20% occurrence of incisional hernia formation surgeons, lack of a control group, or that the distance between after ventral midline celiotomy with enterotomy (12). However, the enterotomy performed for enterolith removal and the ven- other studies did not find any association between incisional tral midline incision was not recorded. complications and enterotomy performed as part of the procedure In conclusion, the overall prevalence of incisional com- (11,15,17,18,31,34). plications following removal of enteroliths was low (13.9%), In the current study, only 1 of the 5 equids that developed an and the application of antimicrobial cefazolin powder in the incisional hernia experienced incisional infection before hernia incision following closure of the linea alba had a statistically formation, suggesting that risk factors for incisional hernia follow- significant effect in reducing the rate of incisional complications. ing enterolith removal may not be associated with earlier signs of Furthermore, proper surgical technique with an emphasis on incisional complications. It has also been reported that incisional meticulous draping of the enterotomy site is critical, especially herniation may be attributed to factors such as uncontrolled when dealing with large enteroliths, which may increase the risk early postoperative exercise, suture material failure, inadequate for incisional complications following exploratory celiotomy. anatomic reconstruction, or violent postoperative recovery (17). Owners should be aware of an increased risk of incisional However, none of these factors were reported in any of the cases complications when large size enteroliths are observed in pre- reported here that developed hernias. operative radiographs. CVJ In a previous report, location of enteroliths (AC or DC) did not significantly affect the number of postoperative complica- References tions (11). In that report, incisional complications were among 1. Blue MG. Enteroliths in horses — A retrospective study of 30 cases. the most frequent short-term postoperative complications Equine Vet J 1979;11:76–84. encountered, with an increased frequency for enteroliths located 2. Cohen ND, Vontur CA, Rakestraw PC. Risk factors for enterolithiasis within the DC compared with the AC. In the current study, among horses in Texas. J Am Vet Med Assoc 2000;216:1787–1794. 3. Dart AJ, Snyder JR, Pascoe JR, Farver TB, Galuppo LD. Abnormal con- 8/10 equids that developed incisional complications had an ditions of the equine descending (small) colon: 102 cases (1979–1989). enterotomy performed in the AC and only 2 had enterotomy J Am Vet Med Assoc 1992;200:971–978. performed in the DC, which contrasts with the aforementioned 4. Hassel DM, Langer DL, Snyder JR, Drake CM, Goodell ML, Wyle A. Evaluation of enterolithiasis in equids: 900 cases (1973–1996). report. This finding may have been due to the large diameter J Am Vet Med Assoc 1999;214:233–237. of enteroliths ( 15 cm) in the 8/10 equids that developed 5. Ferraro GL, Evans DR, Trunk DA, Roberts TT. Medical and surgical incisional complications. Larger enteroliths are more difficult management of enteroliths in Equidae. J Am Vet Med Assoc 1973; 162:208–210. to mobilize to an intraluminal location distant from the primary 6. Peloso JG, Coatney RW, Caron JP, Steficek BA. Obstructive enterolith surgical field and thus enterotomy is more likely to contaminate in an 11-month-old miniature horse. J Am Vet Med Assoc 1992;201: the celiotomy incision. 1745–1746. 7. Pierce RL. Enteroliths and other foreign bodies. Vet Clin North Am Contamination of unprotected ventral midline incisions Equine Pract 2009;25:329–340. during anesthetic recovery was found to be an important risk 8. Schumacher J, Mair TS. Small colon obstructions in the mature horse. factor for the development of incisional drainage following colic Equine Vet Educ 2002;14:19–28. 9. Felizet L. Un calcul et un bouchon extrait, le premier, de l’intestine surgery (21). In our experience, a sutured stent bandage is more d’un cheval, le second, de l’intestine d’un chien. Rev vet (Toulouse) reliable than an adhesive incise drape in maintaining a protective 1877;2:27–28.

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10. Southwood LL. Large colon. In: Auer JA, Stick SJ, Kümmerle JM, 25. Torfs S, Levet T, Delesalle C, et al. Risk factors for incisional complica- France T, eds. Equine Surgery. St. Louis, Missouri: Elsevier, 2019: tions after exploratory celiotomy in horses: Do skin staples increase the 591–621. risk? Vet Surg 2010;39:616–620. 11. Pierce RL, Fischer AT, Rohrbach BW, Klohnen A. Postoperative com- 26. Stick JA. Preparation of the surgical patient, the surgery facility, and plications and survival after enterolith removal from the ascending or the operating team In: Auer JA, Stick JA. Equine Surgery. 4th ed. descending colon in horses. Vet Surg 2010;39:609–615. St. Louis, Missouri: Elsevier, 2014:111–121. 12. Wilson DA, Baker GJ, Boero MJ. Complications of celiotomy incisions 27. Costa-Farre C, Prades M, Ribera T, Valero O, Taurà P. Does intraopera- in horses. Vet Surg 1995;24:506–514. tive low arterial partial pressure of oxygen increase the risk of surgical

13. Tnibar A, Grubbe Lin K, Thuroe Nielsen K, et al. Effect of a stent site infection following emergency exploratory laparotomy in horses? ARTICLE bandage on the likelihood of incisional infection following exploratory Vet J 2014;200:175–180. coeliotomy for colic in horses: A comparative retrospective study. Equine 28. Isgren CM, Salem SE, Archer DC, Worsman FC, Townsend NB. Vet J 2013;45:564–569. Risk factors for surgical site infection following laparotomy: Effect of 14. Durward-Akhurst SA, Mair TS, Boston R, Dunkel B. Comparison of season and perioperative variables and reporting of bacterial isolates in two antimicrobial regimens on the prevalence of incisional infections 287 horses. Equine Vet J 2017;49:39–44. after colic surgery. Vet Rec 2013;172:287. 29. Darnaud SJ, Southwood LL, Aceto HW, Stefanovski D, Tomassone L, 15. Phillips TJ, Walmsley JP. Retrospective analysis of the results of Zarucco L. Are horse age and incision length associated with surgical site 151 exploratory laparotomies in horses with gastrointestinal disease. infection following equine colic surgery? Vet J 2016;217:3–7. Equine Vet J 1993;25:427–431. 30. Colbath AC, Patipa L, Berghaus RD, Parks AH. The influence of suture 16. McIlwraith CW. Complications of laparotomy incisions in the horse. pattern on the incidence of incisional drainage following exploratory Proc Am Assoc Equine Practnrs 1978;24:209–216. laparotomy. Equine Vet J 2014;46:156–160. 17. Kobluk CN, Ducharme NG, Lumsden JH, et al. Factors affecting 31. Kilcoyne I, Nieto JE, Dechant JE. A comparative study of the effect of incisional complication rates associated with colic surgery in horses: different stent bandages on the likelihood of incisional complications 78 cases (1983–1985). J Am Vet Med Assoc 1989;195:639–642. following exploratory laparotomy in horses with colic. Equine Vet Educ 18. Gibson KT, Curtis CR, Turner AS, McIlwraith CW, Aanes WA, Stashak 2017;29:38–38. TS. Incisional hernias in the horse. Incidence and predisposing factors. 32. Mair TS, Smith LJ. Survival and complication rates in 300 horses Vet Surg 1989;18:360–366. undergoing surgical treatment of colic. Part 3: Long-term complications 19. Stone WC, Lindsay WA, Mason D, Wilson DG. Factors associated with and survival. Equine Vet J 2005;37:310–314. acute wound dehiscence following equine abdominal surgery. Equine 33. Kaneps A. Hernias. In: Auer JA. Equine Surgery. 1st ed. Philadelphia, Colic Resident Symposium 1991:52. Pennsylvania: WB Saunders, 1992. 20. Honnas CM, Cohen ND. Risk factors for wound infection following 34. Ingle-Fehr JE, Baxter GM, Howard RD, Trotter GW, Stashak TS. celiotomy in horses. J Am Vet Med Assoc 1997;210:78–81. Bacterial culturing of ventral median celiotomies for prediction of post- 21. Galuppo LD, Pascoe JR, Jang SS, Willits NH, Greenman SL. Evaluation operative incisional complications in horses. Vet Surg 1997;26:7–13. of iodophor skin preparation techniques and factors influencing drain- 35. Evans DR, Trunk, DA, Hibser NK. Diagnosis and treatment of entero- age from ventral midline incisions in horses. J Am Vet Med Assoc lithiasis in equidae. Compend Contin Educ Pract Vet 1981;3:383–390. 1999;215:963–969. 36. Biermann NM, McClure JT, Sanchez J, Saab M, Doyle AJ. Prospective, 22. French NP, Smith J, Edwards GB, Proudman CJ. Equine surgical randomised clinical trial of four different presurgical hand antiseptic colic: Risk factors for postoperative complications. Equine Vet J 2002; techniques in equine surgery. Equine Vet J 2019;51:600–605. 34:444–449. 37. Isgren CM, Salem SE, Townsend NB, Timofte D, Maddox TW, Archer 23. Mair TS, Smith LJ. Survival and complication rates in 300 horses DC. Sequential bacterial sampling of the midline incision in horses undergoing surgical treatment of colic. Part 2: Short-term complica- undergoing exploratory laparotomy. Equine Vet J 2019;51:38–44. tions. Equine Vet J 2005;37:303–309. 24. Smith LJ, Mellor DJ, Marr CM, Reid SW, Mair TS. Incisional complications following exploratory celiotomy: Does an abdominal bandage reduce the risk? Equine Vet J 2007;39:277–283.

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CVJ / VOL 61 / OCTOBER 2020 1091 FOR PERSONAL USE ONLY Review Article Compte rendu

Teleconsulting in the time of a global pandemic: Application to anesthesia and technological considerations

Daniel S.J. Pang, Jessica M. Pang, Opal-Jane Payne, Frazer M. Clement, Terrie Faber

Abstract — As a result of the various restrictions associated with the current COVID-19 pandemic, the practice of veterinary telehealth is likely to grow substantially. One area in which high quality care can be maintained while respecting physical distancing is teleconsulting, which describes the relationship between an attending and off-site consulting veterinarian. This guide uses a dentistry case to illustrate the provision of real-time anesthesia consulting, with a focus on the technological considerations central to facilitating live, 2-way video-communication. Case selection, teamwork, and patient safety are also discussed.

Résumé — Téléconsultation en temps de pandémie globale : application à l’anesthésie et considérations technologiques. Comme résultats des différentes restrictions associées à la présente pandémie de COVID-19, la pratique de télésanté vétérinaire est appelée à croître considérablement. Un domaine dans lequel des soins de haute qualité peuvent être maintenus tout en respectant la distanciation physique est la téléconsultation, qui décrit la relation entre un vétérinaire traitant et un vétérinaire consultant hors-site. Ce guide utilise un cas de dentisterie pour illustrer les exigences de consultation en temps réel pour l’anesthésie, avec une emphase sur les considérations technologiques essentielles pour faciliter une communication vidéo bidirectionnelle en direct. La sélection de cas, le travail d’équipe et la sécurité du patient sont également discutés. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1092–1100

Introduction cine, teletriage, telemonitoring, and teleconsulting (1). The most important of these is “telemedicine,” a term that is frequently elehealth is a rapidly emerging area of veterinary medicine, misunderstood and variably defined (2,3). the growth of which is likely to be accelerated during T Telemedicine is similarly defined by the Canadian Veterinary the current severe acute respiratory syndrome coronavirus 2 Medical Association (CVMA) and the American Veterinary (SARS-CoV-2) and the coronavirus 2019 (COVID-19) pan- Medical Association (AVMA) as the practice of veterinary medi- demic. Telehealth is an umbrella term that describes “all uses cine at a distance, or between sites, using telecommunication of technology to deliver health information, education or care technology to exchange medical information (1,4). Critically, remotely” (1). Under this umbrella, there is a host of “tele-” telemedicine must occur within a valid veterinary-client-patient- terms describing specific aspects of telehealth, such as telemedi- relationship (VCPR), as it relates to the practice of veterinary medicine. Within Canada, each province and territory has its own definition of a VCPR, but there is broad overlap such that Veterinary Clinical and Diagnostic Sciences, Faculty of core principles are shared [(5), page 11]. Veterinary Medicine, University of Calgary, Alberta (DSJ Pang, In contrast, teleconsulting describes the relationship between JM Pang); Clinical Sciences, Faculty of Veterinary Medicine, an attending veterinarian (who has a VCPR) and a consulting Université de Montréal, St-Hyacinthe, Québec (DSJ Pang); veterinarian who is providing advice. The attending veterinar- Alberta Veterinary Dentistry, Calgary, Alberta (Payne, Faber); ian remains responsible for the veterinary medical care of the Oracle Corporation, Oracle Parkway, Reading, UK (Clement). animal, unless the consulting veterinarian is providing medical Address all correspondence to Dr. Daniel Pang; e-mail: advice or expertise directly to the animal owner, in which case [email protected] the consulting veterinarian becomes the attending veterinar- Dr. Daniel Pang receives operating funds from the Natural ian and is required to meet the licensing requirements of the Sciences and Engineering Research Council of Canada (NSERC) jurisdiction in which the animal is located and have a valid Discovery Grant (424022-201). VCPR (4). Use of this article is limited to a single copy for personal study. The purpose of this review and guide is to share recent experi- Anyone interested in obtaining reprints should contact the ences with providing teleconsulting services for anesthesia sup- CVMA office ([email protected]) for additional port, with a focus on considerations surrounding technology, copies or permission to use this material elsewhere. case selection, communication, and teamwork.

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Dentistry case example The smartphone camera was initially positioned to provide A 13-year-old, 9 kg, neutered male Shih Tzu cross dog was a frontal view of the dog and 2 AHTs performing induc- presented for general anesthesia and referral dental surgery to tion of general anesthesia. Salbutamol (Teva-Salbutamol HFA complete dental work that was aborted due to concerns about 100 mg/actuation; TEVA Canada, Toronto, Ontario), 200 mg, anesthesia. The dog had been anesthetized 3.5 mo previously was administered via a pediatric aerosolizing chamber connected REVIEW ARTICLE REVIEW for a dental procedure at the referring veterinary hospital but to a tight-fitting face mask, followed by IV fentanyl (50 mg/mL; the anesthesia was terminated shortly after induction due to Sandoz Canada, Boucherville, Quebec), 2 mg/kg body weight

respiratory complications (increased abdominal effort associ- (BW), and 5 min of pre-oxygenation with 100% O2 via a ated with radiographic diagnosis of left cranial and caudal lung tight-fitting face mask. Instrumentation for an electrocardio- lobe atelectasis; cause undetermined, suspected endobronchial gram (ECG) and with a pulse oximeter provided continuous intubation). Atelectasis had resolved when radiographs were monitoring and audible signals during induction with IV repeated 3 d later. The dog also had a history of dysplasia and fentanyl (2 mg/kg BW), midazolam (5 mg/mL; Sandoz Canada osteoarthritis in multiple limbs and an increased respiratory Inc), 0.1 mg/kg BW, and alfaxalone (10 mg/mL; Alfaxan, Jurox effort (panting) with prolonged exertion. A complete blood cell Pty, Rutherford, NSW, Australia), 3 mg/kg BW, until endotra- count and serum biochemistry were completed on the morning cheal intubation was possible. Intubation was confirmed with of the aborted procedure. Abnormalities included a mild eryth- bilateral thoracic auscultation during intermittent positive pres- rocytosis [RBC: 9.3 3 1012/L, reference range (RR): 5.83 to sure ventilation (IPPV) and capnography. 9.01 3 1012/L] and a moderate elevation in alkaline phos- Following intubation, the camera was positioned to provide a phatase (ALP) (401 U/L, RR: 23 to 212 U/L). The increased simultaneous view of the physiologic monitor, fluid pumps, ven- ALP was attributed to enzyme induction due to chronic tilator bellows, and anesthetic machine. The lead AHT was in administration of a low-dose of prednisolone for inflammatory constant communication with the consulting anesthetist, provid- bowel disease. ing feedback regarding anesthetic depth, physiologic status, and Physical examination findings and blood analysis on the the dental procedure. The attending veterinarian (dentist) and morning of surgery included a moderate tachycardia (144 beats/ other members of the healthcare team also provided feedback as min), erythrocytosis (packed cell volume 64%, RR: 36.6% needed (speakerphone function was used for communication). to 54.5%), total protein within reference range (74 g/L, The consulting anesthetist directed several interventions dur- RR: 52 to 82 g/L), hypoglycemia (blood glucose: 3.4 mmol/L, ing the course of the anesthesia including volume resuscitation RR: 3.89 to 7.95 mmol/L), and a nervous but calm demeanor. [Lactated Ringer’s Solution (Lactated Ringer’s Solution USP, Heart rhythm, bilateral femoral pulses, bilateral lung field aus- Baxter, Mississauga, Ontario), IV bolus of 10 mL/kg body cultation, tracheal auscultation, and respiratory rhythm and weight (BW) and Voluven (6% hydroxyethyl starch 130/0.4 rate were normal. There was no history of coughing, cyanosis, in 0.9% sodium chloride, Fresenius Kabi Canada, Toronto, syncope, stridor, or stertor before or after the anesthetic episode. Ontario), 5 mL/kg BW, in addition to a 5 to 10 mL/kg BW An American Society of Anesthesiologists (ASA) physical status per hour, IV maintenance rate of Lactated Ringer’s Solution], classification of 2/5 was assigned. blood glucose management, adjustments of IPPV settings, and The day before the procedure, a successful trial (20 min) of administration of analgesics both as boluses and variable rate the videoconferencing equipment to be used for the procedure infusions. Left and right infraorbital and inferior alveolar dental was performed, which also provided the opportunity to try blocks were performed (1.5 mg of 0.5% bupivacaine HCl with various camera positions. epinephrine per site; bupivacaine 5 mg/mL 1 epinephrine The videoconference started at 0950. A smartphone (iPhone 7; 0.0091 mg/mL, Vivacaine, Septodont, Cambridge, Ontario). Apple, Cupertino, California, USA) was mounted on a mobile The duration of the procedure was approximately 3 h. The IV stand in the dental suite and the consulting anesthetist used lead AHT and consulting anesthetist formulated a recovery a laptop computer (MacBook Air 11-inch; MacOS v10.15.3, and extubation plan in advance of turning off the isoflurane Apple) with built-in camera and microphone. A free videocon- vaporizer. For recovery, the camera was repositioned to face ferencing platform was used (Zoom; San Jose, California, USA) the dog, showing a view of its head (in sternal recumbency), with a unique call-in ID, and the Wi-Fi Internet connections with audible Doppler ultrasound, ECG, and pulse oximeter were password protected at both locations. During the first monitoring, along with oxygen administration by mask. The 10 min, the dog was visually assessed, physical examination consulting anesthetist directed the recovery phase and timing findings were discussed, and a plan for anesthesia was reviewed of extubation, in the presence of the attending veterinarian. with the lead animal health technologist (AHT) anesthetist. The Remote continuous observation continued for a further 10 min anesthetic considerations and potential interventions for eryth- post-extubation. The consulting anesthetist remained available rocytosis, as well as the procedures for avoiding and detecting by telephone for the remainder of the day and was notified by endobronchial intubation were discussed in detail. The moderate text message when the patient was discharged to its owner. Post- tachycardia was attributed to the patient’s nervous demeanor. procedure follow-up was provided by the attending veterinarian, A detailed procedural document was developed to help AHT, and consulting anaesthetist by telephone. manage the case, including checklist items, to compensate for The videoconference quality was adequate for communica- the limitations of teleconsulting (Appendix I, available from tion and visualization; however, several minor problems were https://doi.org/10.7910/DVN/NIZ51Y). encountered. There were 6 interruptions in the video feed, each

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Table 1. General considerations when setting up a teleconsultation with a specific example illustrated using the Zoom videoconferencing platform. General considerations Example Device Software (installed, upgraded) Operating system and Zoom software up-to-date on cell phone (in operating room) and laptop (with teleconsultant) Power (chargers, sockets) Confirmed available (day before during test call) Positioning (mounting/field of vision) Mounting cell phone on portable IV stand tested day before (height and field of view) Video capture Minimum resolution $ 720 p, frame rate . 30 fps Video viewing Minimum 1 MP (e.g., 1334 3 750 pixels), frame rate . 30 fps

COMPTERENDU Security (passwords, virus, etc.) Password-protected cell phone and laptop Recording capability Not performed (requires consent from participants). Paper anesthetic record maintained Storage memory Not used (no recording) Spare device? S martphone [with alternative (FaceTime) videoconferencing software installed]

Network Data transfer rate up 1 down to Internet . 5 to 10 Mbps Security (Wi-Fi password, VPN) Password-protected Wi-Fi network (all locations) Backup connectivity (mobile data/wired?) Cell phone data (3G) available as backup

Service Features (video, voice, screenshare, multi-participant) Zoom: videoconferencing with option to switch to voice-only as needed to improve connectivity. Additional communication available via live chat function. Cost Free Security (encryption, limiting participants) Zoom: unique session ID, password required to join session, “waiting room” function enabled (host controls who joins the session), session “locked” by host once all participants have joined (prevents additional parties joining), screen sharing capabilities controlled by host. End-to-end encryption provided. Reliability Assessed during a test call the day before Accounts/numbers/handles to be used Login and connection tested during test call

Preparation tests Dry run call (same numbers/handles, devices, Performed $ 1 day before procedure networks, locations) Image and sound quality Test using planned location and monitoring equipment (ability to see monitor screen) Instrument legibility As above Check switchover to backup device/network Check backup cell phone number is correct and signal service is good at both locations

Information provided in the example is for illustrative purposes. Due to the rapid pace of advances in technology, performing a test call is always recommended and the security features of videoconferencing platforms should be confirmed before use.

lasting approximately 5 to 15 s (video froze and a “poor signal” capturing and transmitting digitized data (6–8). In veterinary message appeared on the screen). Audio continued to function medicine, reports of telemedicine and telehealth emerged in during these times so no recourse to an alternative means of the 1990s, but they have not yet experienced the same growth communication was necessary. At one point, the iPhone battery as in human medicine (2,9–11). A lack of familiarity and per- was low and needed to be recharged to continue the call. The haps comfort with technologies available may be slowing this camera in the dental suite was accidentally moved several times growth (2). and had to be repositioned. Finally, the video quality was accept- A recent, albeit small survey of veterinarians in clinical able, though it was noticed that red waveforms on the monitor practice (n = 76 respondents), found that approximately 1/3 display were harder to see and the video feed was occasionally of respondents hardly ever/never used telehealth (n = 27/76) out of focus, though it remained usable. or telemedicine (n = 26/76) and use of videoconferencing for communication was low (n = 10/76) (2). Approximately 17% Discussion (n = 9/54) of respondents stated that telehealth and telemedicine Telehealth and telemedicine are well-established concepts in were the same thing, reflecting its frequent interchangeable use human medicine, emerging in the early 20th century and in the human literature. Over 100 definitions of telemedicine enjoying a rapid increase in use in the 1990s with the advent of have been identified in the human literature (3). It should be Internet access combined with decreasing costs of technology for noted that the sample surveyed may not be representative of

1094 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY the profession [more than 75% of respondents were $ 40 y old Table 2. Sample residential Internet service. and most (60%) were male)]. Interestingly, those surveyed were Download speed Upload speed selected based on association with a veterinary college’s distrib- Time of day Ping (ms) (Mbps) (Mbps) uted clinical year program, potentially impacting exposure of 0730–0800 5 to 18 46.1 to 90.2 40.8 to 68.4 the next generation of veterinarians to telehealth. 1200–1300 11 to 14 90.2 to 90.3 70.6 to 72.4 REVIEW ARTICLE REVIEW Telemedicine has been successfully applied to all phases of 1500–1600 2 to 18 48.6 to 90.2 16.9 to 72.0 1730–1830 14 to 19 87.8 to 90.2 72.0 human anesthetic practice, from pre-operative consultations, Data are ranges following daily testing during the week (Mon–Fri) by a co-author through intra-operative monitoring to post-operative and (DP) in his home. Ping speed reflects connection quality to server 100 km away. intensive care monitoring (12). The earliest reports of remote Data collected with speedtest.net. Note: Data reflect distance/number of monitoring of general anesthesia in real time (“synchronous”) (9) connections. described the application of both purpose-built devices for collecting and transmitting information where data transmission services compete to provide good quality, reliable, and easy-to- speeds were limited (see Technology) and the use of existing use software for setting up and running video and voice calls telecommunications (13–15). and multi-participant conferences. The use of real-time telemedicine contrasts with a store-and- forward (“asynchronous”) approach with which most veterinar- Video capture ians are familiar. The store-and-forward approach commonly Options for video (and sound) capture include static and mobile applies to teleconsulting for diagnostic imaging, in which data video cameras. As technology has advanced, smaller handheld are collected and stored by the attending veterinarian, then devices provide an acceptable level of quality, removing the need forwarded for evaluation (7). The greatest challenge of real-time for additional hardware and software to connect a standalone applications is a time-sensitive dependency on technology. video camera to a computer for transmission. The inherent While the basis of this paper was the stimulus to meet a advantage of using a video camera built into a device capable of demand for anesthesia support within the constraints of the transmission reduces options to laptop computers, tablets, and current pandemic, telehealth has an important role to play smartphones. For laptops and tablets, most popular devices all in accessibility to veterinary and human healthcare (remote have “high-definition” or “ultra-high-definition” (. 1080 pixels) settings, limited numbers of general practitioners and special- video cameras, recording at 24 to 60 frames per second (fps), ists) (2,9,12,15). with similar specifications for current smartphones. The remainder of this discussion describes specific consider- Smaller devices have the advantages of portability, availabil- ations and challenges in performing teleconsulting in real time ity, and ubiquity, enabling ad-hoc consultations. Smartphones with video; a summary table illustrates the key points provided or other devices with mobile connectivity as well as Wi-Fi can (Table 1). be used in a wider variety of locations and provide a built-in backup communication channel. Mobile phone Internet in Technology the US and Canada is currently used by around 80% of the Historically, both general purpose videoconferencing software population, making phones highly accessible and potentially and purpose-built systems have been successfully used (13,14). capable of supporting video and sound transmission for tele- Key considerations in equipment and platform selection are cost, consulting (17,18). data security, and performance. In human medicine, particularly Whether hand-held or affixed to a mobile stand (as described for surgery but also for pre-operative anesthesia consulting, in the reported case), portability has the advantage of using a dedicated towers incorporating video cameras, microphones, and single device to easily capture different areas of the room, as electronic (often modular) instruments (electronic stethoscopes needed. In some instances, it could be advantageous to have and otoscopes, and fiberoptic cameras) are available (12,16). For simultaneous unrestricted views of the patient and physiologic supervised surgery (“telementoring”), these are often combined monitor, requiring 2 devices and a means of transmitting 2 video with telestrator capabilities (being able to indicate landmarks streams (13). Early reports, in which transmission capabilities and features on the surgeon’s monitor) (16). These units have were limited to satellite phones (data transfer rates of 64 Kbps), relatively high upfront and maintenance costs, currently preclud- maximized use of available bandwidth by pairing a single video ing their use in veterinary medicine. In contrast, the combina- camera (on operating field) with physiologic data fed directly tion of a video camera (e.g., smartphone), monitor (e.g., laptop into a purpose-built device for data integration and transmis- computer/tablet), and videoconferencing platform, as described sion (14). in the presented case, is suitable for most veterinary needs. In recent years, streaming video and Internet video call/ Video transmission conferencing services have become very popular, driving huge There are numerous considerations regarding video transmis- investments in related technologies. Affordable consumer devices sion, including data transfer rate, videoconferencing platform, now have good quality cameras, microphones, and displays and data security. The ability to view and provide timely input with processors capable of efficiently encoding and decoding on viewed information depends on the achievable data transfer “high-definition” video. Large investments in fixed and mobile rate (sometimes referred to as bandwidth or connection speed). Internet access continue to drive down the cost of device con- With high quality video, data transfer rates , 128 Kbps are nectivity while improving performance. Meanwhile multiple associated with greater technical difficulties; lag or latency in

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Table 3. Selected applications for videoconferencing. Platform Encryption Secure login Free? Comments Skype Y, chats stored on Password Y company servers Skype for Business Y, end-to-end possible Password N Being replaced by MS Teams Zooma,b Optional end-to-end when Password Y (limited 40 minute Can control participants using application duration for $ 3 devices) joining calls and lock calls (preventing people joining) Microsoft Teamsb End-to-end Password, multifactor N Limited to users of authentication Office365 suite WhatsApp End-to-end Optional (depends on Y COMPTERENDU device security) FaceTime End-to-end Optional (depends on Y (Mac devices) device security) REACTSb Y Password N KARL STORZ VisitOR1b Y Password N Accepts inputs from auxiliary wired and wireless signals (e.g., physiologic monitor, electronic stethoscope). Data transmitted on private global network KARL STORZ Viewpointb Y Password N* TeamViewerb,c End-to-end Password, multifactor N authentication

Note: Data based on information collected during week of April 27, 2020. Technology changes frequently and users should check that current provisions meet their needs. a Opt-in security features available, including password protection and waiting room (users joining call can be screened before access is provided). b HIPAA compliant (additional subscription service required for MS Teams). c Provides remote screen sharing. Voice support must be provided separately. * Software and private global network can be accessed from supported personal devices.

video and audio (16). Modern residential wired or wireless round-trip delay at the network level, indicating a lower limit Internet connections are typically capable of upload and down- on video/voice delay (Table 2). load rates much higher than this, enabling higher video resolu- Videoconferencing services and applications commonly tions and frame rates (Table 2). Videoconferencing platforms measure and react to changing network conditions, improving provide minimum recommended rates ranging from 1.5 to or degrading video and voice quality in order to maintain a call 2 Mbps, for example (19). Minimum rates assume the minimum with acceptable delays (22). of 2 devices are in use, with a higher transfer rate required if Wired network connections (e.g., Ethernet) provide reli- more devices are conferencing. able data transfer at high rates with low delays but may be As data transfer rates have rapidly increased over time awkward for portability and positioning. Mobile data con- (Edholm’s Law), delays in video transmission have subsequently nections (2.5G/3G/4G/5G) may offer a useful connectivity decreased so that delays with current networks are in the milli- alternative with acceptable data transfer rates and delays, though second range (16). In a simulated surgery study, delays in excess subject to variable signal quality and commonly at greater cost of 500 ms were associated with surgical delays and errors (20). than a fixed Internet connection (23). Importantly, these delay times are 1-way, that is the transmission Disconnections during videoconferencing have been infre- time in 1 direction (e.g., from surgical suite to viewer), and do quently reported in the literature, with 1 study (using Wi-Fi) not consider the additional time to respond, a consideration reporting 7 disconnections, totalling 10 min out of 279 min during teleconsulting. For interactive voice or video calls, of anesthesia teleconsulting time, none of which affected care 1-way mouth-to-ear delays of , 150 ms are recommended or necessitated use of planned backup communications (24). to avoid a perceptible degradation in quality of experience to The experiences in the reported case highlight the possibility participants (21). of technical problems. Many users will have prior experience Advertised Internet data transfer rates are usually considerably with communication issues and may naturally anticipate the higher than achievable rates as a result of network congestion potential need to reconnect, drop to voice only, or try another and other factors (Table 2). For a connection between 2 devices, communications channel. Given the possibility of technical the slowest link in the chain, perhaps a weak local Wi-Fi net- problems or failures, having an alternative method of commu- work or lower upload rate, will limit the achievable data transfer nication is strongly recommended (13,25). In the case described, rate. The ping time between 2 devices measures the current the backups included an alternative videoconferencing platform

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(FaceTime, Apple) and telephone. Additionally, in the described menting the service, giving a good degree of security assuming case, a trial was conducted the day before the planned case, the service provider is trusted (27,28). facilitating familiarization with the technology and software. An alternative approach to dedicated services and videocon- An important consideration that is well-described in the ferencing platforms, is to use a hybrid setup, in which physi- human medical literature, but minimally in the veterinary ologic monitor screens can be shared remotely and voice calling REVIEW ARTICLE REVIEW literature, is security of data during transmission and potential provided through an alternative means such as telephone (32). breaches of confidentiality (7,11,12,14,25,26). On involved Though less convenient than a single package for video and devices and networks, basic security mechanisms such as mak- voice, this may be suitable for occasional use. ing use of passwords, antivirus software, password protected and encrypted Wi-Fi, and other security hygiene methods should Video viewing be implemented. Minimum requirements for video viewing are not well-estab- There are several methods available to protect data in trans- lished in telehealth. Several papers have discussed different mission, including the use of dedicated, legally compliant aspects of display quality, though these largely focus on specific services, encrypted videoconferencing platforms, and Virtual specialty requirements, which tend to exceed the specifications Private Networks (VPN). In North America, legally com- needed for synchronous teleconsulting (33,34). Screen resolu- pliant services have been designed to comply with human tions of approximately 0.75 MP (1024 3 768 pixels) have been healthcare regulations to protect the privacy and security of used successfully for surgical telementoring and limited applica- health information such as the US Health Insurance Portability tions in veterinary radiology (16,35). and Accountability Act of 1996 (HIPAA), which cover the Screen size is a further consideration, with surgeons remotely secure transfer and storage of data (records, images, and supervising laparoscopy favoring monitor screen sizes . 100 video) (27–29). Their development and maintenance come at a over a 50 smartphone (36). This may have added importance if cost, which is recouped from users, limiting current adoption in more than 1 window is displayed concurrently (e.g., physiologic veterinary medicine. When based on a suite of dedicated hard- monitor and room view). A more general statement can be made ware, initial and ongoing maintenance costs are high, though regarding frame rates, with 30 to 60 fps perceived as smooth there may be a role in centers wishing to provide regular remote to the human eye, with a minimum acceptable threshold of support (27). Systems centered on software that can be accessed 15 fps (37). As fps rate decreases, there is a longer delay between through personal devices (smartphones, laptops, tablets) come at frames with the risk of the scene appearing “jittery” with moving a lower cost, with ongoing payments used to support continued objects jumping between points rather than moving smoothly development and maintenance (28). (as in reality) (37). Existing videoconferencing platforms vary considerably in the levels of security available, reflecting how communications Patient selection and risk are accessed, transmitted, and stored (Table 3). Hosting servers In the current COVID-19 pandemic, the CVMA consid- dedicated to videoconferencing on-site is cost-prohibitive and ers veterinary practice and services essential (38) and at the hosted services are generally used provided they meet legislated time of writing, all provinces and territories classify veterinary security requirements (30). Many services provide built-in practice and services as essential. In some cases, veterinary care encryption of data. Some services claim to provide “end-to-end” has been restricted as emergency or urgent care. The Alberta (device-to-device) encryption of data, where the service itself is Veterinary Medical Association does not currently make this unable to decrypt the transported data. However, as a service distinction but states that: “What [veterinary] practices must user, it is not generally possible to be certain whether end-to-end provide is a safe environment for both their veterinary staff encryption is actually applied, in which jurisdiction(s) servers and clients.” (ABVMA members bulletin, April 16, 2020). The are located, how data are routed, how new software versions argument in favor of performing the described case was based behave or how operating company policies change. In some on a welfare concern from dental disease and high likelihood of instances, videoconferencing platforms can be compliant with pain. Untreated dental disease is an animal welfare issue and, health regulations for management of patient data, but this is in many cases, dental treatment should not be considered an typically a paid service and may require a contract between the elective procedure (39). The practice was able to follow pro- provider and user (31). vincial guidelines on physical distancing, barring clients from VPNs are used by organizations to allow remote sites and entering the practice, and appropriate use of personal protective workers to connect to their private internal networks over the equipment (PPE). The considerations for providing telecon- public Internet using encrypted connections. General purpose sulting versus in-person support for this case were primarily VPN services aimed at consumers securely connect their devices centered on minimizing the number of personnel in the work- to the public Internet. These consumer VPNs give a degree of place when appropriate support could be provided remotely, local privacy and anonymity, but do not protect data traversing and the perceived anesthetic risk of the case. It is currently the Internet unencrypted when it leaves the VPN. For public unknown how synchronous teleconsulting affects procedural videoconferencing services reached over the Internet, using a risk for a patient. General considerations, which apply to all consumer VPN to access them does not give significant extra cases (patient selection, teamwork, client communication), are security. Dedicated services use encrypted connections directly discussed in this and the following sections within the context between applications running on devices and the systems imple- of teleconsulting.

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As a specialty, anesthesia recognized the contribution of small changes in 1 part of the system can have a rapid, direct, human medical error to patient morbidity and mortality before and major impact on the patient (43,45). it was more widely appreciated and human error is now correctly An initial case planning discussion by videoconference served viewed within the context of a systems approach to understand- the dual purpose of testing the technology (13), ensuring per- ing and preventing adverse events (see Teamwork) (40–45). tinent patient information (history and current health status) Furthermore, a large part of anesthesia management is preven- had been clearly communicated and allowing the 2 anesthetists tive: patient stabilization before anesthesia, real-time interpre- (AHT responsible for anesthesia and consulting anesthetist) tation of physiologic data and early intervention to prevent or to establish a working relationship. The attending veterinarian limit adverse effects. Together, this proactive, rather than reac- participated in the planning videoconference and approved of tive, approach improves peri-operative stability and outcomes. the proposed plan before the procedure. The role of telehealth In contrast, many of the basic technical skills employed by anes- during preoperative patient evaluation in human anesthesia has COMPTERENDU thetists do not require advanced training and can be performed become widespread (12,46). In this case, the AHT responsible by a competent general practitioner or registered AHT. for anesthesia (under the direct supervision of the attending The risks associated with general anesthesia are multifacto- veterinarian) had examined the patient and was able to discuss rial, and are variably influenced by species, age, and health current physical findings. status among other factors. In this case, ASA physical status Given the critical role of communication in medical and classification (including absence of indication for invasive blood veterinary error and adverse events (in which harm occurs to pressure monitoring and acceptable cardiopulmonary status) patients or personnel), the initial videoconference was a key part and client comfort with the procedure played an important of case preparation (47). The establishment of a shared mental role in case selection. Cases in which the ASA physical status model (shared mission and plan to achieve it), flattening of any classification was . 2, or when clients were uncomfortable with hierarchy between the 2 anesthetists, structured communication, the lack of in-person support, were recommended for referral and minimal use of slang/jargon all contribute to clear, timely or delayed. Additionally, training, experience, and proficiency communication and a consequent reduction in errors and adverse are considerations when teleconsulting, as the physical act of events (42,48,49). The consulting anesthetist used a checklist delivering anesthetic care is dependent on the attending veteri- that consisted of sequential steps outlined in an anesthetic plan- narian and AHT. In this case, the patient was referred because ning document that was shared and discussed with the lead AHT of anesthetic complications during a dental procedure that was anesthetist 4 d before the procedure. The same document was left uncompleted. A definitive cause of the complications was used as a guide to review the physical examination and blood never elucidated and having an anesthesiologist teleconsulting analysis findings on the morning of the procedure, ensure the was considered prudent. anesthetic machine had been leak-tested and the correct circuit The consulting anesthetist in this case was residency-trained was prepared, review pre-medication and induction drug calcu- and had extensive clinical and teaching experience in academic lations/volumes and sequence of drug administration, review and private veterinary hospitals. The consultant had previously salbutamol administration and pre-oxygenation techniques, and worked with the attending veterinary dentist but had no experi- finally intubation equipment preparedness and plan. ence with the healthcare team in that particular hospital setting During the procedure, all discussion between the consulting prior to the first videoconference trial. anesthetist and AHT anesthetist took place in the presence of As described in the presented case, and reflected in the litera- the attending veterinarian (speakerphone function was used) ture, complications can be well-managed with a well-prepared and it was clear from the working relationships established that and trained team (13,14). There is some indication that hav- the attending veterinarian maintained primary responsibility for ing more than one person dedicated to anesthetic monitoring patient care. Teleconsulting is subject to the restrictions of the (“cross-monitoring”) can aid in early detection of abnormali- VCPR and any existing legal framework surrounding consulta- ties (13). tion in a specific jurisdiction.

Teamwork Client communication For the reported case, the veterinary care team comprised Client consent for anesthesia teleconsulting was obtained by the the attending veterinarian and 3 AHTs (one dedicated to the attending veterinarian as per the established VCPR. The consult- dental procedures, one dedicated to anesthesia, and the third ing anesthetist had a telephone conversation with the client in providing support as necessary). The team composition allowed the week before the procedure, during which the patient’s clini- a clear division of labor and responsibilities between dental cal history, current health status, and teleconsulting plan were procedures and anesthesia, similar to practice in an academic reviewed. The limitations of remote versus in-person anesthesia center (or larger referral centers). As with any surgical proce- support and specific anesthetic considerations relating to the dure conducted by a multidisciplinary team, there is a risk of patient were discussed in detail, including that ultimate case errors and adverse events, particularly when personnel are less responsibility and decision-making rested with the attending familiar with one another or communication is poor (41,42). veterinarian. The client was encouraged to contact the consult- Additionally, the delivery of anesthesia depends on interactions ing anesthetist with follow-up questions or concerns as needed. between anesthetist, patient, personnel, and equipment (43–45). The owner was very satisfied with the service provided and with These interactions are frequently “tightly coupled,” so that even the follow-up communication.

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Overall, following discussion between the attending veteri- 12. Bridges KH, Mcswain JR, Wilson PR. To infinity and beyond: The past, narian and owner, it was felt that the risk was manageable and present, and future of tele-anesthesia. Anesth Analg 2020;130:276–284. 13. Fiadjoe J, Gurnaney H, Muralidhar K, et al. Telemedicine consulta- acceptable. tion and monitoring for pediatric liver transplant. Anesth Analg 2009; 108:1212–1214. Future 14. Cone SW, Gehr L, Hummel R, Merrell RC. Remote anesthetic monitor-

ing using satellite telecommunications and the Internet. Anesth Analg ARTICLE REVIEW It is anticipated that telehealth will continue to grow and evolve 2006;102:1463–1467. in veterinary medicine, with this occurring at an accelerated rate 15. Cubano M, Poulose BK, Talamini MA, et al. Long distance telementor- under the selection pressure of the current pandemic. Important ing. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 1999;13:673–678. considerations during this period will be the maintenance 16. Antoniou SA, Antoniou GA, Franzen J, et al. A comprehensive review of of a distinction between telemedicine and other branches of telementoring applications in laparoscopic general surgery. Surg Endosc telehealth, accepted means of establishing a VCPR, optimizing 2012;26:2111–2116. 17. Mobile Fact Sheet. Available from: https://www.pewresearch.org/ use of available technology, awareness of technological limita- Internet/fact-sheet/mobile/ Last accessed August 17, 2020. tions (particularly data security) and the potential adoption 18. Number of mobile phone Internet users in Canada from 2017 to 2023. of videoconferencing suites and platforms dedicated to tele- Available from: https://www.statista.com/statistics/482507/canada- mobile-phone-internet-users/ Last accessed August 17, 2020. health. When done well, telehealth promises a host of benefits 19. System requirements for Zoom rooms. Available from: https://support. including maintaining adequate veterinary services during zoom.us/hc/en-us/articles/204003179-System-Requirements-for-Zoom- times of restricted access and movement, remote access to gen- Rooms Last accessed August 17, 2020. 20. Anvari M, Broderick T, Stein H, et al. The impact of latency on surgi- eral and specialist services, support for isolated communities cal precision and task completion during robotic-assisted remote tele (clients and veterinarians) and underserved populations, and presence surgery. Comput Aided Surg 2005;10:93–99. reduced client and patient travel for pre- and post-procedural 21. Implementing quality of service over Cisc MPLS VPNs. Available from: https://www.ciscopress.com/articles/article.asp?p=471096&seqNum=6 follow-up (2,9,50). Last accessed August 17, 2020. 22. Wien M, Cazoulat R, Graffunder A, Hutter A, Amon P. Real-time Conclusion system for adaptive video streaming based on SVC. IEEE Transactions on Circuits and Systems for Video Technology 2007;17:1227–1237. This report shows that anesthesia teleconsulting can be success- 23. Canada Mobile Network Experience Report. Available from: https:// fully implemented, including the management of anesthetic www.opensignal.com/reports/2020/02/canada/mobile-network- complications. While there are numerous technological aspects experience Last accessed August 17, 2020. 24. Miyashita T, Mizuno Y, Sugawara Y, et al. A pilot study of tele- to consider, the performance of existing technology and com- anaesthesia by virtual private network between an island hospital and a munications networks can be harnessed to provide a positive mainland hospital in Japan. J Telemed Telecare 2015;21:73–79. experience for all parties and facilitate high quality patient care. 25. Tutunaru AC, Chernevsky R, Ozolins V, Sandersen C, Duritis I. Anesthesia case of the month. J Am Vet Med Assoc 2017;250:984–987. 26. Papageorges M. Regulations and other issues. Clin Tech Small Anim Acknowledgments Pract 2001;16:127–129. The authors thank Dr. P. Buote DVM (Alberta Veterinary Medical 27. VISITOR1 from Karl Storz — Telemedicine evolves into remote presence. Available from: https://www.karlstorz.com/de/en/visitor1- Association) and J. Hahn (KARL STORZ Endoscopy-America) telemedicine-evolves-into-remote-presence.htm Last accessed August 17, for helpful discussions during the drafting of this paper. CVJ 2020. 28. Reacts. Available from: https://reacts.com Last accessed August 17, 2020. References 29. Health Insurance Portability and Accountability Act of 1996 (HIPAA). Available from: https://www.hhs.gov/hipaa/index.html Last accessed . 1 Veterinary telehealth: The basics. Available from: https://www.avma.org/ August 17, 2020. resources-tools/practice-management/telehealth-telemedicine-veterinary- 30. Baker J, Stanley A. Telemedicine technology: A review of services, equip- practice/veterinary-telehealth-basics Last accessed August 17, 2020. ment, and other aspects. Curr Allergy Asthma Rep 2018;18:60. 2. Watson K, Wells J, Sharma M, et al. A survey of knowledge and use of 31. HIPAA Business Associate Agreement. Available from: https://www. telehealth among veterinarians. BMC Vet Res 2019;15:474. hipaajournal.com/hipaa-business-associate-agreement/ Last accessed 3. Telemedicine: Opportunities and developments in Member States: August 17, 2020. Report on the second global survey on eHealth 2009. Available from: 32. TeamViewer. Available from: https://www.teamviewer.com/en-us/ Last https://www.who.int/goe/publications/ehealth_series_vol2/en/ Last accessed August 17, 2020. accessed August 17, 2020. 33. Randell R, Ambepitiya T, Mello-Thoms C, et al. Effect of display resolu- 4. Veterinary Telemedicine — Position Statement. Available from: https:// tion on time to diagnosis with virtual pathology slides in a systematic www.canadianveterinarians.net/documents/veterinary-telemedicine- search task. J Digit Imaging 2015;28:68–76. position-statement Last accessed August 17, 2020. 34. Puchalski SM. Image display. Vet Radiol Ultrasound 2008;49:S9–13. 5. Veterinary Oversight of Antimicrobial Use — A Pan-Canadian 35. Noel PG, Fischetti AJ, Moore GE, Le Roux AB. Off-site smartphone Framework for Professional Standards for Veterinarians. Available vs. Standard workstation in the radiographic diagnosis of small intes- from: https://www.canadianveterinarians.net/policy-advocacy/veterinary- tinal mechanical obstruction in dogs and cats. Vet Radiol Ultrasound oversight-of-antimicrobial-use-in-canada Last accessed August 17, 2020. 2016;57:457–461. 6. Gravenstein JS, Berzina-Moettus L, Regan A, Pao YH. Laser mediated 36. Budrionis A, Hartvigsen G, Lindsetmo RO, Bellika JG. What device telemedicine in anesthesia. Anesth Analg 1974;53:605–609. should be used for telementoring? Randomized controlled trial. Int J 7. Strode SW, Gustke S, Allen A. Technical and clinical progress in tele- Med Inform 2015;84:715–723. medicine. JAMA 1999;281:1066–1068. 37. Chen JYC, Thropp JE. Review of low frame rate effects on human per- 8. Augestad KM, Lindsetmo RO. Overcoming distance: Video-conferencing formance. IEEE Transactions on Systems, Man, and Cybernetics 2007; as a clinical and educational tool among surgeons. World J Surg 2009; 37:1063–1076. 33:1356–1365. 38. Coronavirus (COVID-19). Available from: https://www.canadian 9. Mars M, Auer RE. Telemedicine in veterinary practice. J S Afr Vet Assoc veterinarians.net/coronavirus-covid-19 Last accessed August 17, 2020. 2006;77:75–78. 39. World Small Animal Veterinary Association Global Dental Guidelines. 10. Gyles C. Veterinary telemedicine. [editorial]. Can Vet J 2019;60:119. Available from: https://wsava.org/Global-Guidelines/Global-Dental- 11. Leung D. Apropos telemedicine. Can Vet J 1999;40:318–320. Guidelines/ Last accessed August 17, 2020.

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40. Kohn LT, Corrigan JM, Donaldson MS, America COQOHI. To Err is 47. Wallis J, Fletcher D, Bentley A, Ludders J. Medical errors cause harm Human. Washington, DC: National Academy Press, 2000. in veterinary hospitals. Front Vet Sci 2019;6:12. 41. Pang DSJ, Rousseau-Blass F, Pang JM. Morbidity and mortality confer- 48. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude ences: A mini review and illustrated application in veterinary medicine. and relationship to decreased postoperative morbidity and mortality Front Vet Sci 2018;5:43. following implementation of a checklist-based surgical safety interven- 42. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to tion. BMJ Qual Saf 2011;20:102–107. reduce morbidity and mortality in a global population. N Engl J Med 49. Leonard M, Graham S, Bonacum D. The human factor: The critical 2009;360:491–499. importance of effective teamwork and communication in providing safe 43. Gaba DM, Maxwell M, Deanda A. Anesthetic mishaps: Breaking the care. Qual Saf Health Care 2004;13 Suppl 1:i85–90. chain of accident evolution. Anesthesiology 1987;66:670–676. 50. Bishop GT, Evans BA, Kyle KL, Kogan LR. Owner satisfaction with use 44. Reason J. Safety in the operating theatre — Part 2: Human error and of videoconferencing for recheck examinations following routine surgical organisational failure. Qual Saf Health Care 2005;14:56–60. sterilization in dogs. J Am Vet Med Assoc 2018;253:1151–1157. 45. Sutcliffe KM. High reliability organizations (HROs). Best Pract Res Clin Anaesthesiol 2011;25:133–144.

COMPTERENDU 46. Kamdar N, Huverserian A, Regev A, Beck L, Mahajan A. Telemedicine for anesthesiologists: Preoperative evaluation and beyond. ASA Monitor 2018;82:16–19.

1100 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Brief Communication Communication brève

Influence of abdominal elevation on radiographic measurements of the thoracolumbar interspinous spaces in asymptomatic horses

Charlène Pigé, Isabelle Masseau, Alvaro G. Bonilla

Abstract — The objective of this study was to determine if abdominal elevation could induce radiographically visible widening of the interspinous spaces in the thoracolumbar region of standing sedated horses and facilitate the surgical approach to the region. Radiographs centered on T13 and T18 were taken while applying different degrees of tension on a wide strap placed under the abdomen of 7 healthy horses. Then, the interspinous spaces between T11 and L2 were measured following a standardized method. The interspinous spaces widen radiographically between T11 to L2, except for T18–L1. Thus, the reported technique could potentially facilitate the surgical approach for horses with impinging and overriding dorsal spinous processes.

Résumé — Influence de l’élévation abdominale sur les mesures radiographiques des espaces intervertébraux thoraco-lombaires chez des chevaux asymptomatiques. L’objectif de la présente étude était de déterminer si l’élévation abdominale pouvait causer un élargissement radiographique visible des espaces intervertébraux dans la région thoraco-lombaire de chevaux sous sédation en position debout et faciliter l’approche chirurgicale de la région. Des radiographies centrées sur T13 et T18 furent prises tout en appliquant différents degrés de tension sur une large courroie placée sous l’abdomen de sept chevaux en santé. Puis, les espaces intervertébraux entre T11 et L2 furent mesurés en suivant une méthode standardisée. Les espaces intervertébraux s’élargissaient radiographiquement entre T11 à L2, sauf pour T18–L1. Ainsi, la technique radiographique rapportée ici pourrait potentiellement faciliter l’approche chirurgicale chez des chevaux avec empiètement et chevauchement des apophyses épineuses. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1101–1105

mpinging and overriding of the spinous processes (IORDSP) position, which has also been reported to increase the width of I is one of the most common reasons for thoracolumbar the interspinous spaces, is contraindicated in standing surgery pain in sport horses and is commonly managed with sur- due to hemodynamic and respiratory concerns (8). Thus, an gery (1–4). Lateral recumbency reportedly facilitates the surgical alternative system that can widen the interspinous spaces in approach to the region by allowing widening of the interspinous standing animals may facilitate the surgical approach in affected spaces secondary to relaxation of the epaxial musculature (3). horses and warrants investigation. Nevertheless, most surgical techniques to treat IORDSP are It is well-known that abdominal elevation produces thoraco- performed with the horse standing to avoid the risks associated lumbar flexion (9). This flexion may potentially lead to widen- with general anesthesia (5–7). Moreover, a low head and neck ing of the thoracolumbar interspinous spaces. However, to the authors’ knowledge, no studies have documented this change. Department of Clinical Sciences, College of Veterinary Based on the “bow-and-string” model, we hypothesized that a Medicine, University of Montreal, St. Hyacinthe, Quebec. slight abdominal elevation on standing horses could reduce tension on the thoracolumbar column and subsequently increase Address all correspondence to Dr. Alvaro G. Bonilla; e-mail: the width of the interspinous spaces (10). The aim of this study [email protected] was to determine if applying a slight abdominal elevation to Dr. Pigé’s current affiliation is UC Davis William R. Pritchard healthy standing horses would lead to widening of interspi- Veterinary Medical Teaching Hospital, University of California, nous spaces and mimic the widening observed radiographically Davis, California, USA. between spinous processes in lateral recumbency (3). This study Funding was provided by the Equine Health Funds from the was conceived as a proof of concept study before recruiting College of Veterinary Medicine of the University of Montreal, horses affected with IORDSP for standing surgery. The project supported by Zoetis. was approved by the Animal Use Ethics Committee of the Use of this article is limited to a single copy for personal study. University of Montreal. Anyone interested in obtaining reprints should contact the Seven mares from the teaching herd of the University of CVMA office ([email protected]) for additional Montreal were recruited for the study. All mares had a normal copies or permission to use this material elsewhere. physical examination, showed no clinical signs of back pain, and

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A thoracolumbar motion was deemed normal; however, none of the mares were in active work. For the study, horses were placed in standing stocks and were lightly sedated with detomidine hydrochloride and butorphanol tartrate, both at 0.01 mg/kg body weight (BW), IV. A 173-cm long 3 51-cm wide leather strap was attached to one of the stock’s sidebars. The strap was then positioned under the horse’s abdomen, with the cranial aspect of the strap placed immediately caudal to the xyphoid process. The other end of the strap was held by 1 or 2 assistants (Figure 1). Assistants wore appropriate radiation safety equipment consisting of lead apron, thyroid shield, leaded gloves, and glasses and dosimeters.

COMMUNICATIONBRÈVE The mares were continually monitored by 1 of the investigators to ensure that they stood squarely on all 4 feet, preventing lateroflexion or rotation of the spine. The animals were also continuously monitored for any signs of discomfort (anxiety or respiratory distress) during the procedure. During the procedure, horses’ heads were positioned on a head support to allow a neutral head and neck position (horse’s mouth at the level of B the shoulder) based on the reported influence of head and neck position on interspinous space measurements (Figure 1) (8). In addition, this neutral stance is commonly favored during standing surgery to improve patient balance and avoid complications while the horse is sedated. Three series of 2 consecutive radiographs of the spinous processes centered on T13 and T18, both marked with barium paste on the dorsal midline, were taken while applying various degrees of tension on the abdominal strap and consequently obtaining different degrees of abdominal elevation: i) Tension 0 (T0): No abdominal elevation ii) Tension 2 (T2): Maximum abdominal elevation achieved for each horse iii) Tension 1 (T1): T2 divided by 2 This region of interest was chosen due to the higher prevalence of IORDSP identified around the anticlinal vertebra (T15) (3,4,6). The abdominal elevation obtained using the abdominal strap was extrapolated to centimeters from a centimeter scale on the stock’s side bar and a centimeter scale on the edge of the strap (Figure 1). All radiographs were acquired using a mobile X-ray machine Figure 1. Methodology used to perform manual abdominal elevation in an asymptomatic mare. A — A lightly sedated mare (Practix Convenio; Philips Medical Systems, Hamburg, stands squarely on all 4 feet inside standing stocks with the Germany). For each of the 3 positions described, left to right head and neck placed in a neutral position and resting on a latero-lateral radiographs centered on T13 and T18 spinous head support. The markers (white arrows) palmar/plantar to each foot ensure consistent foot placement during acquisition processes were taken. The exposure values used were 83 kV and of the radiographs. A leather abdominal strap is attached to 28 to 32 mAs for the T13-centered radiograph and 90 to 95 kV the non-visible side of the stocks sidebar and placed under the and 45 to 55 mAs for the T18-centered radiograph, according horse’s abdomen. The horse is then subjected to abdominal elevation by manually pulling on the strap. The desired tension to the horse’s size. No body parts of the operator were exposed (T1 or T2) is maintained by 1 or 2 assistants pulling on the strap. to the primary X-ray beam at any time. The dosimeters of the The assistants are kneeling during image acquisition to avoid operator did not record any radiation above the allowed occupa- the primary X-ray beam. The mobile X-ray unit (black asterisk) is located on the left side of the horse and barium markers tional limit of 1 mSv annually. The digital cassette (CR HD5.0 (white points) are placed at the level of the spinous processes General, 35 3 43 cm; Agfa HealthCare NV, Mortsel, Belgium) of T13 and T18. B — Close-up view of the system used to was held perpendicular to the X-ray beam and as close as possi- determine the degree of abdominal elevation (T0, T1 and T2). A centimeter scale (white tape on the right) was placed on ble to the horse to minimize image distortion by magnification. the caudal edge of the abdominal strap. A second centimeter Following acquisition of the image, radiographs were ano- scale (white tape on the left) was applied directly on the stock’s nymized to ensure unbiased radiographic evaluation of the sidebar allowing both scales to be simultaneously assessed side- by-side as the abdominal strap was pulled by the assistant/s. horse and the degree of tension used by the investigators. Since X-ray beam angle has been shown to influence interspinous

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space width located 3 positions away from the X-ray beam center (11), our radiographic measurements were limited to between T11 and T16 for projections centered on T13 and

between T15 and L2 for projections centered on T18. Note that BRIEF COMMUNICATION the space T15–16 was measured in both radiographs. Prior to performing interspinous space width measurements, a single observer (CP) applied landmarks (P1,P2) on each radiographic projection for standardization purposes. Subsequently, each of the 3 observers took 2 separate sets of measurements as follows (Figure 2): a first line (D1) representing the width of the spinous processes of a given vertebra at the level of its most caudal aspect and a second line (D2) which was drawn by extending the line D1 to the cranial edge of the following caudal vertebra. Next, the interspinous space width or D3 was directly calculated by an Excel file (D3 = D2 2 D1) used to record measurements. The width of each interspinous space (D3) was then divided by the width of the spinous process of the cranial vertebra (D1) to obtain a D3 measurement (D3c) corrected for magnification, allowing objective comparison of measurements A performed at T0, T1 and T2. An intra-class correlation coefficient was used to determine the intra- and inter-observer agreement on interspinous space width measures. Data recorded by the 3 observers were used to determine the effect of abdominal elevation (T0, T1, T2) on widening of the interspinous spaces using a repeated measures linear model. Intra- and inter-observer agreement was excellent for radiographs centered on T13 and good for those centered on T18. Radiographic measurements revealed that the mean value of the interspinous spaces from T11 to L2 was significantly higher at T1 and T2 versus T0, except for the interspinous spaces T15–T16 and T18–L1 on radiographs centered on T18. For radiographs centered on T13, maximum manual abdominal elevation (T2) allowed an average increase or widening of the interspinous spaces from T11 to T16 between 50% and 80% from baseline (T0). These percentages are equivalent to an increase in width of the interspinous spaces from T11–T16 ranging on average from 2.7 mm to 5 mm. For radiographs centered B on T18, the widening obtained at T2 from T16 to T18 and L1–L2 was between 15% and 103% from baseline (T0) which Figure 2. Representative radiographic image illustrating the standardized method used to measure the interspinous corresponds to an increase ranging on average from 1.4 mm to space (IS). The radiograph was acquired with the X-ray beam 2.2 mm. centered on T13. Cranial is to the left. A barium marker is visible As hypothesized, the use of a large leather strap to manually above T13. The linear markers were added with the same visualization software (OsiriX Lite, version 9.0; Pixmeo SARL, elevate the abdomen in standing horses resulted in radiographi- Geneva, Switzerland) used to perform the interspinous space cally visible widening of the interspinous spaces between T11 to measurements. A — P1 = line parallel to the cranial third of the L2, except for the interspinous space T18–L1. Our interspinous dorsal aspect of the spinous process of the cranial vertebra; P2 = line parallel to P1 drawn across the spinous process space measurements were made at the level of the most caudal (SP) at the level of the most caudal aspect of the spinous aspect of the spinous processes for standardization purposes, process. B — D1 = width of the spinous process of the cranial but if we consider the anatomy of the region, thoracolumbar vertebra; D2 = extension of D1 line up to the cranial edge of the caudal vertebra. D3 = D2 2 D1 is calculated by the Excel flexion should widen the interspinous spaces further dorsally file and represents the interspinous space width. D3c = D3/D1 where contact between adjacent spinous processes tends to start to correct for magnification. In this image, D1 and D2 have in affected horses (2). This study only included asymptomatic been drawn on different spinous processes to illustrate the measurement method more clearly but this was always done horses and results may vary in horses affected with IORDSP in the same spinous process during the study. where ligament fibrosis and boney remodeling are present. Nonetheless, lateral recumbency has been reported to widen the interspinous spaces and facilitate surgical access in horses with IORDSP where those changes are present (3).

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Radiographic measurement of the interspinous spaces is limitation of our study and could be responsible for the lack of commonly used during the diagnosis of IORDSP and sev- significant widening of 2 interspinous spaces measurements on eral measuring techniques have been reported in foals and radiographs centered on T18. Alternatively, the lack of signifi- adults (8,11–13). Nonetheless, these measurements can be cant interspinous space widening in the caudal thoracolumbar affected by lateral recumbency, head and neck position, or radio- region could be attributed to intrinsic properties of the body graphic beam position (3,8,11). We decided to develop our own in this region (9). standardized measurement protocol that could be applicable There were other limitations in this study. Recruited horses to all spinous processes regardless of their shape (8,11–13). had no clinical signs related to IORDSP and we were unable to We decided to standardize the location at which each observer predict the amount of interspinous space widening necessary to would perform the interspinous space measurement to prevent facilitate the surgical access to the region. From a surgical point a second measuring variable (observers may measure the inter- of view, we believe that an increase of 3 mm or more would be spinous space at slightly different locations) but this may have enough to facilitate the introduction of a rigid scalpel blade or

COMMUNICATIONBRÈVE artificially affected our intra- and inter-observer agreement. In Metzenbaum scissors during ISLD. This degree of widening addition, this is a novel measuring technique and therefore, its was achieved in 4/7 horses between T11–L2. Therefore, future repeatability has not been tested previously. studies are needed to determine whether widening of the inter- Berner et al (8) reported the influence of head and neck spinous spaces using abdominal elevation with the reported position on the interspinous spaces between thoracic spinous technique will be enough to facilitate the surgical approach in processes in healthy horses. They showed that a low head and standing horses with IORDSP and the absolute value in mm neck position resulted in widening of the interspinous spaces. required to subjectively facilitate the surgery. However, the information reported is insufficient to draw In conclusion, this proof of concept study demonstrated comparisons with our study and we were unable to determine that manual abdominal elevation increases the interspinous whether the widening obtained by lowering the head and neck space width between T11 and L2, except for T18–L1, in was similar to the widening obtained with the abdominal strap. horses asymptomatic for back pain and has potential clinical Nevertheless, we decided to maintain the head and neck in a relevance. Nonetheless, further investigations are needed to neutral position during our study since this position would best validate the technique in horses affected with IORDSP. In such mimic the resting stance preferred for a sedated horse while back cases, a high capacity X-ray unit, able to achieve 75 to 120 kV surgery is being performed. and 100 to 250 mAs, should be used to provide clear vertebral The technique used to elevate the abdomen was well-tolerated margins and subsequent accurate measurements on radiographs in all horses and easy to replicate. Horses were lightly sedated centered on T18. allowing them to stand squarely and preventing vertebral rotation during image acquisition (8). However, the personnel Acknowledgment required, and the method used to obtain abdominal elevation The authors thank G. Beauchamp from the College of may be limiting factors for clinical cases. If the technique used Veterinary Medicine of the University of Montreal for perform- herein is to be applied during interspinous ligament desmotomy ing the statistical analysis. CVJ (ISLD) or partial ostectomy of the spinous processes in the standing horse, a method of abdominal elevation not requiring References 1 or 2 assistants to maintain the tension on the abdominal strap 1. Jeffcott LB. Disorders of the thoracolumbar spine of the horse — A would be desired. survey of 443 cases. Equine Vet J 1980;12:197–210. The lack of significant differences between T15–T16 and 2. Butler JA, Colles CM, Dyson SJ, Kold SE, Poulos PW. The verte- T18–L1 on radiographs centered on T18, and the variability bral column. In: Clinical Radiology of the Horse. 4th ed. Hoboken, New Jersey: John Wiley & Sons, 2016:531–607. among observers for measurements caudal to T16 could be in 3. Jacklin BD, Minshall GJ, Wright IM. A new technique for subtotal part attributed to the pronounced noise provided by scattered (cranial wedge) ostectomy in the treatment of impinging/overriding radiation on radiographs obtained in this region (centered spinous processes: Description of technique and outcome of 25 cases: Subtotal (cranial wedge) ostectomy for impinging/overriding spinous on T18). Radiography of the equine thoracolumbar spine is processes. Equine Vet J 2014;46:33–44. technically challenging and often requires radiographic equip- 4. Walmsley JP, Pettersson H, Winberg F, McEvoy F. Impingement of ment with high outputs (75 to 120 kV and 100 to 250 mAs) the dorsal spinous processes in two hundred and fifteen horses: Case selection, surgical technique and results. Equine Vet J 2002;34:23–28. to obtain high quality diagnostic images (2). The requirement 5. Brink P. Subtotal ostectomy of impinging dorsal spinous processes in for stocks with side bars to perform our study forced us to use 23 standing horses. Vet Surg 2014;43:95–98. a mobile X-ray machine with limited output and consequently, 6. Coomer RPC, McKane SA, Smith N, Vandeweerd J-ME. A controlled study evaluating a novel surgical treatment for kissing spines in standing suboptimal penetration of the spinous processes in the thicker sedated horses. Vet Surg 2012;41:890–897. thoracolumbar region. The blurred margins of the caudal 7. Perkins JD, Schumacher J, Kelly G, Pollock P, Harty M. Subtotal ostec- thoracolumbar spinous processes occasionally made it difficult tomy of dorsal spinous processes performed in nine standing horses. Vet Surg 2005;34:625–629. to obtain accurate measurements on radiographs centered at 8. Berner D, Winter K, Brehm W, Gerlach K. Influence of head and T18. This limitation led to a lower inter- and intra-observer neck position on radiographic measurement of intervertebral distances agreement on radiographs centered at T18, and hindered our between thoracic dorsal spinous processes in clinically sound horses. Equine Vet J 2012;44:21–26. ability to determine whether contact was present between adja- 9. Denoix JM. Spinal biomechanics and functional anatomy. Vet Clin cent spinous processes. Retrospectively, this is an important North Am Equine Pract 1999;15:27–59.

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10. Van Weeren PR, McGowan C, Haussler KK. Science overview: 12. Erichsen C, Eksell P, Holm KR, Lord P, Johnston C. Relationship Development of a structural and functional understanding of the between scintigraphic and radiographic evaluations of spinous processes equine back. Equine Vet J 2010;42:393–400. in the thoracolumbar spine in riding horses without clinical signs of 11. Djernaes JD, Nielsen JV, Berg LC. Effects of X-ray beam angle and back problems. Equine Vet J 2004;36:458–65.

geometric distortion on width of equine thoracolumbar interspinous 13. Sinding MF, Berg LC. Distances between thoracic spinous processes in BRIEF COMMUNICATION spaces using radiography and computed tomography — A cadaveric Warmblood foals: A radiographic study. Equine Vet J 2010;42:500–503. study. Vet Radiol Ultrasound 2017;58:169–175.

Answers to Quiz Corner Les réponses du test éclair

1. B) Panosteitis affects larger breed dogs and is associated with 5. E) Serum antibody enzyme-linked immunosorbent assay (ELISA) estrus. and fecal culture of subclinical carriers of Mycobacterium B) La panostéite affecte les chiens de grande race et est associée avium subspecies paratuberculosis are insensitive (30% to à l’œstrus. 50%). The incubation period for the disease is measured in years, during which time fecal shedding and environmental 2. E) Heartworm is not transmitted from fleas or lice, nor may it contamination occur. The organism is tolerant of most envi- be ingested through milk. The mosquito only transmits L3. ronments and is thought to live for up to 12 months outside E) Le ver du cœur n’est pas transmis par les puces ou les poux, of the host. The clinical signs of the disease are pronounced ni par l’ingestion de lait. Les moustiques transmettent seu - and not easy to mistake: profuse, watery, green diarrhea, lement les larves L3. extreme weight loss, and normal appetite. 3. D) The most likely diagnosis is scrotal hernia. E) L’essai d’immunoabsorption enzymatique (test ELISA) et la D) Le diagnostic le plus probable est une hernie scrotale. culture des fèces des porteurs subcliniques de Mycobacterium avium ssp. paratuberculosis sont insensibles (30-50 %). La 4. A) The other choices may cause one or two of the clinical signs période d’incubation pour la maladie se mesure en années, but not all of them, particularly the lymphadenopathy. durant lesquelles l’excrétion fécale et la contamination de A) Les autres choix peuvent causer un ou deux des signes l’environnement ont lieu. L’organisme est tolérant à la plu- cliniques mentionnés mais pas tous, particulièrement la part des environnements et on croit qu’il vit jusqu’à 12 mois lymphadénopathie. à l’extérieur de l’hôte. Les signes cliniques sont évidents et spécifiques : diarrhée aqueuse abondante de couleur verte et perte de poids extrême malgré un appétit normal.

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canadianveterinarians.net FOR PERSONAL USE ONLY Brief Communication Communication brève

Ixodes scapularis ticks and Borrelia burgdorferi on Prince Edward Island: Passive tick surveillance and canine seroprevalence

Alexandra H. Foley-Eby, Christine Savidge, Vett K. Lloyd

Abstract — Ticks and canine sera were submitted by veterinarians from Prince Edward Island over a 15-month period spanning 3 tick seasons. The objective of the study was to determine the infection prevalence of Borrelia burgdorferi, a causative agent of Lyme disease, in the province’s ticks and the seroprevalence in its dogs. It was found that 97.8% (n = 368) of ticks submitted were Ixodes scapularis, a species capable of transmitting Borrelia burgdorferi; 10.3% of these ticks [95% confidence interval (CI): 3.6% to 17.0%] were infected. Provincial canine seroprevalence for the 199 submitted samples was estimated at 3.0% (95% CI: 1.0% to 5.1%).

Résumé — Ixodes scapularis et Borrelia burgdorferi sur l’Île-du-Prince-Édouard : Surveillance passive des tiques et séroprévalence canine. Des tiques et du sérum canin furent soumis par des vétérinaires de l’Île-du-Prince-Édouard durant une période de 15 mois couvrant trois saisons de tiques. L’objectif de l’étude était de déterminer la prévalence d’infection à Borrelia burgdorferi, un agent causal de la maladie de Lyme, dans les tiques de la province et la séroprévalence chez les chiens. Il fut trouvé que 97,8 % (n = 368) des tiques soumises étaient Ixodes scapularis, une espèce capable de transmettre B. burgdorferi; et que 10,3 % de ces tiques [intervalle de confiance de 95 % (CI) : 3,6 % à 17,0 %)] étaient infectées. La séroprévalence canine provinciale pour les 199 échantillons soumis était estimée à 3,0 % (CI 95 % : 1,0 % à 5,1 %). (Traduit par Dr Serge Messier) Can Vet J 2020;61:1107–1110

yme borreliosis, or Lyme disease, is a spirochetosis transmit- portion of infected dogs the outcome of infection is serious (2). Lted by Ixodes spp. ticks (1). The agents of Lyme disease are As the behaviors of dogs put them at a higher risk of exposure members of the genus Borrelia, collectively known as the Lyme than their human companions, dogs make a sensitive sentinel borreliosis group. The most common Lyme borreliosis species species to predict human infections (3). Both of these reasons in North America is Borrelia burgdorferi sensu stricto. Ixodes emphasize the value of monitoring canine exposure to tick- scapularis and Ixodes pacificus are the only 2 species of ticks rou- vectored pathogens in a given area. tinely monitored for B. burgdorferi in Canada and I. scapularis is Ixodes scapularis was first found on Prince Edward Island the vector most commonly found in the Atlantic provinces (1). (PEI) in 1989 and the first isolation of B. burgdorferi in Atlantic Borrelia burgdorferi infections cause disease in dogs, other Canada took place in PEI in 1992 (4,5). There has been limited animals, and humans. Dogs which are infected seroconvert, published research focused on Lyme disease on PEI since its ini- which can be detected using traditional immunoassays such tial documentation over 25 y ago. The report of ticks on migra- as enzyme-linked immunosorbent assay (ELISA) and Western tory bird species on the island (6) and the absence of deer, the blot (2). Previous studies have suggested that most, but not all, primary host for adult female ticks, has led to the assumption B. burgdorferi-infected dogs are asymptomatic; however, for a pro- that only adventitious ticks are present on the island. However, PEI does possess abundant mid-sized wildlife and agricultural ruminants, which could act as adequate hosts for adult ticks, Department of Biology, Mount Allison University, 63B York so short- or long-term support of tick populations cannot be Street, Sackville, New Brunswick E4L 1E4 (Foley-Eby, Lloyd); excluded (7,8). Regardless of the origin of the ticks, previous Atlantic Veterinary College, University of Prince Edward Island, studies have shown that ticks can be present in sufficient num- 550 University Avenue, Charlottetown, Prince Edward Island bers to pose a health risk even in the absence of deer (7,8). C1A 4P3 (Savidge). This study focussed on identifying the risk of Borrelia burg- Address all correspondence to Dr. Vett K. Lloyd; e-mail: dorferi infections to dogs on PEI. This was accomplished by [email protected] passive surveillance of the island’s ticks and a canine serological Use of this article is limited to a single copy for personal study. study, supported by the participation of local veterinary clin- Anyone interested in obtaining reprints should contact the ics. This study was approved by the animal care committees at CVMA office ([email protected]) for additional both Mount Allison University and the University of Prince copies or permission to use this material elsewhere. Edward Island.

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Ixodes scapularis Dermacentor variabilis Haemaphysalis leporispalustris Rhipicephalus sanguineus Ixodes cookei Ixodes scapularis 97.8% COMMUNICATIONBRÈVE

Figure 1. Tick species recovered by passive surveillance on Prince Edward Island from October 2016 to January 2018.

In September 2016, letters were sent to 13 mixed or small- The detection of 1 amplicon, but not both, was communicated animal primary care veterinary practices across PEI, inviting to the participating veterinary clinics as such results can identify them to participate in research investigating the presence of other species of pathogenic Borrelia species (12); however, only tick and Borrelia species in the province. Eleven of those clinics those samples for which both amplicons could be detected were indicated interest and were provided with consent forms for considered positive for surveillance purposes and are reported collecting canine sera and ticks from their patients. Between here. Tick infection prevalence was calculated for each tick sea- October 2016 and January 2018, 445 ticks and 199 serum son to obtain a mean infection prevalence with 95% confidence samples were submitted to Mount Allison University (Sackville, interval (CI). New Brunswick) for testing. This period spanned 3 tick seasons: For canine serological testing, participating clinics were asked Fall 2016 (Sept 2016–Jan 2017), Spring 2017 (Feb 2017– to avoid dogs vaccinated against B. burgdorferi (to avoid cross- Aug 2017), and Fall 2017 (Sept 2017–Jan 2018). Ticks were reactivity on Western blots) and to select patients presented for not recovered in all months. routine surgeries, avoiding selecting animals showing clinical signs Ticks were tested for Borrelia species infection as described of infection. Each sample was tested using the SNAP 4Dx Plus previously (9). Briefly, ticks were photo-documented and mor- Test (IDEXX Laboratories, Westbrook, Maine, USA), a form of phologically identified to species, life stage, sex, and state C6 ELISA. Each test was run and interpreted according to the of engorgement using the key developed by Keirans and manufacturer’s protocol. Enzyme-linked immunosorbent assay Litwak (10) and the University of Rhode Island’s TickEncounter seropositivity prevalence was calculated for each tick season to Resource Center’s tick engorgement resource (11). Ticks were obtain a mean infection prevalence with 95% CI. In addition, washed in ethanol and cut in half longitudinally; half of each ELISA-positive samples, each with an accompanying negative sample was archived in the tick bio-bank at Mount Allison sample from the same clinic, were tested by immunoblotting University while the other half was used for DNA extrac- (Western blotting) using commercially prepared B. burgdorferi tion (9). DNA from the ticks and any internal microorgan- IgG Marblot Western blot strips (Trinity Biotech Bray, County isms was extracted using the AquaGenomic kit (MultiTarget Wicklow, Ireland) to provide information on possible regional Pharmaceuticals, Colorado Springs, Colorado, USA) following differences in seroreactivity to specific B. burgdorferi antigens, the manufacturer’s instructions. DNA was then subjected to as has been noted in humans (13). The immunoblots were nested polymerase chain reaction (PCR) to amplify the FlaB processed as described by the manufacturer with the excep- and OspA genes from B. burgdorferi: 40 cycles for both inner tion that an alkaline phosphatase-labeled sheep polyclonal and outer primers for each gene, GoTaqGreen taq polymerase secondary antibody to dog IgG (Abcam Cambridge, United (Promega Corporation, Madison, Wisconsin, USA), anneal- Kingdom, ab112837;1:50,000 dilution) was used in order ing temperatures 55°C and 58°C for outer and inner primer to detect canine antibodies and the immunoblot strips, both sets, respectively, extension times 45 s (9). Negative controls positive and negative, were incubated in the sera overnight at were included with each set of amplifications. Amplicons were 4°C, for convenience. To quantify seroreactivity, using imag- detected by agarose gel electrophoresis and amplicons of the ing software, the gray value as a measure of band intensity, of correct size (outer primer amplicons 503 bp and 487 bp and each B. burgdorferi-indicative band (bands 18, 23, 28, 30, 39, inner amplicons of 447 bp and 350 bp for FlaB and OspA, 41, 45, 58, 66 and 93 kDa) from ELISA-negative samples was respectively) were considered positive indicators for these genes. averaged and compared to bands from ELISA-positive samples. Information on the species, sex, life stage, and state of engorge- Any sample in which 5 or more of the B. burgdorferi significant ment and Borrelia sp., if found, for each tick was returned to bands were darker than the average produced by the ELISA- the veterinary practice from which the sample was submitted. negative bands was considered positive. Two-sample t-tests were

1108 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY BRIEF COMMUNICATION

Figure 2. Number of Ixodes scapularis ticks recovered from each of the 4 federal electoral districts of Prince Edward Island [inset: Elections Canada (14)], shown, left to right, from the northwest to the southeast.

performed to compare the gray values of each significant band positive/negative test result for its ticks, a binary response/depen- between ELISA-positive and ELISA-negative samples. dent variable. No significant difference was found suggesting a In total, 445 ticks were submitted, but data from samples largely uniform distribution of infection in ticks among districts. unaccompanied by a submission data form and those removed In total, 7/199 canine serum samples were seropositive for from animals that had travelled out-of-province in the previous Borrelia using the C6 ELISA. This test also detects the tick- 2 wk were eliminated. After the data were filtered, 368 ticks vectored pathogens, Anaplasma or Ehrlichia, and mosquito- remained that were presumably encountered in PEI. Of these vectored heartworm. No seroreactivity to Anaplasma or Ehrlichia samples, 97.8% (n = 360) were I. scapularis. Other recovered was detected; 1 heartworm positive result was found in a dog species included Dermacentor variablis (n = 2), Haemaphysalis that had recently traveled to New Brunswick. One of the Borrelia leporispalustris (n = 4), Rhipicephalus sanguineus (n = 1), and seropositive samples was submitted without an accompanying Ixodes cookei (n = 1) (Figure 1). submission form, leaving the dog’s travel history and home district Location information provided on submission forms was unknown, so that sample was excluded. This gives an amended used to identify the areas from which ticks were recovered. The Borrelia burgdorferi seroprevalence in PEI dogs of 3.02% (6/198; 4 Federal Electoral Districts of PEI, which represent similar 95% CI: 0.97% to 5.09%). Seropositive dogs were found in human populations, so presumably also canine populations every district. A logistic regression detected no significant effect of (14), are shown in Figure 2. Of the I. scapularis collected on district (serving as a categorical independent variable) on whether PEI, 19.7% (n = 71) were from Egmont, 16.9% (n = 61) from a dog was seropositive (a binary response/dependent variable). Malpeque, 11.9% (n = 43) from Charlottetown, and 51.4% All 7 seropositive sera were also assessed by subsequent Western (n = 185) from Cardigan. A Chi-square test with uniform dis- blot. Two-sample t-tests detected significant differences between tribution as the null hypothesis, indicated that this distribution the means of the band intensity (gray values) for each significant differed significantly from a uniform distribution (2 = 138.78, band (band 18 P  0.0001, 23 P  0.0001, 28 P  0.0005, P  0.00001,  = 0.05). The number of I. scapularis recovered 30 P  0.01, 39 P  0.005, 41 P  0.05, 45 P  0.0001, from Cardigan was greater than the number recovered in any 58 P  0.0005, 66 P  0.001 and 93 kDa P  0.001) between other district (Figure 2). ELISA-positive and ELISA-negative samples. The significant dif- Infection prevalence of B. burgdorferi in I. scapularis ticks pas- ferences for these antigens between the positive and negative sera sively collected on PEI was calculated at 10.3% (95% CI: 3.6% suggest that the results were not the product of false-positive or to 17.0%; 37 positive ticks), with an additional 8.9% (32) of negative ELISA results. No out-of-province travel in the previous ticks testing positive for only 1 of the 2 target genes. A logistic 2 mo was indicated on the accompanying completed forms for the regression was performed to detect whether the district, serv- 6 dogs with positive sera. However, some studies have shown that ing as a categorical independent variable, had an effect on the dogs may remain seropositive for more than a year (2), so some of

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the dogs in this study could have been infected out-of-province Acknowledgments if there had been prior travel. Nevertheless, given the number of We thank the veterinarians and staff of the participating clinics ticks recovered from dogs on PEI during this time period and the as well as members of the public for supporting this study. This prevalence of tick infection, it seems likely that most of these dogs study was funded by Natural Sciences and Engineering Research represent infections acquired on the island. Council (NSERC) Discovery Grant to VKL, a New Brunswick Results from passive surveillance of ticks on PEI showed Innovation Foundation (NBIF) STEM grant to AHF-E, and that I. scapularis is the most commonly recovered species, IDEXX Laboratories, in the form of SNAP 4DxPlus® test kits. representing 97.8% of submitted ticks. Other species, both CVJ those normally resident in Canada and those presumably introduced from further afield, were also recovered on the References island. Ixodes scapularis is the primary vector for transmission of 1. Sperling J, Sperling F. Lyme borreliosis in Canada: Biological diversity B. burgdorferi in the eastern part of Canada. Molecular test- and diagnostic complexity from an entomological perspective. Can

COMMUNICATIONBRÈVE ing showed that 10.3% of those ticks were infected with Entomologist 2009;141:521–549. 2. Littman MP, Gerber B, Goldstein RE, Labato MA, Lappin MR, Moore B. burgdorferi. This study also identified a potential bias in tick GE. ACVIM consensus update on Lyme borreliosis in dogs and cats. populations towards eastern parts of the province. Proximity of J Vet Intern Med 2018;32:887–903. the eastern regions to New Brunswick and Nova Scotia (13 and 3. Lindemayer JM, Marshall D, Onderdonk AB. Dogs as sentinels for Lyme disease in Massachusetts. Am J Public Health 1991;81: 23 km away, respectively), both of which are considered high- 1448–1455. risk areas for Lyme disease (15), and the movement of birds 4. Cawthorn RJ, Horney BS, Maloney R. Lyme disease vector, Ixodes among provinces may be responsible for the higher tick density dammini (the northern deer tick), identified in Prince Edward Island. Can Vet J 1990;31:220. in these areas. However, despite the approximately equal popula- 5. Artsob H, Garvie M, Cawthorn RJ, et al. Isolation of the Lyme tion in eastern PEI relative to other regions on the island, more disease spirochete, Borrelia burgdorferi, from Ixodes dammini (Acari: vigilant tick collection and/or submission in this region might Ixodidae) collected on Prince Edward Island, Canada. J Med Entomol 1992;29:1063–1066. also explain this increased tick recovery. The tick and canine sera 6. Scott JD, Durden LA. New records of the Lyme disease bacterium collection period in this study encompassed 2 fall and 1 spring in ticks collected from songbirds in central and eastern Canada. Int J tick seasons; a longer study period would allow monitoring Acarol 2015;41:241–249. 7. Rand PW, Lubelczyk C, Holman MS, Lacombe EH, Smith RP, Jr. of annual differences in tick abundance, species composition, Abundance of Ixodes scapularis (Acari: Ixodidae) after the complete distribution, infection prevalence, and canine seroprevalence. removal of deer from an isolated offshore island, endemic for Lyme Understanding the origin of the ticks on PEI might not only Disease. J Med Entomol 2004;41:779–784. 8. Duffy DC, Campbell SR, Clark D, DiMotta C, Gurney S. Ixodes scapu- explain current patterns, but also help to predict future changes. laris (Acari: Ixodidae) deer tick mesoscale populations in natural areas: Additionally, monitoring Borrelia species infections in wildlife Effects of deer, area, and location. J Med Entomol 1994;31:152–158. populations would help determine if Borrelia burgdorferi and 9. Wills MK, Kirby AM, Lloyd VK. Detecting the Lyme disease spirochete, Borrelia burgdorferi, in ticks using nested PCR. J Vis Exp other species are being maintained in enzootic cycles. 2018;132:e56471. The number of ticks recovered during the 15-month period 10. Keirans JE, Litwak TR. Pictorial key to the adults of hard ticks, fam- of this study, the 10% infection prevalence, and the canine ily Ixodidae (Ixodida: Ixodidea), east of the Mississippi River. J Med Entomol 1989;16:435– 448. seroprevalence serve to suggest that, while lower than in neigh- 11. University of Rhode Island [homepage on the Internet] c2005–2018 bouring provinces, there is a current risk of Lyme disease to TickEncounter Resource Center: Adult-stage female Ixodes scapularis both the canine, and by extension, human residents of PEI. (a.k.a. blacklegged or deer tick) growth comparison. Available from: https://tickencounter.org/tick_identification/deer_female_tick_growth_ The willingness and enthusiasm shown by the veterinarians of comparison Last accessed July 22, 2020. Prince Edward Island who chose to participate in this study 12. Lewis J, Lloyd VK. Identification of Borrelia bissettii in Ixodes scapularis suggest that their community is already aware of the risk of ticks from New Brunswick, Canada. Can J Microbiol 2019;65:155–161. 13. Ogden NH, Arsenault J, Hatchette TF, Mechai S, Lindsay LR. Antibody Lyme disease to their patients and that they are actively search- responses to Borrelia burgdorferi detected by western blot vary geo- ing for ways to address this risk. It also suggests that the veteri- graphically in Canada. PLoS One 2017;12:e0171731. nary community will be key to ongoing awareness among the 14. Elections Canada [homepage on the Internet] Maps of Prince Edward Island [updated 2018 August 27]. Available from: http://www.elections.c a/ island’s human population. Informing clients that infected ticks content.aspx?section=res&dir=cir/maps2/pei&document=index&lang=e are present and posing a health risk for both dogs and humans Last accessed July 22, 2020. on PEI and educating clients on the availability of vaccines, 15. Public Health Agency of Canada [homepage on the Internet] Surveillance of Lyme disease [updated 2018 August 14]. Available from: tick prevention, removal, and testing are key to minimizing the https://www.canada.ca/en/public-health/services/diseases/lyme-disease/ cases of canine Lyme disease and alerting humans to the threat surveillance-lyme-disease.html Last accessed July 22, 2020. of tick-vectored diseases.

1110 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Student Paper Communication étudiante

Left-sided dacryostenosis in a dog

Jamey Erjavec

Abstract — A 1.5-year-old neutered male black Labrador retriever dog was presented to a referral teaching hospital for evaluation of chronic, continuous, mucoid discharge and associated conjunctivitis of the left eye. Nasolacrimal flush revealed a patent duct on the right side but not on the left side. Computed tomography (CT) with a dacryocystogram identified severe stenosis or atresia of the left nasolacrimal duct. The patient was referred to a veterinary ophthalmologist for a reconstruction of the left nasolacrimal system. Ultimately, a conjunctivobuccostomy was performed and resolved all ocular clinical signs. Key clinical message: Dacryostography, a procedure in which the lacrimal punctum is cannulated, and iodinated contrast is instilled into the nasolacrimal system was combined with CT to enable excellent visualization and evaluation of the nasolacrimal canal.

Résumé — Dacryosténose unilatérale gauche chez un chien. Un chien Labrador noir mâle castré âgé de 1,5 ans fut présenté à un hôpital vétérinaire d’enseignement pour évaluation d’un écoulement mucoïde chronique continu associé à une conjonctivite de l’œil gauche. Un rinçage naso-lacrymal a révélé un canal fonctionnel du côté droit mais pas sur le côté gauche. Un examen par tomodensitométrie (CT) avec un dacryocystogramme identifia une sténose sévère ou une atrésie du canal naso-lacrymal gauche. Le patient fut référé à et un ophtalmologiste vétérinaire pour une reconstruction du canal naso-lacrymal gauche. Ultimement, une conjonctivobuccostomie fut réalisée et a permis de résoudre tous les signes cliniques oculaires. Message clinique clé : La dacryostographie est une procédure par laquelle le punctum lacrymal est canulé, et du milieu de contraste iodé est instillé dans le système naso-lacrymal combiné avec l’examen par CT a permis une excellente visualisation et évaluation du canal lacrymal. (Traduit par Dr Serge Messier) Can Vet J 2020;61:1111–1114

1.5-year-old male neutered black Labrador retriever dog and inferior lacrimal puncta were present bilaterally, the caniculi A was referred to the Atlantic Veterinary College (AVC) in associated with the puncta were patent, the right nasolacrimal September 2019 because of continuous discharge from the left duct was patent, but the left duct was obstructed. Mucopurulent eye over a 1-year period. In June 2019, the dog was examined debris was eliminated from the nasolacrimal caniculi of the by a referring veterinary ophthalmologist and was diagnosed left eye during this flush. The dog was referred to the AVC for with bilateral ectropion, a mucin deficiency of the left eye, gray- computed tomography (CT) imaging of the head. A CT scan green and mucoid ocular discharge, associated conjunctivitis, a with intravenous contrast study was performed and results lipid deposit in the ventral aspect of the cornea in the left eye, revealed that the lacrimal glands were normal bilaterally, with and persistent pupillary membranes in the 5 o’clock position of no evidence of an inflammatory lesion or mass-like lesion to the left eye. No anomalies of the right eye were identified. The explain the left nasolacrimal duct obstruction. The proximal left ophthalmic examination also revealed that both the superior nasolacrimal canal was noted to be mildly enlarged compared to the right, but this was felt to be an incidental conformational finding. Upon review of the imaging findings, a repeat CT scan Atlantic Veterinary College, University of Prince Edward Island, with dacryocystography was recommended for optimal evalua- Charlottetown, Prince Edward Island. tion of the nasolacrimal ducts. Address all correspondence to Jamey Erjavec; e-mail: At presentation to the AVC in September 2019, the dog was [email protected] bright, alert, and responsive, but mildly anxious. The dog was Use of this article is limited to a single copy for personal study. in good body condition and no abnormal findings were seen on Anyone interested in obtaining reprints should contact the physical examination, apart from left-sided epiphora (Figure 1). CVMA office ([email protected]) for additional At this time, the dog was receiving tobramycin and dexametha- copies or permission to use this material elsewhere. sone ophthalmic solution (Tobradex, 0.3%/0.1%; Novartis

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B COMMUNICATIONÉTUDIANTE

Figure 1. Left-sided mucoid and serous ocular discharge in a 1.5-year-old dog.

Pharmaceuticals Canada, Dorval, Quebec), q6h, cyclosporine (Optimmune, 0.2%; Intervet/Merck Animal Health, France), q12h, and oclacitinib (Apoquel, 5.4 mg; Zoetis, Kirkland, Quebec), q24h. Ophthalmic examination by a second veterinary ophthalmologist confirmed the previously noted anomalies. No anomalies were detected with the neuro-ophthalmic examination. Results of Schirmer tear tests, fluorescein stain uptake, and tonometry were all within normal limits, with the exception of a negative Jones test from the left nostril. Flushing of Figure 2. A — Tubing sutured in place with non-absorbable the nasolacrimal system of both eyes under general anesthesia suture to the inside of the mouth (white arrow shows the tubing). confirmed patency of the inferior and superior puncta bilaterally B — Tubing sutured in place with non-absorbable suture to the skin at the inner aspect of the left lower eyelid at the medial via the canniculi, a patent right nasolacrimal duct, patent upper canthus (white arrow denotes the tubing). and lower left canniculi, and obstruction of the left nasolacrimal duct. A CT scan of the head with dacryocystography was performed under the same general anesthesia (1). The owners requested a dacryocystorhinostomy, as this was For the dacryocystogram procedure, an 18-gauge catheter was recommended to be the most effective surgical treatment. The placed in the superior lacrimal punctum of each eye. Contrast dog was taken to the referring veterinary ophthalmologist for medium (3 mL) was flushed through the right upper lacrimal this procedure. This surgery entailed that a skin incision be made punctum, canniculi and nasolacrimal duct, and contrast medium under the eye and lateral to the nose (2,3). A small hole is made was observed to exit the right nostril. The same procedure was into the bone and a passage is surgically created by implanting a attempted through the left upper punctum; however, contrast polythene tube from the lacrimal sac to the nasal cavity, creating medium was seen leaking from around the catheter and not a permanent fistula. The tube is removed 8 wk after the pro- at the level of the left nostril. The CT scan revealed a patent cedure. Dacryocystorhinostomy was chosen over other surgical right nasolacrimal system with contrast medium surrounding options to preserve the functional portions of the dog’s naso- the right nasal turbinates. As for the left side, a small amount lacrimal system. For the procedure, the dog was anesthetized, of contrast medium was detected in the mid to dorsal left nasal and the left eye was flushed with a dilute iodine solution and a cavity and filling of the proximal left nasolacrimal canal with drop of topical anesthetic [Proparacaine hydrochloride solution most of the contrast medium superficially on the left side of (Alcaine, 0.5%; Novartis Pharmaceuticals)] was placed in the the head/face. These findings were consistent with an atresia or conjunctival fornix. The upper lacrimal caniculus of the left severe stenosis of the left nasolacrimal canal and a patent right eye was flushed with fluorescein stain using a 24-gauge catheter nasolacrimal canal. Each upper lacrimal punctum was flushed placed in the superior punctum. The stain was noted to exit the with 9 mL of sterile saline and 1 mL of neomycin sulfate, lower punctum but not the left nostril. The same procedure was dexamethasone, and polymyxin B sulfate solution (Maxitrol, repeated with the catheter in the lower punctum of the left eye 3.5 mg/g/0.1%/6000 U/g; Novartis Pharmaceuticals, London, while pressure was placed on the superior punctum of the same UK) after the procedure to remove any residual iodine, decrease eye to try to force the stain to exit the nose. This was repeated inflammation, and prevent infection. a few times and the nose was carefully examined through the Treatment options discussed with the owners included medi- left nostril. On nasal inspection, a region of reddened nasal tis- cal management of the epiphora, or surgical correction of the sue was observed but there was no drainage of fluid or foreign left nasolacrimal duct by a veterinary ophthalmologist. material from the left nostril. Next, an olive-tipped nasolacrimal

1112 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY cannulation wire with tubing was attached into the left lower Discussion lacrimal punctum and directed through the nose. It was not Diseases of the nasolacrimal system are common in small ani- possible to push the wire through to create an opening out of mal medicine. They are most often categorized as problems the left nostril. The procedure was then repeated using the upper with drainage of tears resulting in epiphora (4). Epiphora may punctum. The bluntness of the olive-tip and the fine nature of be caused by congenital absence or occlusion of the lacrimal PAPER STUDENT the wire prevented a recreation of an opening out of the left puncta, congenital or acquired obstruction of the nasolacri- nostril. At this time, the nasolacrimal system was re-flushed mal duct, or inflammation/infection of the nasolacrimal duct through the lower punctum while this wire remained in place in (dacryocystitis) (4). Imperforate puncta are the most common the upper punctum and a piece of foreign material that appeared congenital abnormalities seen in dogs; imperforate upper puncta consistent with a grass awn was removed from the lower punc- are commonly asymptomatic, whereas imperforate lower puncta tum. The wire was then removed from the upper punctum and usually result in epiphora. Dacryostenosis or atresia of the naso- nose, and the nasolacrimal system was flushed 2 more times. No lacrimal system is less common and more difficult to correct. additional foreign material was noted, and the fluorescein stain Though rarely reported in dogs and cattle, it is more commonly was still not exiting the left nostril. reported in horses and human infants (5–8). Due to the surgical findings, the surgical approach was revised and a conjunctivobuccostomy was performed. An 18-gauge Given the age, duration, and ocular findings in this dog, needle was used to recreate a draining path from the mid-lower the top differential diagnosis for improper drainage of tears conjunctival sac/fornix of the left eye and into the mouth along was congenital absence, or failure of the nasolacrimal duct to the lateral aspect of the upper teeth. Next, a piece of 0.033-mm fully canalize. Between days 22 and 26 of gestation, the surface tubing (Micro-Renothane; Braintree Scientific, Braintree, ectoderm that lines the groove of the maxillary process should Massachusetts, USA) was placed retrograde through the needle become buried in mesenchyme as a column of cells. These cells from the mouth to the inner lower eyelid and the needle was should form a cord with 2 proximal ends and 1 distal end; these removed. The tubing was sutured to the skin at the medial become the inferior and superior puncta and the nasal opening, canthus of the lower eyelid of the left eye (Figure 2A) and to the respectively. This cord should eventually hollow to form a patent inside of the mouth (Figure 2B) with non-absorbable suture. It duct between the eye and the nostril. Failure of this hollowing was recommended that the tube remain in place for at least 8 wk results in congenital nasolacrimal malformations (5). to minimize the risk of scarring or stenosis of the new tear drain- Computed tomography was chosen over standard radio- age path. Should the tubing become dislodged before 6 to 8 wk, graphic analysis of the nasolacrimal duct because it produces there would be a higher risk of the tear duct system becoming a 3D image, whereas radiographs only produce a 2D image. non-functional. There was mild bleeding from the lower punc- Furthermore, at least 2 radiograph views must be taken and tum of the left eye and from the left nostril during surgery, and a contrast medium must be injected into the nasolacrimal duct few drops of blood were noted from the left nostril during recov- to ensure visualization of the nasolacrimal system as there are ery. The dog was sent home on 7 d of oral meloxicam (Metacam, many overlying structures in the skull, and an abnormality or 1.5 mg/mL; Boehringer Ingelheim, Danbury, Connecticut, foreign material could easily be missed due to superimposition USA), 15 d of amoxicillin and clavulanic acid (Clavaseptin, of the images (9). Computed tomography can better highlight 500 mg; Vétoquinol, Lavaltrie, Quebec), and topical gatifloxa- soft tissue structures, which were believed to be the underlying cin (Zymar, 0.3%; Bristol-Myers Squibb, St. Laurent, Quebec), cause of the dog’s abnormal duct (dacryostenosis or atresia). topical nepafenac (Nevanac, 0.1%; Alcon, Mississauga, Ontario) To facilitate the drainage of tears in patients with abnormal and topical tear supplement (Theoloz Duo, 3% trehalose/0.15% nasolacrimal systems, surgical intervention is required to cre- sodium hyaluronate; Thea, Newcastle-under-Lyme, UK) until ate a patent communication between the lacrimal sac and the the first post-operative recheck 14 d after surgery. The dog was nasal cavity (dacryocystorhinostomy); the conjunctival fornix sent home with an E-collar to prevent rubbing of the left eye. It to the nose (conjunctivorhinostomy); the conjunctival fornix was recommended that the E-collar remain on at all times until to the maxillary sinus (conjunctival maxillary sinusotomy); the tubing was removed. or the conjunctival fornix to the oral cavity (conjuctivobuc- One month after surgery, the dog developed a non-painful, costomy) (5,10). A dacryocystorhinostomy approach can be firm swelling over the left cheek. The dog was restarted on oral challenging because the lacrimal sac is poorly developed in dogs meloxicam and clavulanic acid for 15 d. The client was also and cats and covered partially by the lacrimal bone and ocular advised to apply a warm compress to the area 3 times/day for muscles (5). A conjunctivorhinostomy is an easier approach 1 wk for 15 min each time. The swollen area never drained and because in a dacryocystorhinostomy, the periosteum and max- resolved during that 1-week period. illary bone must be incised and there are variable amounts of There has been no in-person follow-up since the 1-month hemorrhage reported when entering the nasal cavity (5). A post-operative recheck. The dog’s tubing stayed in place for 5 wk conjunctivobuccostomy was performed in this dog because after surgery. At 3 mo after surgery, the dog was off all medica- it is technically easier than the other approaches and reduces tions and had no recurrent eye infections. There was minimal the risk of hemorrhage given that the facial bones are not tearing in the left eye compared to the right eye, and the client involved (5). had not called to indicate any concerns once the swelling had In summary, a CT scan with intravenous contrast study was resolved. not adequate for diagnosing the condition in the dog herein,

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but a CT scan with dacryocystogram gave optimal imaging of References the nasolacrimal system. It allowed for full visualization of the 1. Dacryocystography. Radiopaedia [homepage on Internet]. c 2005–2020. abnormal duct, ruling out obstructive inflammation (dacryocys- Available from: https://radiopaedia.org/articles/dacryocystography Last titis) or a mass-like lesion; this in turn, gave the owners all the accessed August 11, 2020. 2. Long RD. The relief of epiphora by conjunctivorhinostomy. J Small information needed to make the decision to move ahead with Anim Pract 1975;16:381–386. surgical correction. There are many different surgical approaches 3. Dacryocystorhinostomy. John Hopkins Medicine [Homepage on the available for this condition, with conjunctivobuccostomy being Internet]. John Hopkins University of Medicine c2020. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/ ideal in this dog given the easier technical approach and reduced dacryocystorhinostomy Last accessed August 11, 2020. risk of hemorrhage. Success of the procedure depends on not 4. Fayolle P, Hidalgo A, Klein A, Moissonnier P, Scotti S, Vanore M. A having dislodgement of the tubing before 6 to 8 wk after sur- new surgical method for the control of the epiphora in dogs: Modified parotid duct transposition. J Small Anim Pract 2007;48:279–282. gery, which can result in scarring and further obstruction of 5. Slatter D. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, the duct. Given the reduced tearing of the left eye and lack Pennsylvania: Saunders, 2003:1349–1360. of recurrent eye infections, this surgery was deemed a success 6. Gelatt, K. Veterinary Ophthalmic Surgery. 1st ed. Gainesville, Florida:

COMMUNICATIONÉTUDIANTE Elsevier, 2011:146–148. in this dog. Removal of the foreign body from the tear duct 7. Katowitz J, Katowitz W. Pediatric Oculoplastic Surgery. 2nd ed. Sham, system appeared to play a significant role in reducing the dog’s Switzerland: Springer, 2018:467–480. ocular signs. 8. Brink P, Schumacher J. Canaliculosinostomy as a long-term treatment of seven horses for permanent obstruction of the nasolacrimal duct. Vet Surg 2015;45:110–114. Acknowledgments 9. Maggs D, Miller P, Ofri R. Slatter’s Fundamentals of Veterinary I thank Dr. Chantale Pinard and Dr. Cheryl Cullen for being Ophthalmology. 4th ed. St. Louis, Missouri: Saunders, 2008:152–165. 10. Champagne E, Giuliano E, Moore C, Pope E. Dacryocystomaxil the primary veterinarians on this case, and for their contribu- lorhinostomy for chronic dacryocystitis in a dog. Vet Ophthalmol tions and guidance during the writing of this case report. CVJ 2006;9:89–94.

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1114 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY The Art of Private Veterinary Practice L’art de la pratique vétérinaire privée

Fixed and flexible practice communication

Myrna Milani

ormally, members of Drs. Lacombe and Odetti’s staff and the drug? Had he missed something? Should he ask his client N client base use a combination of fixed and flexible orienta- to bring the dog in for a comprehensive work-up even though tions in their communication with others. They do this based he knows her finances are limited? Why did his long-time client on their awareness of which form is likely to produce the desired seem uncomfortable in his presence? What had changed? results under those circumstances. For example, Dr. Lacombe In this situation, the client and the practitioner developed often has fixed preferences regarding the best treatments for spe- a successful working relationship based on their mutual deter- cific problems based on his long experience. If the client objects mination to do the best for the animal. The veterinarian was to the treatment, he is apt to feel annoyed. On the other hand, determined to prescribe the treatments he believed were the best younger Dr. Odetti does not share her partner’s orientation. She for the animal based on his knowledge and experience. His client recognizes that different treatment options for the same problem was equally determined to ensure that her animal received those may be valid under certain circumstances. treatments exactly as directed by the veterinarian. Their individual orientations could create communication Like Dr. Lacombe, most practitioners would consider this problems for the practice owners. However, just because they clinician-client relationship a match made in heaven — until feel strongly about their personal preference does not undermine something changed. In this case, the client felt so proud of their respect for the other or the other’s approach. They also rec- her working relationship with the practitioner that she felt ognize that, just because they lean toward one orientation more embarrassed to tell him that her rheumatoid arthritis increas- than the other, does not mean they cannot adopt the alternate ingly made it difficult for her to medicate her dog as directed. approach if they believe it will benefit their patients and clients. She also felt sure the treatment regimens he prescribed for her For example, Dr. Lacombe considers Ms. Tanaka the ideal animals were the best ones, which is what she wanted for them. client because she always does whatever he tells her to do to And she also valued his good opinion of her and did not want help her animals. Moreover, Ms. Tanaka takes pride in her abil- to jeopardize their working relationship. But most important to ity to do exactly what the veterinarian tells her to do. However, her, she felt uncomfortable sharing details about her intermittent when her cocker spaniel does not respond to treatment as physical limitations with him. Dr. Lacombe expected, he does not know what bothers him Although working with practitioners with fixed ideas regard- more: the animal’s lackluster response to the oral medication or ing the best treatment may inspire clients who prefer this degree the slight hesitancy that replaces his client’s normal can-do spirit of certainty, it can create problems if the treatment does not when she brings her dog in again. Feeling he does not know her work for the client or the animal for some reason. Sometimes well enough to ask if something is troubling her, he prescribes this results in the practitioner blaming the client for the treat- another course of the medication he believes will work the best. ment’s failure. Other times, the opposite occurs: the client Nonetheless, the case continues to bother him. Was the drug blames the practitioner for prescribing a treatment program they he felt so sure about no longer the best treatment for the dog’s could not implement as directed. Either way, the result may be a relatively common problem? Had the dog become resistant to communications disaster. Some clients may feel so disenchanted with the practitioner they go to another practice. Other times, they stay in the practice but request appointments with another Dr. Milani is a behavior and bond practitioner, teacher, and veterinarian in it. author of several books on the interaction of animal behavior, Ms. Tanaka believed that she and Dr. Lacombe had reached health, and the human-animal relationship. an impasse. Unlike when they agreed on their respective roles, Use of this article is limited to a single copy for personal study. she no longer believed she could meet his expectations. At Anyone interested in obtaining reprints should contact the the same time, he sensed that his tried and true approach no CVMA office ([email protected]) for additional longer worked for her for some reason. However, neither of copies or permission to use this material elsewhere. them believed discussing this was professional or appropriate.

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Although she felt disloyal to the veterinarian, she opted to “I used to feel comfortable formulating the best treatment schedule her next appointment with his partner rather than for patients and expecting my clients to do their parts. Most of move to a new practice. them did and I never gave it a second thought,” Dr. Lacombe Fortunately, the two veterinarians respected each other wistfully recollects. “But now clients who previously would and wanted the best for the client and her animals. While do whatever I asked no longer can for legitimate reasons. As Ms. Tanaka initially dreaded encountering Dr. Lacombe at the a practice-owner, I understand their dilemma and know how veterinary clinic, he always greeted her with a smile and a posi- frustrating it can be. The practice currently cannot afford the tive comment about her dog or cat. While she sometimes found salary increases we’d planned because of decreased revenues. We Dr. Odetti’s options confusing compared to Dr. Lacombe’s black had to postpone the purchase of the new equipment we planned and white “This is what I want you to do” presentations, she also to buy at the beginning of the year. For the first time, I daily found the younger woman’s presence less intimidating. That, in find myself scrambling to find options that will meet everyone’s turn, made it easier for the client to confide her concerns about needs: family, staff members, clients. I wish I had Dr. Odetti’s her own medical condition and how this could impact her ani- skill at this!” mals’ well-being. Ms. Tanaka soon realized that, while she liked Meanwhile, Dr. Odetti is discovering that her own orienta- Dr. Lacombe’s direct approach to what she should do relative to tion has its downside, too.

L’ART DE LA PRATIQUE VÉTÉRINAIREPRATIQUE LA DE PRIVÉE L’ART her animals, she preferred the options Dr. Odetti gave her when “Yes, I still want to give my clients options,” she admits. it came to dealing with her intermittent problems treating them. “But doing that takes time and right now implementing and Once this rapport was established, Dr. Odetti asked for updating procedures designed to protect staff and client health the client’s permission to add a note to her animals’ records while ensuring animal health and welfare is my top priority. regarding her condition. Though it would mean sharing that I have so much going on in my head, I can’t even give my clos- information with the other veterinarians should she be unavail- est loved ones the attention they deserve. Sometimes I wish able herself, it would ensure that the client could implement I had Dr. Lacombe’s ability to focus strictly on the animal’s any treatments prescribed for her animals. She also assured problem, tell the client what they need to do, and send them Ms. Tanaka that, although the veterinarians in the practice had on their way!” different communicating styles, the animals’ health was every- Dr. Odetti also faces clients who perceive her as a sympathetic one’s first priority. They all recognized that, just as their patients’ listener to whom they could pour out their problems as in the needs could change, so could their clients’. past. These were energy-vampires in the best of times. In times In this pre-COVID-19 scenario, the veterinarians accept their when family, friends, co-workers, and other clients may want own, their colleagues’, and their clients’ preferred communica- her support for far more serious problems, she finds these clients tion approaches and the benefits and costs of each. They also bothersome. recognize that their clients have their own orientations and tend Most practitioners have a client communication style that to gravitate to practitioners who share these. At the same time works for them as well as most of their clients. Experienced though, they acknowledge that client orientations may change. practitioners may have honed this skill over the years. Novice When this happens, initially they may feel miffed if the client ones may adapt and change theirs based on client responses as chooses another veterinarian in the practice. But they do not needed. Most veterinarians also recognize that other practitio- blame the new practitioner for the client’s choice. ners will have different styles that some clients prefer and this In the current COVID-19 era, much has changed and contin- is normal. However, thanks to COVID-19, all practitioners ues to change on a daily basis. Practice owners, staff members, must accept that, regardless how successful their client com- and clients all may be coping with physical or mental health-, munication orientations may be, the best ones always remain home-, and work-related changes. Even those in areas relatively a work in progress. untouched by the virus may be facing economic or other losses precipitated by the pandemic.

1116 CVJ / VOL 61 / OCTOBER 2020 FOR PERSONAL USE ONLY Classifieds Petites annonces Business Directory Annuaire des entreprises

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»Digital & Dental X-Ray »Underw ater Treadmills Practice One Consulting Canadian Integrated Supplier of »Infusion Pumps/Monitors Veterinary Equipment & Digital »Cages »&D Catigital Condos & Dental X-Ray Practice Valuations  Practice Purchase Radiography Solutions »»AUssisinderw Loopater –Treadmills Practice Sale  Practice Management Canadian Integrated Supplier of A»ntiInfusion-inflamma Pumpstion /Monitors 227GVeterinary Brunswick Equipment Blvd. & Digital »CagesCentrifuges & Cat Condos Pointe-Claire,Radiography Quebec Solutions »Sterilization»Assisi L oop – Dr. Frank Richardson, DVM, MBA 1-877-440-4494 »Lighting/ATntiables/-inflammation Veterinary Management Consultant [email protected] Brunswick Blvd. Treatment Rooms»Centrifuges Pointe-Claire, Quebec »Sterilization PO Box 176 Phone: (902) 531-2617 1-877-440 -4494 »Lighting/Tables/ Western Shore, Nova Scotia E-mail: [email protected] [email protected] Treatment Rooms B0J 3M0 Fax: (902) 531-2618

Reaching Canada’s Veterinarians Get your message into Committed to helping you achieve financial success The Canadian in your veterinary practice. Veterinary Journal For more information contact: Veterinary Advisory Group Laima Laffitte (519) 291-3040 [email protected] Advertising and Sponsorship www.wardanduptigrove.com Consultant Tel.: (613) 673-2659 Fax: (613) 673-2462 Integrating Accounting, Wealth Management & Consulting Solutions e-mail: [email protected]

CVJ / VOL 61 / OCTOBER 2020 1117 FOR PERSONAL USE ONLY PPPVS CALMING CARE Print Trade Ad_CVJ_8-125x10-875in EN FINAL.pdf 1 2020-09-08 9:00 AM

FOR PERSONAL USE ONLY

WHAT IF… A PROBIOTIC COULD HELP ANXIOUS DOGS FEEL CALMER? Introducing Purina® Pro Plan Veterinary SupplementsTM Calming Care with Biﬁdobacterium longum (BL999), a probiotic strain shown to help dogs maintain calm behaviour. In a blinded crossover design study, 90% of dogs showed an improvement in displaying anxious behaviours such as jumping, pacing, and spinning*.

Helps dogs cope with Helps dogs maintain Helps blunt cortisol external stressors like positive cardiac activity response to anxious separation, unfamiliar visitors, during stressful events, events and supports a novel sounds, or changes in promoting a positive healthy immune system routine and location emotional state

For more information, visit www.proplanveterinarydiets.ca or call us at 1-866-844-VETS (8387). Have a case Consult? We are here to help. Contact our Canadian Veterinary Nutrition team at [email protected].

* McGowan, R. T. S. (2016). “Oiling the brain” or “Cultivating the gut”: Impact of diet on anxious behavior in dogs. Proceedings of the Nestlé Purina Companion Animal Nutrition Summit, March 31-April 2, Florida, 91-97.

® Your Pet, Our Passion.® Purina trademarks are owned by Société des Produits Nestlé S.A.