The Canadian Veterinary Journal La Revue Vétérinaire Canadienne Hydronephrosis in a Dairy Calf: a Diagnosis Delayed by a Clinician’S Bayesian Brain Reasoning

October/Octobre 2018 October/Octobre The Canadian Veterinary Journal

La Revue vétérinaire canadienne Vol. 59, No. 10 Vol. 59,

October/Octobre 2018 Volume 59, No. 10 The Canadian Veterinary Journal La Revue vétérinaire canadienne Hydronephrosis in a dairy calf: A diagnosis delayed by a clinician’s Bayesian brain reasoning

Radiation therapy for the treatment of canine progressive cutaneous angiomatosis: Description of 2 cases

Successful surgical resolution of a ceco- cecal intussusception in a 15-month-old Angus heifer

Occult tonsillar squamous cell carcinoma in 2 dogs presenting for treatment of primary oral squamous cell carcinoma

Successful management of doxorubicin overdose and extravasation in a dog with lymphoma

Urinary bladder herniation through inguinal ring in a female cat

Radiotherapy and pasireotide treatment of a growth hormone producing pituitary tumor in a diabetic dog

Fracture-associated osteosarcoma of the femur in a cat

Antimicrobial resistance in mastitis, respiratory and enteric bacteria isolated from ruminant animals from the Atlantic Provinces of Canada from 1994–2013

Overlooked sources of Salmonella contamination in the pig production network: Slaughterhouse yard pathways and mudguards and carpets from transport trucks

Serological survey of canine vector-borne diseases in Saskatchewan, Canada

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OCTOBER/OCTOBRE 2018 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

CASE REPORTS RAPPORTS DE CAS 1062 Hydronephrosis in a dairy calf: A diagnosis delayed by a clinician’s Bayesian brain reasoning Hélène Michaux, Sébastien Buczinski, Gilles Fecteau, Jean-Marc Benoit 1067 Radiation therapy for the treatment of canine progressive cutaneous angiomatosis: Description of 2 cases Paola Laganga, Laura Marconato, Simona Cancedda, Vito Ferdinando Leone, Carla Rohrer-Bley, Federica Rossi ARTICLE 1071 Successful surgical resolution of 1099 Antimicrobial resistance in mastitis, a ceco-cecal intussusception in a respiratory and enteric bacteria isolated 15-month-old Angus heifer from ruminant animals from the Atlantic Gustavo Ferlini Agne, Ricardo M. Stockler, Provinces of Canada from 1994–2013 Thomas Passler, Herris Maxwell, Robert Cole Babafela B. Awosile, Luke C. Heider, Matthew E. Saab, J.T. McClure 1075 Occult tonsillar squamous cell carcinoma in 2 dogs presenting for treatment of primary BRIEF COMMUNICATIONS oral squamous cell carcinoma COMMUNICATIONS BRÈVES Nicholas J. Rancilio, Christopher M. Fulkerson 1105 Overlooked sources of Salmonella 1079 Successful management of doxorubicin contamination in the pig production overdose and extravasation in a dog network: Slaughterhouse yard pathways with lymphoma and mudguards and carpets from Kristin S. Kicenuik, Nicole C. Northrup, transport trucks Dawn M. Clarke, Lisa J. Bazzle Alexandra Elayiz Henry, Ann Letellier, 1085 Urinary bladder herniation through inguinal Jean-Charles Côté, Gabriel Desmarais, Virginie Lachapelle, Nadia Bergeron, ring in a female cat Sylvette L. Lewandowsky, Philippe Fravalo Miranda de la Vega, Katy L. Townsend, Jesse Terry, Sarah Nemanic 1109 Serological survey of canine vector-borne diseases in Saskatchewan, Canada 1089 Radiotherapy and pasireotide treatment of a M. Casey Gaunt, Anthony P. Carr, Susan M. Taylor growth hormone producing pituitary tumor in a diabetic dog 1112 Assessing the sharpness of hypodermic Francesco Zublena, Alice Tamborini, needles after repeated use Carmel T. Mooney, Susan M. North, Kadin Majcher, Dustin Eichorn, Cheryl Waldner, Monika A. Lobacz, Dan Andrew, James Johnston, Chris Clark, Murray Jelinski Vanessa Woolhead, Heather Covey, Herbert A. Schmid, David B. Church, 1049 QUIZ CORNER Stijn J.M. Niessen TEST ÉCLAIR 1096 Fracture-associated osteosarcoma of the femur in a cat Jared I. Baum, Owen T. Skinner, Sarah E. Boston

CVJ / VOL 59 / OCTOBER 2018 1035 FOR PERSONAL USE ONLY FOR PERSONAL USE ONLY

OCTOBER/OCTOBRE 2018 Contents Table des matières

FEATURES RUBRIQUES SPÉCIALES

EDITORIAL BOOK REVIEW ÉDITORIAL COMPTE RENDU DE LIVRE 1041 Surprising new findings on veterinarians’ 1120 Diagnostic Techniques in Veterinary mental health and well-being/De nouveaux Dermatology résultats surprenants sur la santé et le Cheryl Vargo bien-être des vétérinaires Carlton Gyles NOTICES ANNONCES 1045 VETERINARY MEDICAL ETHICS DÉONTOLOGIE VÉTÉRINAIRE 1074 Index of Advertisers Index des annonceurs PRACTITIONERS’ CORNER 1108 New Products LE COIN DES PRATICIENS Nouveaux produits 1115 What is your diagnosis? Leila Bedos, Ruth Dennis, Adrien Aertsens 1118 Industry News Nouvelles de l’industrie SPECIAL REPORT 1125 Classifieds RAPPORT SPÉCIAL Petites annonces 1119 West Nile virus in horses — What do you need to know to diagnose the disease? Julie Paré, Alison Moore NEWS | NOUVELLES

COMMENTARY 1051 NEWS COMMENTAIRE NOUVELLES 1121 Access to veterinary care for low-income Heather Broughton, Isabelle Vallières Canadians Martha J. Harding

THE ART OF PRIVATE VETERINARY PRACTICE L’ART DE LA PRATIQUE VÉTÉRINAIRE PRIVÉE 1123 Communication: Too compliant client communication Myrna Milani

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 2018 L’Association canadienne des médecins vétérinaires détient le droit d’auteur complet L’Association canadienne des médecins vétérinaires 2018 sur tous les articles contenus dans le présent numéro.

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Surprising new findings on veterinarians’ mental health and well-being De nouveaux résultats surprenants sur la santé et le bien-être des vétérinaires

arlier this year Merck Animal Health (MAH) reported on lus tôt cette année, Merck Santé animale a publié un E the results of a study of mental health and well-being of P rapport sur les résultats d’une étude sur la santé mentale veterinarians in the United States (1). The study was undertaken et le bien-être des vétérinaires aux États-Unis (1). L’étude avait because of several publications that indicate veterinarians have a été entreprise parce que plusieurs publications indiquaient que high rate of suicide associated with an exceptionally high level of les vétérinaires affichaient un taux élevé de suicide qui était mental distress, that high student debt is a serious concern, and associé à un taux exceptionnellement élevé de détresse mentale, that there is a problem with compassion fatigue and burnout. A que la dette étudiante élevée représentait une préoccupation research team was charged with conducting a study to investigate importante et qu’il existait un problème d’usure de compassion mental health and well-being of US veterinarians. The team et d’épuisement professionnel. Une équipe de recherche a été designed a study to determine whether a mental health crisis chargée de réaliser une enquête afin d’étudier la santé mentale exists in the profession in the US, to identify factors contribut- et le bien-être des vétérinaires américains. L’équipe a donc conçu ing to the crisis if it exists, and to provide advice on responding une étude afin de déterminer s’il existait une crise de santé to it. Specific goals were to measure the frequency of mental mentale au sein de la profession aux États-Unis, d’identifier illness and stress in the profession and to make comparisons to les facteurs contribuant à la crise le cas échéant et de fournir previous studies and to the US population. des conseils afin de gérer la situation. Les objectifs particuliers The researchers sent invitations by e-mail to 20 000 randomly étaient de mesurer la fréquence de la maladie mentale et du stress selected veterinarians and obtained 3540 completed responses. au sein de la profession et d’effectuer des comparaisons avec des They determined that the margin of error was 1/2 1.6% at a études antérieures et au sein de la population américaine. 95% confidence level. The 6-item Kessler Psychological Distress Les chercheurs ont envoyé des invitations par courriel à scoring system was used to measure mental health and a series 20 000 vétérinaires choisis au hasard et ils ont obtenu of standardized questions on satisfaction with life was used to 3540 sondages remplis. Ils ont déterminé que la marge d’erreur measure well-being. était de 1/2 1,6 % avec un intervalle de confiance de 95 %. Major findings from the study were as follows. The prevalence L’échelle de détresse psychologique à 6 questions de Kessler of mental illness among veterinarians was not significantly dif- a été employée pour mesurer la santé mentale et une série de ferent from that in the general population (5.3% of veterinar- questions normalisées sur la satisfaction envers la vie a été ians were distressed, compared with 4.7% in the employed utilisée pour mesurer le bien-être. US population). This percentage is significantly lower than Les principales constatations de l’étude étaient les suivantes. the 9.3% for US veterinarians reported in the Nett study in La prévalence de la maladie mentale parmi les vétérinaires n’était 2015 (2). However, 50% of veterinarians with mental illness were pas significativement différente de celle au sein de la population not receiving treatment. There was significant variation in the en général (5,3 % des vétérinaires étaient en état de détresse, prevalence of mental illness among segments of the profession: comparativement à 4,7 % des personnes ayant un emploi aux younger veterinarians had a higher frequency of distress (8.7% États-Unis). Ce pourcentage était significativement inférieur for the 18 to 34 year group and 9.1% for the 35 to 44 years au chiffre de 9,3 % signalé pour les vétérinaires américains group) compared with older veterinarians (2.8% for the 55 to dans l’étude Nett publiée en 2015 (2). Cependant, 50 % des 64 years age group and 0.7% for the 65 years and over age vétérinaires atteints de maladie mentale ne recevaient pas de

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CVJ / VOL 59 / OCTOBER 2018 1041 FOR PERSONAL USE ONLY

group). The critically important issues that were identified were traitement. Il y avait une variation importante dans la prévalence high student debt, stress levels of veterinarians, and suicide rates. de la maladie mentale parmi les segments de la profession : The level of distress among veterinarians with no student debt les jeunes vétérinaires présentaient une fréquence de détresse was 3% compared with 9.2% to 11.3% among those with stu- supérieure (8,7 % pour le groupe des 18 à 34 ans et 9,1 % pour dent debt. The major self-reported conditions among those with le groupe des 35 à 44 ans) comparativement aux vétérinaires mental health concerns were depression, compassion fatigue/ âgés (2,8 % pour le groupe des 55 à 64 ans et 0,7 % pour le burnout, and anxiety. Surprisingly, only 41% of respondents groupe des 65 ans et plus). Les enjeux d’importance critique qui would recommend a career in veterinary medicine to a family ont été identifiés étaient la dette étudiante élevée, les niveaux member or friend. de stress des vétérinaires et les taux de suicide. Le niveau de Overall well-being in the profession was slightly less than détresse parmi les vétérinaires n’ayant aucune dette étudiante ÉDITORIAL that of the general population — 9.1% of veterinarians were était de 3 % comparativement à entre 9,2 % et 11,3 % parmi suffering from poor well-being, compared with 7.3% in the ceux qui avaient une dette étudiante. Les affections majeures general population. Female veterinarians were disproportion- autodéclarées parmi les personnes ayant des problèmes de ately affected by poor well-being. Younger veterinarians suffered santé mentale étaient la dépression, l’usure de compassion, from poor well-being more frequently than older veterinarians l’épuisement professionnel et l’anxiété. Fait surprenant, (10.3% to 12.3% for ages 18 to 54 compared with 2.0% to seulement 41 % des répondants recommanderaient une carrière 7.9% for ages 55 and over). en médecine vétérinaire à un membre de la famille ou à un ami. There were recommendations for veterinary organizations, L’état de bien-être général de la profession était employers, and veterinarians. Organizations are advised to con- légèrement inférieur à celui de la population en général car tinue to develop and publicize wellness resources, help to reduce 9,1 % des vétérinaires souffraient d’un bien-être médiocre student debt and enhance financial conditions in the profession, comparativement à 7,3 % pour la population en général. Les and educate members on mental health signs and symptoms. femmes vétérinaires étaient affectées de façon disproportionnelle Employers are asked to educate employees and promote a par un bien-être médiocre. Par ailleurs, les jeunes vétérinaires healthy work/life balance, develop mentorship programs to assist souffraient d’un bien-être médiocre plus fréquemment que les new employees, and consider assistance from veterinary social vétérinaires âgés (de 10,3 % à 12,3 % pour les 18 à 54 ans et work professionals. Practitioners are advised to create stress man- de 2,0 % à 7,9 % pour les 55 ans et plus). agement and financial management plans, using professionals to On a présenté des recommandations pour les organisations assist them and to budget time for health-promoting activities. et les employeurs vétérinaires ainsi que pour les employés There is an excellent commentary on the report by Dr. Marie vétérinaires. On a conseillé aux organisations de continuer Holowaychuk (3), which I would recommend. de concevoir et de promouvoir des ressources sur le bien-être, The Merck study has come up with findings that are less d’aider à réduire la dette étudiante et d’améliorer les conditions alarming than those of other US studies as well as studies in the financières de la profession ainsi que d’éduquer les membres UK, a number of European countries, and Australia. The meth- sur les signes et les symptômes liés à la santé mentale. On a odology in the Merck study is impressive and it is worthwhile demandé aux employeurs de sensibiliser les employés et de finding out whether the data from earlier studies are flawed promouvoir un sain équilibre travail-vie personnelle, de créer des or whether different data from other countries are associated programmes de mentorat afin d’appuyer les nouveaux employés with different conditions under which veterinary medicine is et de considérer l’assistance des professionnels du travail social practiced in various countries. Nonetheless, the finding that vétérinaire. On a conseillé aux praticiens de créer des plans pour over 5% of veterinarians suffer severe mental illness such as la gestion du stress et des finances, de faire appel à l’assistance de depression is concerning and much remains to be done. The professionnels ainsi que de prévoir du temps pour les activités Merck study has identified student debt, highly stressed younger favorisant une meilleure santé. Un excellent commentaire a été veterinarians, and failure to seek medical attention as areas that publié sur le rapport par la Dre Marie Holowaychuk (3) et je require more attention by the profession. These are areas on vous recommande vivement cette lecture. which veterinary organizations can start to focus their on-going L’étude Merck a produit des résultats qui sont moins campaigns to address concerns about mental health and well- alarmants que ceux contenus dans d’autres études américaines being of veterinarians. Employers and colleagues also have a ainsi que dans les études réalisées au Royaume-Uni, dans big role to play in assisting veterinarians in practice. It may be plusieurs pays européens et en Australie. La méthodologie easier to prevent than treat mental illness. As a profession and de l’étude Merck est impressionnante et il vaudrait la peine as individuals we also need to take on leading roles in removing de constater si les données des études antérieures étaient the stigma associated with mental health illness, a major block erronées ou si des données différentes provenant d’autres pays to seeking treatment by affected individuals. sont associées à des conditions différentes pour l’exercice de la médecine vétérinaire dans les divers pays. Néanmoins, la statistique voulant que plus de 5 % des vétérinaires souffrent d’une maladie mentale grave comme la dépression est préoccupante et il reste encore fort à faire. L’étude Merck a identifié la dette étudiante, de jeunes vétérinaires très stressés et l’absence de consultations auprès de médecins comme étant des

1042 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY

References 3. Holowaychuk M. What does a recent study reveal about veterinarian mental health? Available from: http://www.criticalcarevet.ca/recent-study- 1. Merck Animal Health Veterinary Wellbeing Study. February 2018. reveal-veterinarian-mental-health/ Last accessed June 27, 2018. ■ Available from: https://www.merck-animal-health-usa.com/pdfs/vca/ MAH-Well-Being-Study.pdf Last accessed June 27, 2018. 2. Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes Carlton Gyles toward mental illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc 2015;247:945–955. EDITORIAL

domaines qui exigent plus d’attention de la part de la profession. Renvois Ce sont des domaines sur lesquels les organisations vétérinaires 1. Merck Animal Health Veterinary Wellbeing Study. Février 2018. Disponible peuvent commencer à axer leurs campagnes en cours afin au : https://www.merck-animal-health-usa.com/pdfs/vca/MAH-Well- d’aborder les préoccupations liées à la santé mentale et au bien- Being-Study.pdf Dernière consultation le 27 juin 2018. 2. NETT, R.J., T.K. WITTE, S.M. HOLZBAUER et al. «Risk factors for être des vétérinaires. Les employeurs et les collègues ont aussi suicide, attitudes toward mental illness, and practice-related stressors un rôle important à jouer pour porter assistance aux vétérinaires among US veterinarians», J Am Vet Med Assoc, 2015, vol. 247, p. 945–955. en exercice. Il pourrait d’ailleurs être plus facile de prévenir 3. Holowaychuk M. What does a recent study reveal about veterinarian mental health? Disponible au : http://www.criticalcarevet.ca/recent-study-reveal- que de traiter la santé mentale. Nous devons aussi assumer des veterinarian-mental-health/ Dernière consultation le 27 juin 2018. ■ rôles de leadership, à titre professionnel et personnel, afin de supprimer les préjugés liés aux problèmes de santé mentale car Carlton Gyles ils représentent un obstacle important empêchant les personnes touchées d’obtenir le traitement dont elles ont besoin.

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16-19 July, 20192019 July, 16-19 Toronto, CanadaCanada Toronto,

8-12 July July 8-12 2019 Toronto, Canada Canada Toronto, 2019 FOR PERSONAL USE ONLY Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — October 2018 Some animal rights advocates argue that humane meat is an oxymoron. They believe killing an animal simply for human benefit is never humane. Other animal rights groups believe that advocating for humane meat improves the lives of more animals more rapidly than promoting a vegan lifestyle. Those involved in conventional animal agriculture believe that humanely raised livestock as well as veganism are passing fads and that modern livestock production has a smaller environmental footprint than humane meat. As a food animal veterinarian with both conventional and humanely raised livestock clients as well as friends and relatives who inquire about animal rights and veganism, you are looked to as a reliable source of information on these matters. It is a struggle, however, for you to stay current in veterinary practice without getting involved in animal welfare controversies. How should you respond to those who seek your council in these matters? Question de déontologie du mois — Octobre 2018 Certains défenseurs des droits des animaux font valoir que la viande éthique est un oxymoron. Ils croient que le fait de tuer un animal simplement pour le bénéfice des humains n’est jamais un geste sans cruauté. D’autres groupes des droits des animaux croient que la préconisation d’une viande produite de manière éthique améliore la vie de plus d’animaux, plus rapidement, que la promotion d’un style de vie végétalien. D’autre part, les personnes travaillant dans l’agriculture animale conventionnelle croient que l’élevage éthique du bétail et le végétalisme sont des modes passagères et que la production du bétail moderne a une empreinte écologique inférieure à celle de la viande produite de manière éthique. Étant donné que vous êtes un vétérinaire pour animaux destinés à l’alimentation ayant des clients possédant du bétail élevé selon des méthodes conventionnelles et selon des méthodes éthiques, des amis et des parents qui désirent s’informer à propos des droits des animaux et du végétalisme se tournent vers vous comme source fiable d’information. Cependant, vous peinez à demeurer au courant de la pratique vétérinaire sans vous mêler à des controverses en matière de bien-être animal. Comment devriez-vous répondre aux personnes qui sollicitent vos conseils sur ces questions?

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

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Ethical question of the month — July 2018 Fur farming has unique welfare challenges. Among these is timely and effective euthanasia of individual animals suffering from injuries or disease from which recovery is unlikely. A captive bolt gun is a safe and effective method of euthanasia for traditional domestic species. However, farmed mink and foxes are difficult to restrain adequately (particularly mature individuals) to ensure proper placement of the gun. Efforts to humanely restrain farmed fur animals for euthanasia often result in additional stress and injuries to the animal and the caretaker. If a safe, practical, and humane means of euthanasia does not exist, is it acceptable to allow farmed fur animals to die naturally? Is there an alternative for today’s fur farmer? Question de déontologie du mois — Juillet 2018 L’élevage des animaux à fourrure présente des défis uniques en matière de bien-être. L’un de ceux-ci est l’euthanasie opportune et efficace des animaux individuels souffrant de blessures ou de maladies lorsque le DÉONTOLOGIEVÉTÉRINAIRE rétablissement est improbable. Un pistolet à projectile captif est une méthode sûre et efficace d’euthanasie pour les espèces domestiques traditionnelles. Cependant, il est difficile de retenir adéquatement les visons et les renards d’élevage (particulièrement les individus adultes) afin d’assurer un placement approprié du pistolet. Les efforts de retenue sans cruauté produisent souvent des blessures et du stress supplémentaires pour l’animal et le préposé. Si une méthode d’euthanasie pratique et non cruelle n’existe pas, est-il acceptable de laisser les animaux à fourrure d’élevage mourir naturellement? Y a-t-il une méthode de remplacement pour l’éleveur d’animaux à fourrure d’aujourd’hui?

Ethical euthanasia — A Comment These are a pair of very odd questions to be asking when in fact Canadian farms.” This requirement has been in effect since safe, practical, and humane methods of euthanasia of ranched December 31, 2013 (2). or fur-farmed animals have been practiced for ages. Bottom line: Asking questions which already have satisfactory As a single example, harking back a quarter-century to the solutions has little rationale, either practically or philosophically. Canadian Council on Animal Care’s Guide to the Care and Use of Experimental Animals, appropriate methods would include References “the use of carbon monoxide, carbon dioxide, and nitrogen ... 1. Olfert ED, Cross BM, McWilliam AA, eds. Guide to the Care and Use of Experimental Animals. Volume 1. 2nd ed. Ottawa, Ontario: Canadian or electrical stunning followed by cervical dislocation” (1). Council on Animal Care, 1993. (ISBN: 0-919087-18-3). Moreover, the National Farm Animal Care Council’s Code 2. National Farm Animal Care Council. Code of Practice for the Care and of Practice for the Care and Handling of Farmed Mink specifi- Handling of Farmed Mink. Available from: https://www.nfacc.ca/pdfs/ codes/mink_code_of_practice.pdf Last accessed August 15, 2018. cally mandates the recommendation of the American Veterinary Medical Association which “recognizes carbon monoxide (CO) Dr. John B. Delack, Saskatoon, Saskatchewan as an approved method of euthanasia for mink” and specifies that “CO from a compressed cylinder must be used on all

An ethicist’s commentary on ethical euthanasia The facts presented in this month’s case are not complete and cogent to argue that there is (or rather, ought to be) one certain therefore much of the question is unclear. Upon conferring benefit for animals raised for human use, namely a genuinely with expert veterinarians associated with the fur industry, we non-horrendous death. As every veterinarian knows, the word determined that the scenario as described would be rare. One “euthanasia” etymologically means “good death.” Unfortunately, expert veterinarian wrote to us that “to offer the concept of historically, as a result of ignorance, lack of concern, or simple allowing an animal that has been determined to be in need stupidity, many modalities for performing “euthanasia” are of euthanasia to ‘die naturally’ is completely wrong from a woefully distant from a good death. I knew for example of one scientific and most importantly from an ethical point of view.” animal shelter that drowned animals it could not place into There is certainly a great deal to debate regarding acceptability homes. Being bludgeoned to death is indeed also very far from of diverse euthanasia methods. But one point that is eminently genuine euthanasia. Similarly, utilizing automobile exhaust to clear is that a natural death is not necessarily a good death. kill animals, as again occurred historically with “animal shelters” To take a ridiculously simplistic example, a person swimming disposing of unwanted animals, is greatly flawed. in high tides may well drown, certainly a natural death, but There are some common methods of killing animals that not a good one. To take some paradigmatic animal-centered fall far short of being genuine euthanasia. One paradigmatic examples, being torn apart by a predator is certainly natural but example has been the use of carbon dioxide to kill animals far from desirable. Similarly, many animal diseases are certainly in research, primarily small rodents. As anyone in veterinary “natural,” but occasion exquisite suffering. In fact, it is quite medicine knows, carbon dioxide kills by suffocation. I have

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many scientist friends who have assured me that CO2 is perfectly sibility that the scenario described in this case could conceivably acceptable, since in some cases it is an anaesthetic. My response occur, under conditions in which euthanasia is required for to such claims is to ask these people to put a chunk of dry ice individual animals. ETHICS MEDICAL VETERINARY

(frozen CO2) into a bag, and then take a deep breath from the Probably as important as what is used for euthanasia is the air in the bag. The feeling that the air is literally being ripped way the animals are handled prior to euthanasia. In recent years, away from you is most unpleasant and terrifying. (There is a largely thanks to the work of Temple Grandin, the cattle indus- reason that treating asthmatics, who cannot expel their CO2 as a try has taken major steps towards minimizing the stress resulting result of bronchial constriction, is a major priority in emergency from pre-slaughter handling. The industry generally deploys rooms.) Furthermore, when CO2 reaches mucous membranes, stunners, or captive bolt pistols, which are placed appropriately carbonic acid is formed, which burns. against the animals’ foreheads and ablate consciousness, virtu- My research indicates that the fur industry uses carbon mon- ally instantaneously. Unfortunately, the slaughter of other food oxide (CO) for euthanasia when recovering pelts. Furthermore, animals is nowhere near as optimal. Pigs are frequently stunned the CO utilized is not derived from automobile exhaust, and by being placed into CO2 tunnels or carousels. Poultry are hung is therefore pure. One cannot detect carbon monoxide, as it is by their feet from conveyor belts and then stunned by electric colorless, odorless, and tasteless. (That is in fact why one should paddles that robotically are fitted to their heads. Immediately keep a carbon monoxide detector in one’s home.) From the thereafter, they are mechanically eviscerated and dumped into point of view of animal welfare, CO is an optimal euthanasia scalding water. The stunning fails more than half the time, agent. What is problematic about it, is that it is extremely dan- and poultry is not covered by the US Humane Slaughter Act. gerous to operators who are involved in administering it, and its The industry is currently seeking better alternatives and my toxic effects are cumulative over time. It ends up binding with colleagues and I have worked on high-altitude hypoxia, which hemoglobin, in effect preventing the body from receiving the induces oxygen deprivation in the brain without suffocation, so requisite amount of oxygen. the animals simply go to sleep. Euthanasia of fur animals such as mink generally occurs in Any euthanasia method can fail if it is administered by uncar- large groups of animals. I have been unable to find out what ing or untrained workers. Since the animals are giving us their method is used when an individual animal is sick, injured, lives, we owe it to them morally to provide a peaceful and non- or suffering, and thus requires euthanasia. I doubt that the traumatic death. This in turn entails methods not causing pain industry would use a method aimed at large groups of animals and distress, gentle handling, and doing as much as possible to for individuals, if only for reasons of cost. I would assume that minimize the animals’ pain and fear. Pursuant to these goals, an injection of pentobarbital would work if the animal can be workers should be well-trained and equipment should always handled, but mink are not tame. It is extremely distressing that be in flawless condition. we have been unable to find a required protocol for such cases, either by networking or searching the Web, leading to the pos- Bernard E. Rollin, PhD

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Another stand out for Anna were Massey’s educators, particularly for her Massey postgraduate Cardiorespiratory and Endocrinology units. “Both are world experts in their fields and degree leads to make these subjects far easier to tackle. By the end of these courses, I could confidently interpret an ECG and an veterinarian’s selection echo, and those complicated Addison’s and Cushing’s cases no longer scared for prestigious residency me!” Anna feels the MVM has made a significant impact on her veterinary The quest for an intellectual challenge “The MVM programme not only got career and says, “Electing to complete after moving to Singapore led me noticed and selected into an the research component of the Masters veterinarian Anna Kokosinska to further Anatomic Pathology residency, but also was instrumental in broadening study. opened the door to some of the best my professional network, not only connections not only at Massey, but also Wanting to explore her new home base throughout New Zealand but also globally with the Pathology world,” she and the surrounds of Asia rather than globally given Massey’s breadth of says. having to work weekends and being contacts and partnerships.” on call led Anna sought to spend her Completing the course from Singapore, Through introductions and time more wisely with distance learning, Anna valued the flexibility of the distance recommendations from the Massey leading her to Massey University’s learning with Massey. University faculty, Anna is about to Master of Veterinary Medicine (MVM). “It allowed me to manage my own work commence the final year of her Anatomic “Furthering my veterinary career while hours in and around other commitments. Pathology residency at the University of still having the flexibility to travel and The programme is extremely flexible and Georgia. spend evenings with my husband and the online resources such as recorded “I feel without the contacts that I made two rescue dogs, I chose to start the lectures were very useful, so there were during the MVM course, this would not MVM programme,” she says. very few schedule commitments. have been possible,” she says. At a crossroads in her career, Anna “There’s a wide range of units on offer was also deciding if she wanted to with flexibility in timeline and required Find out more about Massey University’s pursue further training as an Anatomic contact hours. I really felt like I was able Master of Veterinary Medicine at Pathologist or continue as a veterinarian to choose units that suited my intended massey.ac.nz/mvm. in local practice. specialisation and areas of interest,” she says. “I felt the MVM training would give me the edge required for selection into the highly competitive residency training, and I was right! FOR PERSONAL USE ONLY

Quiz Corner Test éclair

1. Which of the following cell types is a consistent finding 1. Laquelle des cellules suivantes est compatible avec un when diagnosing pemphigus foliaceus? diagnostic de pemphigus foliacé? A. Macrophage A. macrophage; B. Lymphocyte B. lymphocyte; C. Plasma cell C. plasmocyte; D. Acantholytic cell D. cellule acantholysée; E. Spherocyte E. sphérocyte. 2. Which of the following is most correct concerning epileptic 2. Lequel des énoncés suivants est le plus exact à propos des seizures? crises épileptiques? A. They are caused by abnormal activity in the cerebral A. Elles sont causées par l’activité anormale du cortex cérébral. cortex. B. Elles sont causées par l’activité anormale du cervelet. B. They are caused by abnormal activity in the cerebellum. C. Elles sont toujours le résultat d’un traumatisme antérieur. C. They are always the result of previous trauma. D. Elles sont le résultat de l’augmentation de la pression du D. They are the result of an increase in cerebral spinal fluid liquide céphalo-rachidien. (CSF) pressure. E. Elles sont causées par un désordre neurodégénératif du E. They are caused by a neurodegenerative disorder of the prosencéphale. forebrain. 3. Lequel des énoncés suivants est vrai à propos du traitement 3. Which of the following is true regarding treatment for dis- de la coagulopathie intravasculaire disséminée? seminated intravascular coagulopathy (DIC)? A. Du sang entier entreposé ou des globules rouges sont A. Stored whole blood or RBCs are used as the sole treatment. utilisés comme seul traitement. B. Anticoagulants should be given. B. Des anticoagulants doivent être administrés. C. Stored whole blood or RBCs with plasma products are C. Du sang entier entreposé ou des globules rouges avec des used for transfusion. produits du plasma sont utilisés pour les transfusions. D. Sulfas or nonsteroidal anti-inflammatory drugs should be D. Des sulphas ou des anti-inflammatoires non stéroïdiens given to inhibit platelets. doivent être administrés pour inhiber les plaquettes. 4. In equine anemia, which of the following is the preferred 4. Dans l’anémie équine, laquelle des méthodes suivantes est method for evaluation of regenerative response? la préférée pour évaluer la réponse régénérative? A. Peripheral mean cell volume (MCV) ® A. volume globulaire moyen périphérique; B. Peripheral blood reticulocyte count B. numération des réticulocytes du sang périphérique; C. ZYCOMyeloid:erythroid (M:E) ratioRTAL C. rapport myéloïde : érythroïde (M : E); HIDDEN DISEASE. VISIBLE ANSWER. D. Red blood cell (RBC) distribution width D. indice de distribution érythrocytaire.

® ZYCORTAL HIDDEN DISEASE. VISIBLE ANSWER. quiz corner is generously sponsored by le test éclair est généreusement commandité par

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5. A flock of lambs is experiencing high morbidity and moder- 5. Un troupeau d’agneaux présente un taux élevé de morbidité ate mortality due to severe anemia and hypoproteinemia. et un taux modéré de mortalité à cause d’anémie et Necropsy of some lambs reveals the presence of granular d’hypoprotéinémie sévères. La nécropsie d’un certain nombre black abomasal contents. Which of the following is the most d’agneaux révèle la présence de matière granuleuse noire likely diagnosis? dans l’abomasum. Lequel des diagnostics suivants est le plus A. Coccidiosis probable? B. Cryptosporidiosis A. coccidiose; C. Haemonchosis B. cryptosporidiose; D. Colibacillosis C. hémonchose; E. Clostridiosis D. colibacillose; TESTÉCLAIR E. clostridiose.

(See p. 1084 for answers./Voir les réponses à la page 1084.)

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).

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NEWS | NOUVELLES

70th CVMA Convention and Council 70e congrès de l’ACMV et mise à jour Update du Conseil hanks to the participants, speakers, sponsors, exhibitors, râce aux participants, aux conférenciers, aux commanditaires, Tvolunteers and staff, the 2018 CVMA Convention was a Gaux exposants, aux bénévoles et aux employés, le great success. With close to 1100 participants, the 2018 CVMA congrès de l’ACMV a connu un immense succès. Avec près de Convention had the greatest turnout in recent history. The 1100 participants, le congrès 2018 de l’ACMV a connu la plus events took place in the brand new facilities of the JW Marriott haute fréquentation observée récemment. Les activités se sont Parq Vancouver Hotel. The City of Vancouver really came déroulées dans les nouvelles installations de l’hôtel JW Marriott through weather-wise, providing us with perfect summer weather Parq Vancouver. La ville de Vancouver nous a vraiment gâtés sur le while large parts of the country experienced unusual heat. The plan de la météo en nous offrant des conditions estivales idéales program featured 113 concurrent sessions provided by a total tandis que de grandes régions du pays vivaient des canicules of 39 speakers. For the 4th year, the program was approved by inhabituelles. Le programme proposait 113 ateliers parallèles et un the Registry of Approved Continuing Education (RACE). Some total de 39 conférenciers. Pour la quatrième année, le programme 310 participants registered for the social event, which took a été approuvé par le Registry of Approved Continuing Education place on a beautiful summer evening on board The Magic Yacht (RACE). Quelque 310 participants se sont inscrits à l’activité sociale Charters’ 3-level cruise vessel, The Magic Spirit. The event show- qui s’est déroulée par une splendide soirée d’été à bord du navire cased Vancouver’s magnificent shoreline and allowed colleagues de croisière à trois étages de Magic Yacht Charters, le Magic Spirit. and friends to meet over food, beverage and entertainment. L’activité a mis en vedette le splendide littoral de Vancouver et a CVMA Convention — Where Canada’s permis aux collègues et aux amis de se rencontrer et de savourer veterinarians meet des plats, de se rafraîchir de boissons et de se divertir. Every year the CVMA Convention attracts veterinarians from all Congrès de l’ACMV — Lieu de rencontre des areas of Canada and many international guests to meet, interact vétérinaires du Canada and learn. A large number of corporate meetings and events take Chaque année, le congrès de l’ACMV attire des vétérinaires de place during the Convention. The following are just a few of toutes les régions du Canada ainsi que de nombreux invités them: internationaux pour se réunir, interagir et apprendre. Beaucoup de réunions d’organisations se tiennent durant le congrès. En voici quelques exemples : Réunion du NAVL : L’ACMV a été l’hôte de la réunion de cette année du North American Veterinary Leaders (NAVL). Ce groupe se compose des leaders d’organisations provenant des États-Unis, du Mexique et du Canada et il se réunit une fois par année pour discuter de sujets d’intérêt commun.

Boat revelers enjoy themselves. Des passagers profitent de la croisière.

A full exhibit hall and full continuing education sessions made for an extremely successful 2018 CVMA Convention. Le congrès 2018 de l’ACMV a connu un immense succès comme en témoignent un Salon des exposants achalandé et des salles combles pour les séances de formation continue.

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N NAVL meeting: The CVMA hosted this year’s North Sommet de l’ACMV : La présidente désignée de l’ACMV, American Veterinary Leaders’ (NAVL) Meeting. This group Dre Terri Chotowetz, a organisé et présidé le Sommet 2018 comprises the leadership of veterinary organizations from the qui s’intitulait La dynamique changeante de la pratique vétérinaire. United States, Mexico, and Canada and meets annually to dis- Le sommet a attiré environ 175 participants et incluait des cuss areas of common interest. présentations et des discussions sur la «Pratique vétérinaire CVMA Summit: The CVMA’s president-elect, Dr. Terri d’entreprise — son impact sur la profession», des «Expériences Chotowetz, organized and chaired the 2018 Summit entitled en éducation sur la communication vétérinaire pour le succès de The Changing Dynamics of Private Practice. The Summit drew la pratique» et «Comment former des habitudes qui favorisent la approximately 175 participants and included presentations résilience en médecine vétérinaire». and discussions on “Corporate Veterinary Practice — What Forum sur les enjeux nationaux : L’édition 2018 du Forum Does it Mean for The Profession?,” “Experiences in Veterinary sur les enjeux nationaux de l’ACMV sur l’usage thérapeutique Communication Education for Practice Success,” and “How to des cannabinoïdes en médecine vétérinaire a été modérée par la Form Habits that Foster Resilience in Veterinary Medicine.” Dre Joanne Dias, présidente du Comité sur les enjeux nationaux. National Issues Forum: The CVMA’s 2018 National Issues Trois panélistes possédant de l’expertise en médecine des animaux Forum on the Therapeutic Use of Cannabinoids in Veterinary de compagnie, en oncologie et en recherche médicale ainsi qu’en Medicine was moderated by Dr. Joanne Dias, National Issues toxicologie ont fait des présentations devant environ 200 participants Committee chair. Three panelists with expertise in companion en utilisant un format interactif ayant recours à des sondages en animal medicine, medical oncology and research, and toxicology direct et à des discussions libres. L’entrée en vigueur de la nouvelle presented to about 200 participants using an interactive format loi fédérale pour légaliser le cannabis pour consommation humaine employing live polling technology and open discussion. The est prévue le 17 octobre 2018. implementation of new federal legislation to legalize cannabis Il est nécessaire d’étudier l’usage des cannabinoïdes chez for human use is scheduled for October 17, 2018. les animaux de manière plus approfondie et plusieurs projets Use of cannabinoids in animals needs more research and de recherche sont maintenant en cours. Il n’y a pas encore de a number of studies are now underway. As yet, there are no produits approuvés par le gouvernement fédéral pour utilisation

2018 NAVL Meeting: From left to right (back row), Drs. J. de Jong, President-Elect, American Veterinary Medical Association (AVMA); A. Maccabe, Chief Executive Officer, Association of American Veterinary Medical Colleges (AAVMC); J. Donlin, Executive Vice-President, AVMA; C. Fuentealba, AVMA representative to Pan American Association of Veterinary Sciences (PANVET); E. Sabin, AVMA Director of Global Outreach; B. Stemshorn, CVMA representative to PANVET; C. Johnson, President, AAVMC; Mr. J. am Rhyn, CEO, CVMA. (Front row), Drs. E. Villarreal, President, Médicos Veterinarios Zootecnistas de México (FedMVZ); T. McPherson, President, CVMA; M. Topper, President, AVMA; T. Chotowetz, President-Elect, CVMA; F. Suárez-Güemes, Dean, Universidad Autónoma de Mexico (UNAM). Réunion 2018 du NAVL : De gauche à droite (rangée arrière), Drs J. de Jong, président désigné, American Veterinary Medical Association (AVMA); A. Maccabe, président-directeur général, Association of American Veterinary Medical Colleges (AAVMC); J. Donlin, vice-présidente directrice, AVMA; C. Fuentealba, représentante de l’AVMA auprès de la Pan American Association of Veterinary Sciences (PANVET); E. Sabin, directrice des affaires internationales de l’AVMA; B. Stemshorn, représentant de l’ACMV auprès de PANVET; C. Johnson, présidente, AAVMC; M. J. am Rhyn, PDG, ACMV. (Rangée avant), Drs E. Villarreal, président, Médicos Veterinarios Zootecnistas de México (FedMVZ); T. McPherson, présidente, ACMV; M. Topper, président, AVMA; T. Chotowetz, présidente désignée, ACMV; F. Suárez-Güemes, doyen, Universidad Autónoma de Mexico (UNAM).

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chez les animaux. Compte tenu du statut légal du cannabis, les N vétérinaires devraient consulter leur organisme de réglementation provincial pour savoir si et comment ils devraient conseiller les propriétaires et répondre à leurs questions. Sur son site Web, l’ACMV a publié «Mise en garde des médecins vétérinaires : L’exposition au cannabis médicinal chez les animaux de compagnie» (https:// www.veterinairesaucanada.net/documents/exposition-au-cannabis- medicinal-chez-les-animaux-de-compagnie), qui aborde les effets de l’usage du cannabis médical chez les animaux de compagnie, les signes d’exposition excessive au cannabis chez les animaux de compagnie et les catégories de cannabis. L’ACMV a exercé des pressions auprès du gouvernement fédéral pour reconnaître les vétérinaires en tant que «praticien de la santé» afin qu’ils puissent donner accès à leurs patients aux produits de cannabis médical et veiller à ce que les produits de cannabis pour consommation 2018 Summit speakers: Left to right, Drs. M. Holowaychuk, T. Chotowetz, G. Ravetz and humaine soient bien étiquetés afin de protéger les animaux. L’ACMV C. Adams. continue de représenter la profession vétérinaire dans ce dossier et elle maintient le contact avec Santé Canada et d’autres autorités au Conférences du Sommet 2018 : De gauche à droite, Dres M. Holowaychuk, T. Chotowetz, G. Ravetz fur et à mesure que la situation évolue. et C. Adams. Programme des futurs leaders : L’ACMV a offert cet atelier, qui est présidé par le Dr Chris Bell et animé par le Dr Rick DeBowes pour la neuvième année consécutive. Le Programme des futurs federally approved products containing cannabinoids for use in leaders est conçu afin de préserver ou de réintroduire le plaisir animals. Given the current legal status of cannabis, veterinarians en milieu de travail en enseignant aux diplômés récents et aux should consult with their provincial licensing bodies regarding if professionnels chevronnés comment gérer divers défis vécus en and how they should advise pet owners and answer their ques- pratique vétérinaire. Il fournit l’occasion aux personnes d’explorer tions. On its website, the CVMA has published “Veterinarians leur approche face aux réalisations personnelles et professionnelles Caution: Medical Marijuana Exposure in Pets” (www.canadi et à leurs relations de travail avec les collègues. anveterinarians.net/documents/veterinarians-caution-medical- Assemblée générale annuelle (AGA) : Il y avait environ marijuana-exposure-in-pets), which addresses the effects of using 250 personnes présentes à l’AGA 2018 de l’ACMV. La ministre de medical cannabis in pets, signs of excessive cannabis exposure la Santé du Canada, l’honorable Ginette Petitpas Taylor, a envoyé in pets, and classes of cannabis. The CVMA has lobbied the un message aux membres de l’ACMV, dont les extraits suivants : federal government to recognize veterinarians as “medical prac- «…Je tiens également à vous remercier du soutien que vous avez titioners” so that they can grant their patients access to medical offert à Santé Canada pendant l’élaboration et la mise en œuvre cannabis products and to ensure that human cannabis products are properly labeled to protect animals. The CVMA continues to represent the veterinary profession on this file and maintains ongoing contact with Health Canada and other authorities as the situation evolves. Emerging Leaders Program: The CVMA offered this work- shop, chaired by Dr. Chris Bell and facilitated by Dr. Rick DeBowes for the 9th consecutive year. The Emerging Leaders Program is designed to maintain or help bring joy back into the workplace by teaching graduates and experienced professionals alike how to cope with a variety of challenges encountered in veterinary practice. It provides an opportunity for individuals to explore their approach to personal and professional accomplish- ments and their working relationships with colleagues. Annual General Meeting (AGM): The CVMA’s 2018 AGM had approximately 250 attendees. Canada’s Minister of Health, The Honorable Ginette Petitpas Taylor, sent a message to CVMA members including the following excerpts: “…I would like to express my appreciation for the support your organization Dr. Sarah Silcox, President and Director, Canadian Association of Veterinary Cannabinoid has provided to Health Canada throughout the development and Medicine, was one of the presenters at the 2018 National Issues Forum. implementation of the regulatory and policy changes introduced to La Dre Sarah Silcox, présidente et directrice de l’Association canadienne de médecine vétérinaire address the issue of antimicrobial resistance in the animal context… cannabinoïde, a été l’un des conférenciers lors de l’édition 2018 du Forum sur les enjeux We have made significant progress, and much of this is a result of the nationaux.

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N leadership and extensive work of the CVMA to encourage responsible des changements apportés à la réglementation et aux politiques afin antibiotic use….” d’aborder la question de la résistance aux antimicrobiens dans le International veterinary leaders attending the AGM included contexte de la santé animale… Si nous avons accompli de grands Dr. Michael Topper, president, American Veterinary Medical progrès, c’est surtout grâce au leadership exercé par l’ACMV et au Association (AVMA); Dr. John de Jong, president-elect, AVMA; travail considérable qu’elle a effectué pour favoriser une utilisation Dr. Janet Donlin, executive vice-president and chief executive responsable des antibiotiques...» officer, AVMA; Dr. Andrew Maccabe, chief executive officer, Les leaders vétérinaires internationaux qui assistaient à l’AGA Association of American Veterinary Medical Colleges (AAVMC); incluaient notamment : Dr Michael Topper, président, American Dr. Walt Ingwersen, president, World Small Animal Veterinary Veterinary Medical Association (AVMA); Dr John de Jong, président Association (WSAVA); Dr. Edmundo Villarreal, president, désigné, AVMA; Dre Janet Donlin, vice-présidente directrice et Federación de colegios y asociaciones de médicos veterinaries présidente-directrice générale, AVMA; Dr Andrew Maccabe, zootecnistas de México (FedMVZ); Dr. Paula Parker, president, président-directeur général, Association of American Veterinary Australian Veterinary Association (AVA); Dr. Rafaël Laguens, Medical Colleges (AAVMC); Dr Walt Ingwersen, président, World president, Federation of Veterinarians of Europe (FVE); and, Small Animal Veterinary Association (WSAVA); Dr Edmundo Dr. Francisco Suárez-Güemes, dean, Facultad de Medicina Villarreal, président, Federación de Colegios y Asociaciones de veterinaria y zootecnia, Universidad nacional autónoma de Médicos Veterinarios Zootecnistas de México (FedMVZ); Dre Paula México (UNAM). Parker, présidente, Australian Veterinary Association (AVA); The new president and Executive of the CVMA were intro- Dr Rafaël Laguens, président, Fédération des vétérinaires d’Europe duced: Dr. Terri Chotowetz, president; Dr. Melanie Hicks, (FVE); et Dr Francisco Suárez-Güemes, doyen, Facultad de president-elect; Dr. Enid Stiles; vice-president; Dr. Louis Medicina Veterinaria y Zootecnia, Universidad Nacional Autónoma Kwantes, executive member. Dr. Barry Stemshorn remains as de México (UNAM). treasurer, and Mr. Jost am Rhyn, as CEO. The CVMA would On a présenté la nouvelle présidente et le nouvel exécutif de like to extend sincere thanks to Dr. Troye MacPherson, now l’ACMV : Dre Terri Chotowetz, présidente; Dre Melanie Hicks, immediate past-president, for her leadership and many years of présidente désignée; Dre Enid Stiles; vice-présidente; Dr Louis dedication to the CVMA and the veterinary profession. Kwantes, membre de l’exécutif. Le Dr Barry Stemshorn occupera The CVMA and its members honored a number of veteri- de nouveau le poste de trésorier et, M. Jost am Rhyn, celui nary professionals at the Awards Ceremony held following to de PDG. L’ACMV aimerait remercier sincèrement la Dre Troye the AGM: MacPherson, maintenant présidente sortante, de son leadership • Small Animal Practitioner Award: Dr. Matt Read (AB) et de ses nombreuses années de dévouement envers l’ACMV et la • Merck Veterinary Award: Dr. Kathleen Parker (AB) profession vétérinaire.

CVMA Council members and international guests: From left to right (back row), L. Ridgway (RVTTC); Drs. K. MacMillan (PE); T. Arthur (ON); Ms. K. Rundle (in-coming SCVMA President); Drs. M. Brown-Bury (NL); B. Stemshorn (Treasurer); Mr. J. am Rhyn (CEO); Drs. L. Kwantes (AB); C. Bell (MB); C. Armstrong (BC); M. Hicks (Vice-President) (NB); E. Stiles (Executive Member) (QC); K. Machine (WCVM/UCVM/OVC). Front row, Drs. J. Donlin, Executive Vice-President, (AVMA); A. Maccabe, CEO (AAVMC); W. Ingwersen, President (WSAVA); T. Bourque (CVMA Past-President); J. de Jong, President-Elect (AVMA); T. Chotowetz, (CVMA President-Elect); T. McPherson (CVMA President); M. Topper, President (AVMA); R. Laguens, President (FVE); F. Suárez-Güemes, Dean, (UNAM); E. Villarreal, President (FedMVZP); Paula Parker, Past-President (AVA). Membres du Conseil de l’ACMV et invités internationaux : De gauche à droite (rangée arrière), L. Ridgway (TTVAC); Drs K. MacMillan (Î.-P.-É.); T. Arthur (Ont.); Mme K. Rundle (nouvelle présidente des ÉACMV); Drs M. Brown-Bury (T.-N.); B. Stemshorn (trésorier); M. J. am Rhyn (PDG); Drs L. Kwantes (Alb.); C. Bell (Man.); C. Armstrong (C.-B.); M. Hicks (vice-présidente) (N.-B.); E. Stiles (membre de l’exécutif) (QC); K. Machine (WCVM/UCVM/OVC). Rangée avant, Drs J. Donlin, vice-présidente directrice (AVMA); A. Maccabe, PDG (AAVMC); W. Ingwersen, président (WSAVA); T. Bourque (président sortant de l’ACMV); J. de Jong, président désigné (AVMA); T. Chotowetz, (présidente désignée de l’ACMV); T. McPherson (présidente de l’ACMV); M. Topper, président (AVMA); R. Laguens, président (FVE); F. Suárez-Güemes, doyen, (UNAM); E. Villarreal, président (FedMVZP); Paula Parker, présidente sortante (AVA).

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L’ACMV et ses membres ont honoré plusieurs professionnels N vétérinaires lors de la cérémonie de remise des prix qui s’est tenue après l’AGA : • Prix du praticien des petits animaux : Dr Matt Read (Alb.) • Prix vétérinaire Merck : Dre Kathleen Parker (Alb.) • Prix humanitaire de l’ACMV : Dre Helene Van Doninck (N.-É.) • Prix de la pratique de l’année de l’ACMV : Kannon Animal Hospital (N.-B.) • Titre de membre à vie de l’ACMV : Dr Carlton Gyles (Ont.) • Prix du président de l’ACMV : Dr Barry Stemshorn (Ont.) • Prix R.V.L. Walker : Mme Kira Moser (Alb.) Le congrès de l’ACMV a aussi servi de forum à un nombre important de réunions, notamment une réunion des présidents des associations provinciales de médecins vétérinaires (AMV), des groupes nationaux d’espèces et des organismes provinciaux de Dr. Troye McPherson (right), out-going President, places the Chain of Office on the in-coming réglementation de la médecine vétérinaire (organisée par l’ACMV); President, Dr. Terri Chotowetz. le Forum provincial auquel ont participé les PDG, les directeurs généraux, les registraires et le personnel des communications des La Dre Troye McPherson (à droite), présidente sortante, remet la chaîne de fonction à la nouvelle AMV provinciales (organisé par l’ACMV); la réunion annuelle entre présidente, la Dre Terri Chotowetz. l’ACMV et les doyens (organisée par l’ACMV); la réunion du Bureau national des examinateurs avec les organismes de réglementation • CVMA Humane Award: Dr. Helene Van Doninck (NS) de la médecine vétérinaire et les doyens; le Forum des anciens • CVMA Practice of the Year Award: Kannon Animal présidents de l’ACMV (organisé par l’ACMV); le Conseil canadien Hospital (NB) des registraires vétérinaires; et les réceptions d’anciens de l’Atlantic • CVMA Life Membership: Dr. Carlton Gyles (ON) Veterinary College, de l’Ontario Veterinary College, du Western • CVMA President’s Award: Dr. Barry Stemshorn (ON) College of Veterinary Medicine (WCVM) et une réunion de la • R.V.L. Walker Award: Ms. Kira Moser (AB) promotion de 1987 du WCVM. The CVMA Convention also provided a forum for a broad Merci au Comité du perfectionnement professionnel (CPP) number of meetings including but not limited to a meeting de l’ACMV : Dre Natalie Reid, présidente du CPP; Dre Jeanne of the presidents of provincial veterinary medical associations Lofstedt, coordonnatrice scientifique; Dre Susan McTaggart, (VMAs); national species groups; provincial veterinary regulatory membre; Dre Sarah Armstrong, présidente 2018; Dr Jim Berry, bodies (hosted by the CVMA); the Provincial Forum including président 2019; Dre Margaret Brown-Bury, agente de liaison avec CEOs, executive directors, registrars and communications staff le Conseil; membres d’office : Dre Fran Rotondo, représentante of provincial VMAs (hosted by the CVMA); the annual meeting de l’industrie; Mme Shannon Brownrigg, TVA; Mme Nadine between CVMA and deans (hosted by the CVMA); the National Schueller, TVA; et Mme Sarah Cunningham, gestionnaire, Congrès, Examining Board meeting with veterinary regulatory bodies et aux employés de l’ACMV pour leurs efforts et leurs succès and deans; the CVMA Past-President’s Forum (hosted by the considérables! CVMA); Canadian Council of Veterinary Registrars; and alumni Nous remercions aussi sincèrement la Dre Jeanne Lofstedt qui a receptions of the Atlantic Veterinary College, Ontario Veterinary servi de coordonnatrice de la formation continue de l’ACMV pendant College, Western College of Veterinary Medicine (WCVM), and plus d’une décennie. La Dre Lofstedt demeurera responsable du a reunion for WCVM’s Class of ’87. volet de l’ACMV lors de la conférence conjointe ACMV — WSAVA Thank you to the CVMA’s Professional Development (World Small Animal Veterinary Association) qui se tiendra Committee (PDC): Dr. Natalie Reid, PDC chair; Dr. Jeanne du 15 au 19 juillet 2019 à Toronto. Plus tard cette année, la Lofstedt, scientific coordinator; Dr. Susan McTaggart, member; Dre Kathleen MacMillan entamera la planification de la formation Dr. Sarah Armstrong, chair 2018; Dr. Jim Berry, chair 2019; continue de l’ACMV pour 2020 en collaboration avec le CPP. Dr. Margaret Brown-Bury, Council liaison; Ex Officio mem- La Dre MacMillan succédera ensuite à la Dre Lofstedt à titre de bers: Dr. Fran Rotondo, industry representative; Ms. Shannon coordonnatrice de la formation continue de l’ACMV. Brownrigg, RVT; Ms. Nadine Schueller, RVT; and Ms. Sarah Cunningham, manager, Conventions, and to the CVMA staff De la table du Conseil for their tremendous efforts and success! Télémédecine : Le Comité sur les enjeux nationaux de l’ACMV A big thank you as well to Dr. Jeanne Lofstedt for having procède à l’examen et à la révision de l’énoncé de position de 2014 served as CVMA’s continuing education (CE) coordinator for de l’ACMV sur la télémédecine et il a tenu des discussions avec more than a decade. Dr. Lofstedt will remain responsible for the divers intervenants durant le processus d’examen et de révision. CVMA’s portion of the joint CVMA — WSAVA (World Small L’ACMV prévoit provisoirement de faire de la télémédecine, dans Animal Veterinary Association) Conference, July 15–19, le contexte du bien-être animal, le sujet de discussion du Forum 2019, in Toronto. Later this year, Dr. Kathleen MacMillan sur les enjeux internationaux 2019 durant le congrès conjoint de will start preparing the CVMA’s 2020 CE in conjunction with l’ACMV-WSAVA.

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N the PDC. Dr. MacMillan will then succeed Dr. Lofstedt as the Antibiorésistance : La version mise à jour des Lignes directrices CVMA’s CE coordinator. sur l’administration judicieuse des antimicrobiens pour les porcs, la volaille, les bovins de boucherie, les bovins laitiers, les petits From the Council table ruminants et les animaux de compagnie fait actuellement l’objet Telemedicine: The CVMA’s National Issues Committee is d’un projet pilote. Nous informerons tous les intervenants dès que ce reviewing and revising the CVMA’s 2014 position statement on nouvel outil, dont la livraison est prévue pour le début de l’automne Telemedicine and has held discussions with various stakeholders 2018, sera affiché en direct. during the process of review and revision. There is a tentative Le projet de surveillance de l’utilisation des antimicrobiens plan in place by the CVMA to have telemedicine, in the con- de l’ACMV est conçu afin de fournir des données basées sur text of animal welfare, as the topic of discussion for the 2019 la prescription vétérinaire (électronique) et, dans le cas des International Issues Forum during the joint CVMA-WSAVA animaux destinés à l’alimentation, aussi selon les données de Convention. distribution des aliments du bétail. Ce projet favorisera une meilleure Antimicrobial stewardship: Currently, the CVMA’s renewed, antibiogouvernance ainsi que la confiance du public et fournira web-based Prudent Use Guidelines for Swine, Poultry, Beef, des données pour les rapports internationaux, particulièrement Dairy, Small Ruminants, and Companion Animals are being ceux communiqués à l’Organisation mondiale de la santé animale piloted. All stakeholders will be advised as soon as this new tool, (OIE). scheduled for the early fall 2018, goes live. Diètes à base de viande crue pour les animaux de The CVMA’s AMU Surveillance project is designed to pro- compagnie : Le Conseil a approuvé l’énoncé de position révisé vide data based on (electronic) veterinary prescribing and, in the suivant : case of food animals, based also on feed mill dispensing data. This project will foster improved antimicrobial use stewardship «L’Association canadienne des médecins vétérinaires (ACMV) and public trust, and provide data for international reporting, reconnaît les preuves des risques potentiels pour la santé des particularly to the World Organisation for Animal Health animaux de compagnie qui consomment une diète à base de (OIE). viande crue (DBVC) et pour les humains qui entrent en contact Raw meat-based diets for pets: Council approved the fol- soit avec la DBVC ou les animaux consommant une DBVC. lowing revised position statement: L’ACMV estime que les preuves scientifiques documentées sur les risques potentiels pour la santé animale et la santé publique “The Canadian Veterinary Medical Association (CVMA) attribuables à une DBVC l’emportent sur les bienfaits perçus accepts the evidence for potential health risks to pets fed de cette pratique alimentaire.» raw meat-based diets (RMBDs) and to humans who are in contact with RMBDs or with pets fed RMBDs. The CVMA Accès équitable aux produits thérapeutiques vétérinaires holds that the documented scientific evidence of potential à l’échelle mondiale : À titre de membre de la World Small Animal animal and public health risks in feeding RMBDs outweighs Veterinary Association (WSAVA), l’ACMV participe à l’élaboration des any perceived benefits of this feeding practice.” positions de la WSAVA ayant une portée internationale. Le Conseil a approuvé la position suivante : Equitable access to veterinary therapeutics for veterinarians globally: As a member of the World Small Animal «L’accès facile par les professionnels de la santé aux produits Veterinary Association (WSAVA), the CVMA engages in the pharmaceutiques (p. ex., les médicaments, les produits anesthésiques et analgésiques, etc.), aux produits biologiques development of WSAVA positions with global reach. Council (p. ex., les vaccins, etc.), aux parasiticides et aux antiseptiques endorsed the following position: représente l’un des principaux piliers de soins aux patients “Ready access by healthcare professionals to pharmaceuticals appropriés, qu’il s’agisse de la médecine humaine ou (e.g., medicines, anesthetics/analgesics, etc.), biologicals (e.g., vétérinaire. Il existe des inégalités au niveau de la disponibilité vaccines, etc.), parasiticides, and antiseptics is one of the key et de l’accès entre les diverses régions du monde pour diverses pillars of appropriate patient care, whether in human or raisons. Nous exhortons les principaux intervenants (autorités veterinary medicine. Inequities in availability and access exist réglementaires, fabricants et professionnels de la santé) à between various regions of the world for a variety of reasons. rechercher des solutions qui permettront d’élargir l’accès aux We call upon key stakeholders (regulatory authorities, manu- produits thérapeutiques et diagnostiques dont l’efficacité facturers, and healthcare professionals) to seek solutions that a été scientifiquement prouvée tout en assurant la sécurité would broaden access to scientifically proven efficacious et l’inviolabilité de la relation vétérinaire-client-patient 1/2 therapeutics/diagnostics while maintaining safety and pharmacien, le cas échéant.» the sanctity of the veterinary-client-patient 1/2 pharmacist Code de pratiques recommandées aux chenils du relationship, where warranted.” Canada : L’ACMV a publié la nouvelle édition du Code de pratiques Kennel Code: Seven years in the making, the CVMA released recommandées aux chenils du Canada, qui est en préparation its newest edition of the Code of Practice for Canadian Kennel depuis sept ans. Operations. Code de pratiques pour les petits mammifères de Small Mammal Pets Code of Practice: The CVMA estab- compagnie : L’ACMV a formé un groupe de travail pour l’élaboration lished a Working Group to develop such a code. d’un tel code.

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Welfare of Cull Dairy Cows: CVMA Council approved the Bien-être des vaches de réforme : Le Conseil de l’ACMV a N following new position statement: approuvé le nouvel énoncé de position suivant : “The CVMA opposes prolonged transport of compromised «L’ACMV s’oppose au transport prolongé des vaches laitières cull dairy cows because they have an increased likelihood de réforme parce qu’il y a une probabilité accrue de souffrances of suffering when exposed to transport related stressors. The lors de l’exposition aux éléments de stress liés au transport. CVMA supports on-farm animal welfare-based cow culling L’ACMV appuie les décisions de réforme à la ferme pour des decisions and the national standardization of dairy cow best raisons de bien-être des animaux ainsi que la normalisation management practices.” nationale des meilleures pratiques de gestion des vaches laitières.» Housing Systems for Laying Hens: Council approved the following new position statement: Systèmes de logement pour les poules pondeuses : Le Conseil de l’ACMV a approuvé le nouvel énoncé de position suivant : “The CVMA holds that primary consideration should be given to the welfare of the birds when housing systems for «L’Association canadienne des médecins vétérinaires (ACMV) laying hens are adopted. To provide good health and welfare estime que le bien-être des oiseaux devrait être la principale for laying hens, the CVMA supports the evaluation and considération prise en compte lors de l’adoption de systèmes implementation of both enriched/furnished cage systems de logement pour les poules pondeuses. Afin d’assurer la and non-cage colony systems that are compatible with good bonne santé et le bien-être des poules pondeuses, l’ACMV standards of animal welfare.” appuie l’évaluation et l’installation de systèmes de cages enrichies et avec aménagements et de systèmes de colonies Pain Management Framework: The issue of “pain in ani- sans cages qui sont compatibles avec de bonnes normes de mals,” including its recognition and management in animals, is bien-être animal.» fundamental to animal welfare. CVMA Council approved the development of a framework to ensure that there will be consis- Cadre de gestion de la douleur : L’enjeu de la «douleur chez tency in how the CVMA references and discusses pain, including les animaux», y compris sa reconnaissance et sa gestion chez les definitions, strategies, priority activities and actions, recognition animaux, est fondamental pour le bien-être animal. Le Conseil de of new thinking and research in areas such as chronic pain and l’ACMV a approuvé l’élaboration d’un cadre de travail afin d’assurer psychological pain in animals, and new modalities of treatment. de la cohérence dans les mentions et les discussions de l’ACMV sur National Tick Awareness Month: The CVMA launched the la douleur, y compris des définitions, des stratégies, des activités et National Tick Awareness Month in March for the 3rd year in a des actions prioritaires, la reconnaissance des nouveaux modes de row. In partnership with its platinum sponsor, Merck Animal pensée et de la recherche dans des domaines comme la douleur Health, the CVMA produced a number of communication tools, chronique et la douleur psychologique chez les animaux ainsi que including a video series called “What do you really know about les nouvelles modalités de traitement. ticks?” in which Canadian veterinarian, Dr. Scott Stevenson, Mois national de la sensibilisation aux tiques : En mars, provides answers to questions frequently asked by pet owners. l’ACMV a organisé, pour la troisième année consécutive, le Mois Veterinary Technician Program Accreditation: CVMA national de la sensibilisation aux tiques. En partenariat avec son Council approved the accreditation of Ottawa’s Algonquin commanditaire platine, Merck Santé animale, l’ACMV a produit College Veterinary Technician Program. plusieurs outils de communication, dont une série de vidéos intitulée Council on Education (CoE): Since its inception, the «Que savez-vous vraiment au sujet des tiques?», où le vétérinaire CVMA has been a member of the Council on Education canadien Dr Scott Stevenson fournit des réponses aux questions of the American Veterinary Medical Association (AVMA). fréquemment posées par les propriétaires d’animaux de compagnie. All 5 Canadian colleges of veterinary medicine are AVMA/ Agrément des programmes de techniques vétérinaires : CVMA CoE-accredited. Council newly nominated Dr. David Le Conseil de l’ACMV a approuvé l’agrément du Programme de Scammel, a veterinary practitioner from Winnipeg, Manitoba techniques vétérinaires d’Algonquin College à Ottawa. as the CVMA’s representative to the CoE. The CVMA would Council on Education (CoE) : Depuis sa création, l’ACMV est like to thank Dr. Baljit Singh who held this position for the membre du Council on Education de l’American Veterinary Medical past 6 years. Association (AVMA). Tous les cinq collèges de médecine vétérinaire Small business tax: The CVMA was an early member of the du Canada sont agréés par le CoE de l’AVMA/ACMV. Le Conseil a Coalition for Small Business Tax Fairness, which now includes récemment nommé le Dr David Scammel, un praticien vétérinaire approximately 70 organizations. Some of the successes achieved de Winnipeg, au Manitoba, au poste de représentant de l’ACMV by the Coalition were the government’s agreement to decreasing auprès du CoE. L’ACMV aimerait remercier le Dr Baljit Singh qui a the small business tax rate from 10.5% as of January 2017 to occupé ce poste au cours des six dernières années. 10% as of January 2018 and 9.5% as of January 2019. Further, Impôt pour les PME : L’ACMV s’est jointe aux premières the government had planned to restrict the ability to convert heures à la Coalition pour l’équité fiscale envers les PME qui income into capital gains. This would have made it more diffi- regroupe maintenant environ 70 organisations. Parmi les succès cult for small business owners to sell or transfer their business at de la Coalition, citons l’accord du gouvernement pour la réduction retirement to their children. Following pressure by the Coalition, du taux d’imposition des petites entreprises qui passera de 10,5 % the government announced that it will not be moving forward en janvier 2017, à 10 % en janvier 2018 puis à 9,5 % à compter de

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N with these changes. At this time, the Coalition is advocating janvier 2019. De plus, le gouvernement avait prévu limiter la capacité to amend the new rules related to passive investment income de conversion du revenu en gains en capital. Cela aura compliqué la announced in the 2018 federal budget. The government has vente ou le transfert de l’entreprise aux enfants par les propriétaires not kept to its earlier promise to grandfather previous passive de PME au moment de la retraite. Après des pressions exercées investments under the new rules that may increase significantly par la Coalition, le gouvernement a annoncé qu’il n’ira pas de l’avant the 2019 tax bill for some small business owners. The Coalition avec ces changements. À l’heure actuelle, la Coalition préconise offered to work with the government to find a more gradual la modification des nouvelles règles s’appliquant aux placements implementation of the new rules and for indexing the exemp- passifs annoncées dans le budget fédéral 2018. Le gouvernement tion limits to inflation. The Coalition is continuing its efforts to n’a pas tenu sa promesse antérieure de maintenir les placements achieve the best possible solution to keep small business needs passifs antérieurs en vertu des nouvelles règles, ce qui pourrait faire in mind. grimper considérablement la facture d’impôt de 2019 pour certains Webstore: We are now in the 3rd year of operating the propriétaires de PME. La Coalition a offert de travailler avec le CVMA Webstore. This web solution allows veterinary clinics to gouvernement pour trouver une mise en œuvre plus graduelle des sell a broad number of products online to their clients, by direct nouvelles règles et pour l’indexation des limites d’exemption au taux shipment to the client or for pick-up at the clinic, without the d’inflation. La Coalition poursuit ses efforts en vue de tenir compte need for onsite inventory and its associated cost (please note that des besoins des PME et de parvenir à la meilleure solution possible. some provincial regulatory restrictions may apply). The pricing Ma Vitrine Vétérinaire : Nous en sommes maintenant à la of the goods is left to the discretion of the clinic. In order to troisième année consécutive de fonctionnement de Ma Vitrine promote automatic orders for pet food, both Hill’s and Royal Vétérinaire de l’ACMV. Cette solution Web permet aux cliniques Canin have agreed, since last fall, to offer rebates to the Webstore vétérinaires de vendre un grand nombre de produits en ligne à leurs clients averaging approximately $6 per order. clients, soit en les expédiant directement au client ou pour cueillette CVMA-WSAVA Convention 2019, July 15–19, Toronto, à la clinique, sans devoir conserver un inventaire sur les lieux avec Ontario: The CVMA’s 2019 Convention will be a joint event tous les coûts qui s’y rattachent (prière de noter que certaines with the World Small Animal Veterinary Association Congress, restrictions réglementaires provinciales peuvent s’appliquer). Le prix of which the CVMA is a member association. Dr. Jim Berry, des produits est laissé à l’entière discrétion de la clinique. Afin de who is the member association representative for the CVMA, promouvoir les commandes automatiques d’aliments pour animaux, serves as the CVMA’s host committee chair. Hill’s et Royal Canin ont toutes deux consenti, depuis l’automne dernier, à offrir des rabais aux clients de Ma Vitrine Vétérinaire qui (by Jost am Rhyn, CEO, CVMA) s’établissent à environ 6 $ par commande. Congrès 2019 de l’ACMV-WSAVA, du 15 au 19 juillet, à Toronto, en Ontario : Le congrès 2019 de l’ACMV sera un événement conjoint avec le congrès de la World Small Animal Veterinary Association dont l’ACMV est une association membre. Le Dr Jim Berry, qui est représentant de l’association membre pour l’ACMV, servira à titre de président du comité organisateur de l’ACMV. (par Jost am Rhyn, PDG, ACMV)

Editor-in-chief of The Canadian Veterinary Journal, Dr. Carlton Gyles accepts the CMVA Life Membership award at the 2018 CVMA Convention. Congratulations! We are proud of our journal leader. Le rédacteur en chef de La Revue vétérinaire canadienne, le Dr Carlton Gyles, accepte le Titre de membre à vie de l’ACMV lors du congrès 2018 de l’ACMV. Félicitations! Nous sommes fiers du leader de notre revue.

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Vaccines Save Lives! Happy Animal Les vaccins sauvent des vies! N Health Week! Joyeuse Semaine de la vie animale! his month, we celebrate Animal Health Week from e mois-ci, nous célébrons la Semaine de la vie animale du TSeptember 30 to October 6, 2018. The Canadian Veterinary C30 septembre au 6 octobre 2018. L’Association canadienne Medical Association (CVMA) is highlighting the importance des médecins vétérinaires (ACMV) souligne l’importance de la of disease prevention through the campaign slogan, “Vaccines prévention des maladies par le slogan de la campagne, «Les vaccins Save Lives!” sauvent des vies!» This year’s theme is an opportunity to remind animal owners Le thème de cette année représente l’occasion de rappeler aux that preventing disease and illness is always preferable to treat- propriétaires d’animaux qu’il est toujours préférable de prévenir ing an ill animal. Animals can contract communicable diseases la maladie que de traiter un animal malade. Les animaux peuvent through herd exposure, eating contaminated carcasses, casual contracter des maladies transmissibles par l’exposition dans le contact in areas such as dog parks, and environments such as troupeau, en mangeant des carcasses contaminées, par le contact boarding kennels and stables. The safest and easiest way to occasionnel dans des endroits comme les parcs à chiens et dans protect animals against many diseases is through vaccination. des environnements comme les chenils et les écuries. La façon la A vaccinated animal is a happy, safe, and healthy animal. plus sécuritaire et la plus facile de protéger les animaux contre une We’re reminding animal owners about these Five Reasons foule de maladies est la vaccination. Un animal vacciné est un to Vaccinate: animal heureux, protégé et en santé. 1. Vaccinations are safe and effective — they prevent many Nous rappelons aux propriétaires d’animaux ces cinq raisons animal illnesses. de vacciner : 2. Vaccinations protect everyone — they prevent diseases that 1. Les vaccins sont sûrs et efficaces — ils préviennent beaucoup can be passed not only from animal to animal, but also from de maladies animales. animal to human. 2. Les vaccins protègent les humains et les animaux — ils 3. Vaccinations are an important part of annual health exams. préviennent les maladies qui peuvent être transmises non 4. Vaccinations are tailored to each animal based on its breed, seulement d’un animal à un animal, mais aussi d’un animal à age, overall health, and disease exposure risk. un humain. 5. Vaccinations can help avoid costly treatments for diseases 3. Les vaccins sont un élément important des examens annuels. that can be prevented. 4. Les vaccins sont adaptés à chaque animal en fonction de sa Social media race, de son âge, de son état de santé général et de son risque d’exposition aux maladies. The CVMA has promoted Animal Health Week for over 5. Les vaccins peuvent aider à éviter des traitements coûteux 30 years. We invite you to share your celebrations on Facebook, pour des maladies qui peuvent être prévenues. Twitter, and Instagram using the hashtag #AnimalHealthWeek. Médias sociaux Our sponsors L’ACMV fait la promotion de la Semaine de la vie animale depuis Generous support of the 2018 Animal Health Week campaign is plus de 30 ans. Nous vous invitons à partager vos célébrations provided by Principal Sponsor, Petsecure Pet Health Insurance, sur Facebook, Twitter et Instagram en utilisant le mot-clic Program Plus Sponsor, Merck Animal Health, and Program #Semainedelavieanimale. Sponsor, iFinance Canada (Petcard). The CVMA would not be able to carry out the important Nos commanditaires educational campaign that Animal Health Week is without the Le commanditaire principal, Petsecure assurance maladie pour generous support of our sponsors and the dedication of veteri- animaux, le commanditaire de programme plus, Merck Santé nary teams throughout the country. Thank you. animale et le commanditaire de programme, iFinance Canada During this week-long campaign many veterinary clinics and (Petcard) ont fourni un généreux soutien à la campagne de la hospitals host open houses, plan dog washes, organize pet poetry Semaine de la vie animale 2018. or photo contests, and clinic tours. Some veterinarians visit school L’ACMV ne pourrait pas mettre en œuvre l’importante campagne children or appear on television to talk about animal health care. d’éducation de la Semaine de la vie animale sans le généreux soutien de nos commanditaires et le dévouement des équipes vétérinaires partout au pays. Merci. Durant cette campagne d’une semaine, beaucoup d’établissements et de cliniques vétérinaires organiseront des journées portes ouvertes, planifieront des lave-chien, organiseront des concours de poésie sur les animaux de compagnie ou des concours de photos ainsi que des visites de la clinique. Certains vétérinaires visiteront des enfants dans les écoles ou se présenteront à la télévision pour parler à propos de la santé animale.

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N Celebrating 2nd Annual National Registered Veterinary Technologist/ Technician Month Célébration de la deuxième édition annuelle du Mois national des technologues et techniciens vétérinaires agréés he Registered Veterinary Technologists and Technicians echnologues et des techniciens vétérinaires agréés du Canada/ Tof Canada/Technologues et des techniciens vétérinaires TRegistered Veterinary Technologists and Technicians of Canada/ agréés du Canada (RVTTC/TTVAC) is excited to celebrate (TTVAC/RVTTC) se réjouit de célébrer la deuxième édition annuelle the 2nd Annual National Registered Veterinary Technologist/ du Mois national des technologues et techniciens agréés en ce Technician Month this October 2018. The Association has been mois d’octobre 2018. Depuis 1993, l’Association reconnaît les acknowledging registered veterinary technologist/technicians technologues et techniciens vétérinaires agréés à l’échelle nationale (RVTs) nationally with a week since 1993, but the profession lors d’une semaine, mais la profession a bientôt découvert qu’une soon discovered one week wasn’t enough! semaine n’était pas suffisante! Once again the Ontario Association of Veterinary Technicians De nouveau, l’Ontario Association of Veterinary Technicians (OAVT) has been instrumental leading the RVT Month Task (OAVT) a joué un rôle crucial en assumant la direction du Groupe de Force in building both physical and electronic “RVT Month travail du Mois des TVA et en préparant des «Trousses du mois des kits,” which are available through your provincial veterinary TVA» en format papier et électronique. Vous pouvez vous procurer technician/technologist associations. ces trousses par l’entremise de votre association provinciale de The RVT Month kits are for workplaces to highlight their techniciens et technologues vétérinaires. RVT team, educate colleagues and members of the public on Les trousses du Mois des TVA permettent aux cliniques de the veterinary technologist/technician profession. Each veteri- présenter leur équipe de TVA ainsi que de sensibiliser les collègues nary team is encouraged to utilize the kit materials to launch et les membres du public à l’égard de la profession de technologue their own activities and join in on social media with the hashtag et technicien vétérinaire. On encourage chaque équipe vétérinaire à #RVTMonth. Check out the website (www.rvttcanada.ca) or se servir des trousses pour lancer ses propres activités et à participer social media @RVTTC to obtain e-kits, for more activities and aux médias sociaux à l’aide du mot-clic #RVTMonth. Consultez ideas to share. Join together to celebrate RVT Month! notre site Web (www.rvttcanada.ca) ou le média social @RVTTC RVTs contribute greatly to animal health and wel- pour obtenir des trousses électroniques et prendre connaissance fare throughout our nation. National Registered Veterinary d’autres activités et idées à partager. Faites équipe avec nous pour Technologist/Technician Month provides an opportunity to célébrer le Mois des TVA! recognize and honor the individuals who commit to higher stan- Les TVA apportent des contributions importantes à la santé et au dards of medical care for animals, contribute to the profession, bien-être des animaux au pays. Le Mois national des technologues et techniciens vétérinaires agréés offre l’occasion de reconnaître et d’honorer les personnes qui s’engagent à respecter des normes élevées en matière de soins médicaux pour les animaux, à contribuer à la profession et à améliorer le service à la clientèle. Depuis sa création il y a 29 ans, TTVAC a pris de l’expansion et l’organisme

Heather Shannon, RVT, President RVTTC Heather Shannon, TVA, présidente TTVAC

1060 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY and improve client service. Since its inception 29 years ago, the regroupe maintenant six associations provinciales de techniciens et N RVTTC has grown to encompass 6 provincial veterinary techni- technologues vétérinaires ainsi que plus de 7800 TVA individuels. cian/technologists associations and over 7800 individual RVTs. TTVAC aimerait remercier la British Columbia Veterinary The RVTTC would like to thank the British Columbia Technologists Association (BCVTA), l’Alberta Veterinary Technologist Veterinary Technologists Association (BCVTA), Alberta Association (ABVTA), la Saskatchewan Association of Veterinary Veterinary Technologist Association (ABVTA), Saskatchewan Technologists (SAVT), la Manitoba Veterinary Technologists Association of Veterinary Technologists (SAVT), Manitoba Association (MVTA), l’OAVT et l’Eastern Veterinary Technicians Veterinary Technologists Association (MVTA), OAVT and Association (EVTA) de leur travail concerté en vue de la mise en Eastern Veterinary Technicians Association (EVTA) in work- œuvre de cette campagne nationale pour appuyer nos membres. ing together for this truly national campaign in support of our Cette réalisation témoigne de ce que nous pouvons accomplir members. It is a testament that great things can be accomplished lorsque nous travaillons ensemble pour l’atteinte d’un but commun. when we work toward a common goal. Serment du technicien vétérinaire Veterinary technician oath «Je m’engage solennellement à me consacrer à la tâche d’aider les “I solemnly dedicate myself to aiding animals and society by animaux et la société en fournissant d’excellents soins et services providing excellent care and services for animals, by alleviating pour les animaux, en soulageant les souffrances animales et en animal suffering, and promoting public health. I accept my faisant la promotion de la santé publique. J’accepte mes obligations obligations to practice my profession conscientiously and with afin d’exercer ma profession de manière consciencieuse et sensible, sensitivity, adhering to the profession’s Code of Ethics, and fur- de respecter le Code d’éthique de la profession et d’améliorer mes thering my knowledge and competence through a commitment connaissances et mes compétences dans le cadre d’un engagement to lifelong learning.” envers l’apprentissage continu.» (by Heather Shannon, RVT, President RVTTC) (par Heather Shannon, TVA, présidente TTVAC)

Thank you from VWB/VSF huge thank you from Veterinarians without Borders/ Canada. This year, as in years past, those enthusiasts offered A Vétérinaires sans frontiers to the Canadian Veterinary generous support for our work overseas and across Canada Medical Association (CVMA), and all of the individuals who improving the lives of people and animals. We offer a special made donations and supported the silent and live auctions dur- vote of gratitude to the CVMA for providing us space and time ing CVMA’s Convention this past July in Vancouver, British during this busy event, and for the CVMA staff who go out of Columbia. We look forward to the CVMA Convention each their way to welcome us and offer help. year as an opportunity to connect with supporters from across

Merci de VSF/VWB étérinaires sans frontières/Veterinarians without Borders Vremercie sincèrement l’Association canadienne des médecins vétérinaires (ACMV) et toutes les personnes qui ont fait des dons et appuyé l’encan silencieux et en direct qui ont eu lieu durant le congrès de l’ACMV qui s’est tenu en juillet dernier à Vancouver, en Colombie-Britannique. Chaque année, nous nous réjouissons à la pensée du congrès de l’ACMV car c’est l’occasion de rencontrer nos partisans provenant de toutes les régions du Canada. Cette année, comme par les années antérieures, ces partisans ont offert un généreux soutien de notre travail outremer et dans les diverses régions du pays afin d’améliorer la vie des personnes et des animaux. VWB/VSF’s table was a busy gathering spot for staff, volunteers, potential volunteers, and Nous remercions sincèrement l’ACMV de nous avoir fourni l’espace conference goers bidding on silent auction items. et le temps durant cet événement chargé ainsi que le personnel de La table de VSF/VWB était un carrefour pour le rassemblement des employés, des bénévoles, l’ACMV qui déploie des efforts importants pour nous accueillir et des bénévoles éventuels et des délégués qui plaçaient des enchères lors de l’encan silencieux. nous offrir de l’aide.

CVJ / VOL 59 / OCTOBER 2018 1061 FOR PERSONAL USE ONLY Case Report Rapport de cas

Hydronephrosis in a dairy calf: A diagnosis delayed by a clinician’s Bayesian brain reasoning

Hélène Michaux, Sébastien Buczinski, Gilles Fecteau, Jean-Marc Benoit

Abstract — A 3-week-old female dairy calf was presented because of severe weakness and diarrhea. Physical examination and ultrasound findings lead to a tentative diagnosis of intestinal obstruction, although serum biochemistry suggested a primary renal disorder. Reassessment of ultrasound images allowed diagnosis of hydronephrosis that had been misdiagnosed probably because of the clinician’s biased Bayesian reasoning. Pyelonephritis without renal failure was diagnosed 2.5 months later. The calf was euthanized and the diagnoses were confirmed.

Résumé — Une hydronéphrose rénale chez un veau laitier : quand le raisonnement Bayesien du clinicien rend le diagnostic plus difficile. Une génisse âgée de 3 semaines est présenté pour faiblesse générale et diarrhée. L’examen clinique et les images échographiques de l’abdomen sont compatibles avec une obstruction intestinale. Mais les résultats d’analyse biochimique montrent une anomalie rénale. Un examen échographique supplémentaire est compatible avec un diagnostic d’hydronéphrose. Le diagnostic d’hydronéphrose n’avait pas été fait à la première visite probablement suite au raisonnement Bayesien du clinicien. Le veau est revu 2,5 mois plus tard. L’échographie de l’abdomen, les analyses urinaire et sanguine montrent une pyélonéphrite sans insuffisance rénale. Le veau est euthanasié et l’autopsie montre l’hydronéphrose et pyélonéphrite bilatérale. (Traduit par les auteurs) Can Vet J 2018;59:1062–1066

Case description Because of depression and diarrhea observed the day before, metabolic acidosis was suspected. A digestive obstruction was 3-week-old female dairy calf (about 50 kg) was examined suspected because of bloating. at the bovine ambulatory clinic, Université de Montréal A An abdominal ultrasound was performed using a 3.5 MHz for severe weakness. The day before, the owner had observed probe (LogiqBook; General Electric, Wauwatosa, Wisconsin, diarrhea, but had also observed several bloating and diarrheic USA) and revealed small intestinal loops with decreased motil- episodes since birth. Clinical examination revealed abdominal ity and large distended loops with anechoic content. Intestinal distension, depression, dehydration (7%) with dry and pale obstruction (empty loops aboral and distended loops oral) was mucous membranes, enophtalmia, and cold extremities. Rectal suspected. The video recording is available from the correspond- temperature (39.7C), heart rate (132 beats/min), and respira- ing author upon request. tory rate (52 breaths/min) were increased. Lung sounds were A blood sample was submitted for a complete blood (cell) normal. The umbilicus and the joints were normal. A small count (CBC) and serum biochemistry profile. Supportive amount of dry and pasty feces was present. treatment was initiated consisting of IV antimicrobial agents (Trimidox; Vétoquinol, Lavaltrie, Quebec), trimethoprim, 120 mg/45 kg body weight (BW), and sulfadoxine, 600 mg/45 kg Département de sciences cliniques, Faculté de Médecine BW, and ketoprofen (Anafen; Mérial, Baie d’Urfé, Quebec), Vétérinaire (FMV), Université de Montréal, St-Hyacinthe, 3 mg/kg BW, IV, intravenous fluids (1 L of sterile water contain- Québec J2S 2M2. ing 5 g of sodium chloride and 25 g of sodium bicarbonate) to Address all correspondence to Dre Hélène Michaux; e-mail: treat the suspected metabolic acidosis. [email protected] Results from the CBC and the serum biochemistry profile Use of this article is limited to a single copy for personal study. are presented in Table 1 (1st test results). The white blood Anyone interested in obtaining reprints should contact the cells (WBC) [neutrophils 17.06  109/L, reference range CVMA office ([email protected]) for additional (RR): 1.1 to 3.6  109/L; lymphocytes; 2.88  109/L, RR: copies or permission to use this material elsewhere. 4.0 to 10.0  109/L] indicated an inflammatory leukogram.

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Table 1. Results of hematology and serum biochemistry tests for the initial visit (1st test) and for the subsequent examination (2nd visit). Results Analysis 1st test 2nd test Reference range

Hematology REPORT CASE Erythrocytes ( 1012/L) 9.6 9.75 7.4 to 11.6 Hemoglobin (g/L) 62 99 98 to 153 Hematocrit (L/L) 0.19 0.27 0.26 to 0.4 Thrombocytes ( 109/L) 1009 925 412 to 1003 Total solids (g/L) 77 97 68.2 to 85.9 Fibrinogen (g/L) 9 10 2 to 5 Leucocytes ( 109/L) 20.55 6.8 6.2 to 13.6 Neutrophil ( 109/L) 17.06 2.19 1.1 to 3.6 Lymphocytes ( 109/L) 2.88 3.81 4 to 10 Figure 1. Abdominal ultrasound image that shows dilated renal Monocytes ( 109/L) 0.62 0.55 0.2 to 1.3 lobes. F — fibrin, C — cortex. Biochemistry Glucose (mmol/L) 6.3 3.7 2.6 to 4.9 Urea (mmol/L) 39.93 4.67 1.61 to 6.51 Creatinine (mol/L) 354 108 54 to 132 Bilirubin (mol/L) 9.7 12.6 0 to 14 AST (U/L) 56 166 30 to 104 CK (U/L) 327 529 0 to 310 GGT (U/L) 17.0 2.0 9.6 to 39 GLDH (U/L) 8.0 11.0 3 to 45 Total protein (g/L) 60.2 92.0 59.5 to 80 Albumin (g/L) 30.8 16.0 27.7 to 40.4 Globulins (g/L) 29.4 76.0 26.2 to 45.2 Calcium (mmol/L) 2.49 2.26 2.22 to 2.7 Phosphorus (mmol/L) 3.56 1.33 1.05 to 2.83 Potassium (mmol/L) 4.72 2.89 3.86 to 5.28 Sodium (mmol/L) 136.2 132.1 134 to 147 Chloride (mmol/L) 99.2 90.0 96.4 to 109.2 Anion gap (mmol/L) 32.9 16.0 7.3 to 17.9 Magnesium (mmol/L) 0.97 0.74 0.7 to 0.91

Total CO2 (mmol/L) 8.8 29.0 22 to 33 Figure 2. Left kidney showing normal size but signs of AST — aspartate transaminase; CK — creatine kinase; GGT — gamma-glutamyl transferase; GLDH — glutamate dehydrogenase. pyelonephritis. C — cortex, M — medulla, fibrin fragments.

Hyperfibrinogenemia (9 g/L, RR: 2 to 5 g/L) indicated an (Figure 1). The anechogenic fluid was sampled transabdomi- ongoing inflammatory process. The calf had a non-regenerative nally. A watery, colorless, transparent and odorless fluid was anemia (hematocrit 0.19 L/L, RR: 0.26 to 0.4 L/L) with no obtained. Creatinine and BUN concentrations of this sample reticulocytes. Serum or plasma protein concentration was normal. were 30.93 mmol/L and 987 mol/L, respectively, compatible

A severe metabolic acidosis (total CO2: 8.8 mmol/L, RR: 22 to with urine. 33 mmol/L; anion gap: 32.9 mmol/L, RR: 7.3 to 17.9 mmol/L) Because of the poor prognosis without surgical treatment was present (Table 1, 1st test results). Renal insufficiency [blood and the relatively low economic value of the calf, the owner urea nitrogen (BUN) (39.93 mmol/L, RR: 1.61 to 6.51 mmol/L), decided not to treat the animal. Euthanasia was discussed, but creatinine (354 mol/L, RR: 54 to 132 mol/L), and hyper- the owner elected to keep the animal. Antimicrobials were then phosphatemia (3.56 mmol/L, RR: 1.05 to 2.83 mmol/L)] was stopped because of poor prognosis and the possibility that the also present. calf would go to slaughter. A primary renal problem was suspected because of increased The animal was re-examined during a herd health visit, creatinemia and hyperuremia. The initial diagnosis was revised approximately 2.5 mo later. The heifer was eating and growing and misinterpretation of the ultrasonogram was suspected. adequately according to the owner. Physical examination find- The CBC and the serum biochemical profile did not indicate ings were normal except that spontaneous micturition revealed intestinal obstruction as a differential diagnosis; therefore, renal opaque, yellow urine containing whitish solid fibrin filaments. insufficiency became the most probable diagnosis. Urine analysis revealed a density of 1.022 (RR: 1.015 to 1.045), The distended loops with anechoic content were in fact renal pH of 7 (RR: 7 to 8.5), protein 2, and blood 4 (Multistix lobes filled with anechoic fluid. The renal cortex was not visu- 10 SG; Siemens Healthcare Diagnostics, Tarrytown, New York, alized, and the renal pelvis was distended. These findings were USA). Urinary tract infection was suspected. compatible with hydronephrosis (1,2). The transabdominal ultrasound revealed images that were A second ultrasound examination was performed the fol- similar to those observed previously. The affected kidney was lowing day (Draminski 4Vet mini, convex probe 2–8 MHz, identified to be the right one, since the left kidney was clearly Draminski ultrasound scanner; Draminski, Olsztyn, Poland) identified caudally to the liver and appeared normal (Figure 2).

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A RAPPORTCAS DE Figure 3. One calyx of the right kidney with a large amount of fluid and fibrin. F — fluid; Fi — fibrin. B

The liquid within the calyx of the right kidney was still anechoic but several hyperechogenic elements were observed (Figure 3). Percutanous puncture revealed a pink opaque liquid which con- trasted with the first sampling. Protein concentration was 48 g/L and microscopic examination after centrifugation (1500 rpm, 5 min) revealed several neutrophils in the background. Blood samples were collected for a CBC and biochemistry profile. The results revealed hyperglobulinemia (76 g/L, RR: 26.2 to 45 g/L), hypoalbuminemia (16 g/L, RR: 27.7 to 40.4 g/L), hyperfibrinogenemia (10 g/L, RR: 2 to 5 g/L) compatible with a chronic active inflammatory process. The BUN (4.62 mmo/L) and creatinine (108 mmol/L) concentrations (Table 1, 2nd test results) were normal. Considering the grave prognosis, the owner agreed to have the calf euthanized and a complete necropsy was performed at the Faculté de Médecine Vétérinaire. The necropsy examination revealed an enlarged right kidney (10 kg) with adhesions to the colon and cecum. There was no visible parenchyma macroscopically. Round cavities with a fibrous capsule filled with pus and fibrin mixed with urine were found (Figures 4A and 4B). Distal and middle parts of the right ureter were fibrous and the lumen was reduced; however, the hilum was dilated. The left kidney was slightly enlarged and the calyces were dilated with a loss of parenchyma. The left ureter was dilated. The bladder was empty and adhered to the small intestine. Conclusions of the necropsy were severe right hydronephrosis with purulent pyelonephritis due to non-hemolytic Escherichia coli and renal atrophy. The same bacteria were also cultured Figure 4. A — Gross appearance of the right kidney at necropsy. from the liver. B — Gross appearance of the right kidney after longitudinal section. There was a moderate to severe interstitial nephritis (Figure 5) in the left kidney and the ureter was dilated. A slight to moderate subacute peritonitis was also present. in small ruminants and related to mechanical obstruction by uroliths (3). In cattle, some cases of hydronephrosis have been Discussion reported with secondary etiologies such as urolithiasis, urinary Hydronephrosis refers to distension and dilation of the renal pel- bladder eversion, or a tumoral mass in the bladder (2,4,5). vis and calyx with a loss of renal parenchyma. In small animals, However, no case of hydronephrosis in young ruminants has the etiology of hydronephrosis can be genetic or secondary to been described in the literature. As secondary etiologies of mechanical obstruction (prostatitis, cystitis, uroliths, nephro- hydronephrosis seem to be excluded in this case, congenital liths, pyelonephritis or neoplasia). The most frequent cause in all hydronephrosis is a presumptive diagnosis. species is urinary tract obstruction and ureter malformation such After the diagnosis of hydronephrosis, the only treatment as a lack of connection between nephron and collector tubes, that could be proposed to the owner was a nephrectomy of the which is another possible etiology. Hydronephrosis is frequent abnormal kidney combined with supportive therapy (5,6).

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This particular case is interesting because of the “Bayesian brain” of the clinician for medical decision-making. The initial examination lead to a tentative diagnosis of intestinal obstruction because the initial abdominal ultrasound performed at the farm was misinterpreted. Probably biased

by history, the veterinarian was oriented towards a digestive REPORT CASE problem. The clinical examination made the veterinarian think of a digestive problem (flat calf, history of diarrhea, dehydration). At this stage, a hypothetico-deductive process was initiated. The clinician had a main hypothesis and a few clinical signs were used to confirm this hypothesis. While performing the ultrasound examination, the veterinarian wanted to have confirmation he was dealing with an intestinal obstruction; he thought he had that confirmation by seeing structures which looked like dilated intestinal loops. The diagnosis was revised after biochemistry and hematology results were available. Bayes’ theorem is that the post-test probability of a diagnosis is a function of pre-test probability of the diagnosis (known prevalence or clinician’s belief of this probability) and the likelihood of new diagnostic evidence (ratio of the probability to observe this diagnostic evidence in patients with versus without the suspected disease) (7). Two types of error are possible: clinician’s beliefs are wrong or the evaluation of the strength of the new diagnostic evidence is overestimated. Another possibility would be pseudodiagnosticity here, or confirmation bias. New information (ultrasonography results in this case) was not supportive of intestinal obstruction and Figure 5. Gross appearance of the left kidney after should lead the clinician toward the correct diagnosis (hydrone- longitudinal section. phrosis). However the clinician interpreted the new information as support for his initial hypothesis based on history and clinical During the first visit, no sign of pyelonephritis was observed on examination. In this case the clinician intuitively thought that ultrasound but plasma fibrinogen concentration was increased and small intestine obstruction was more probable than hydrone- leukocytosis was present. Those changes could have been the early phrosis. The justification of this behavior is that it keeps the signs of an infection. Unilateral nephrectomy could have been problem as simple as possible. It has been observed that when an option after stabilization of the patient (7). The prognosis is several clinicians agree about clinical findings, they assign them guarded to good if surgery is performed and there is appropriate different values (weight) for interpretation and integration for medical treatment (5,6,8). A previous study of 7 cases (8) indi- a diagnosis (7). cated that severity of the renal insufficiency based on uremia and Bayesian brain is a probabilistic reasoning that deals with creatininemia was not a good prognostic indicator. probabilities depending on clinician experience. From this expe- Signs of pyelonephritis are often fever, hyporexia, colic, rience, the clinician develops a “script” which represents new pyuria. The calf in the present report did not have colic and incoming data with existing knowledge (hypothetico-deductive the rectal temperature was normal, although pyuria was reasoning). This information influences interpretation of clini- observed. The calf had a normal appetite according to the cal signs and then Bayesian brain influences interpretation of owner. Surprisingly, normal blood urea and creatinine values complementary examination towards the more probable diag- were found when there was bilateral pyelonephritis; however, nosis. This is how Bayesian brain can make the clinician arrive creatininemia was high when the calf was seen the first time. at a mistaken diagnosis. One hypothesis could be that during the first visit, there was Finally, another test, the serum biochemistry profile analysis, renal insufficiency the origin of which was prerenal because of had a greater weight than ultrasound as a source of new evidence dehydration. This dehydration was addressed with hydrotherapy in this case: increased BUN and creatinine concentrations are more and the creatininemia resolved after treatment. specific for a renal problem. That is why the post-test probability In one study, 3 of 7 cows with bilateral pyelonephritis had of the diagnosis of intestinal obstruction decreased, whereas the normal concentrations of urea and 2 had normal concentra- probability of a renal problem increased. Then, this last hypothesis tions of creatinine in the blood (8). Bilateral involvement of had its own pre-test probability (the test was then ultrasound) and the kidney does not mean that more than 70% of the nephrons considering ultrasound images, it was less likely that those images are nonfunctional (8). corresponded to a disease other than hydronephrosis.

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Facing difficult cases, it is useful to have results of several 2. Harrisson G, Biller DS, Wilson DG, Castleman WL. Ultrasonographic complementary examinations whenever possible. Considering diagnosis of hydronephrosis in a cow. Vet Radiol Ultrasound 1992;33:49–51. results of all examinations will reduce the likelihood of mis- 3. Bidault C. Urologie et nephrology des ruminants. Doctoral Thesis, takes. Alternatively, one could seek the interpretation of the Ecole Nationale Vétérinaire d’Alfor, Maisons-Alfort, Val-de-Marne, results from several clinicians, because each one has his/her own France 2009. 4. Chandler KJ, O’Brien K, Huxley JN, Thompson H, Fitzpatrick Bayesian brain. JL. Hydronephrosis and renal failure in two Friesian cows. Vet Rec This article deals with the first described case of untreated 2000;146:646–648. renal hydronephrosis in a calf that was further complicated 5. Vogel SR, Desrochers A, Babkine M, Mulon PY, Nichols S. Unilateral nephrectomy in 10 cattle. Vet Surg 2011;40:233–239. by pyelonephritis. Performance of a nephrectomy to treat the 6. Miesner MD, Anderson DE. Unilateral nephrectomy of cattle. Vet Clin hydronephrosis may have permitted the calf to survive and pos- North Am Food Anim Pract 2008;24:497–500. 7. Higgs J, Jones MA, Loftus S, Christensen N. Clinical Reasoning in the sibly avoid pyelonephritis. CVJ

RAPPORTCAS DE Health Professions. 3rd ed. St. Louis, Missouri: Elsevier, 2008. 8. Braun U, Nuss K, Wehbrink D, Rauch S, Pospischil A. Clinical and References ultrasonographic findings, diagnosis and treatment of pyelonephritis in . 1 Floeck M. Ultrasonography of bovine urinary tract disorders. Vet Clin 17 cows. Vet J 2008;175:240–248. North Am Food Anim Pract 2009;25:651–667.

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Radiation therapy for the treatment of canine progressive cutaneous angiomatosis: Description of 2 cases

Paola Laganga, Laura Marconato, Simona Cancedda, Vito Ferdinando Leone, Carla Rohrer-Bley, Federica Rossi

Abstract — Two dogs with histologically confirmed progressive cutaneous angiomatosis were presented because of extensive and progressive cutaneous lesions of 1 hind limb causing pain and lameness. Radiation therapy was offered to treat disease recurrence after amputation in the first case and as first treatment in the second case. Metronomic therapy was added in both dogs. Complete and partial regression of the cutaneous lesions was achieved, respectively, with a period of 31 months of disease-free interval (first case) and 12 months of stable disease (second case). Self-limiting grades I and II acute side effects were observed. Radiation therapy can be an alternative to surgery in the treatment of inoperable cutaneous progressive angiomatosis.

Résumé — Radiothérapie pour le traitement de l’angiomatose cutanée progressive canine : description de 2 cas. Deux chiens ayant un diagnostic d’angiomatose cutanée progressive confirmé par histologie ont été présentés en raison de lésions cutanées vastes et progressives d’un membre postérieur qui causaient de la douleur et de la boiterie. La radiothérapie a été offerte pour traiter la récidive de la maladie après l’amputation dans le premier cas et comme premier traitement dans le deuxième cas. La thérapie métronomique a été ajoutée chez les deux chiens. Une régression complète et partielle des lésions cutanées a été obtenue, respectivement, avec un intervalle de 31 mois sans maladie (premier cas) et de 12 mois de maladie stable (deuxième cas). Des effets secondaires aigus spontanément résolutifs de grades I et II ont été observés. La radiothérapie peut représenter un traitement de remplacement à la chirurgie pour le traitement de l’angiomatose cutanée progressive inopérable. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1067–1070

n dogs, progressive cutaneous angiomatosis (PCA) is a lesions can be difficult to treat. In this report, 2 cases of PCA I rare and poorly documented disease (1–3). Clinically, it is treated with radiation therapy (RT) and metronomic therapy characterized by cutaneous reddish-purple plaques or nodules are described. slowly increasing in size or number. Reported localizations are the limbs/digits, and rarely the muzzle (1,3). A single case of Case descriptions skeletal/non-skeletal angiomatosis is described in the litera- Case 1 ture, in which the cutaneous lesions were associated with bony A 9-year-old, castrated male, 27.5-kg mixed breed dog was involvement (4). Bleeding and/or pain are often associated with referred to the Centro Oncologico Veterinario for evaluation this condition. In most cases, histology is needed to differenti- of treatment options for PCA. The dog had undergone 2 con- ate this benign tumor-like condition from hemangiosarcoma. secutive treatments of laser photocoagulation to treat multiple Reported treatment options include surgery and laser photo- interdigital nodules attributable to PCA at 8 and 3 mo before coagulation therapy for localized lesions; however, inoperable referral. At presentation, the dog showed multiple reddish cutaneous Centro Oncologico Veterinario, Sasso Marconi (Bologna), Italy nodules, painful at palpation, involving the right hind limb, (Laganga, Marconato, Cancedda, Leone, Rohrer-Bley, Rossi); extending from the interdigital region to the tarsal region. Division of Radiation Oncology, Vetsuisse Faculty, University Additional findings were interdigital dermatitis, marked mus- of Zuerich, Switzerland (Rohrer-Bley); Clinica Veterinaria cular atrophy of the leg and mild popliteal lymphadenopathy. dell’Orologio, Sasso Marconi (Bologna), Italy (Rossi). The skin was otherwise normal, including skin in the scrotal Address all correspondence to Dr. Federica Rossi; e-mail: and anal regions. Fine-needle aspiration of the nodules was [email protected] not conclusive, showing blood contamination and rare stellate Use of this article is limited to a single copy for personal study. cells; however, the popliteal lymph node showed lymphoid Anyone interested in obtaining reprints should contact the hyperplasia and was interpreted as reactive. The dog was initially CVMA office ([email protected]) for additional treated with oral thalidomide as single agent (Thalidomide; copies or permission to use this material elsewhere. Fagron Italia s.r.l., Quarto Inferiore, Bologna, Italy), 2 mg/kg

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Figure 1. Computed tomography reformatted images [multi-planar reconstruction (MPR) dorsal plane and virtual reality (VR), medium frequency spatial reconstruction algorithm, post-IV contrast examination] of the right hind limb of a mixed breed dog (case 1). Note the multiple cutaneous nodules enhancing in the venous phase (arrows).

Figure 2. Computed tomography reformatted images body weight (BW), q24h; however, after 5 mo oral piroxicam (MPR sagittal plane and VR, medium frequency spatial reconstruction algorithm, post-IV contrast examination) of the (Piroxicam; Pfizer Italia s.r.l., Latina, Italy), 0.3 mg/kg BW, left metatarsal and tarsal regions of a mixed breed dog (case 2). q24h, and oral cyclophosphamide (Endoxan; Baxter s.r.l., A proliferation of small tortuous subcutaneous vessels spreading Lurago d’Erba, Como, Italy), 7 mg/m2, q24h were added proximally along the venous path and causing severe soft tissue thickening is visible. because of progressive disease. This lead to disease stabilization for an additional 12 mo. Eventually, new nodules occurred in the inguinal region. Total body computed tomography (CT) were repeated every 3 mo, and showed no abnormalities. After showed multiple contrast-enhancing nodules in the paw, tibial, 9 mo, medical therapy was stopped due to the complete clinical and femoral region especially along the lateral saphenous vein response. The dog did well for an additional 22 mo (31 mo after (Figure 1). Regional lymph nodes, abdominal organs, and tho- start of RT) without any further treatment. Forty-six months rax were within normal limits. Because of drug-unresponsive after the first presentation, a follow-up total body CT scan was pain and low quality of life, right limb amputation followed repeated, showing thickening of the obturator muscle adjacent by RT at the surgical scar and inguinal region was carried out. to the surgical scar and a second area of soft tissue abnormality Histology confirmed the diagnosis of PCA. Radiation therapy lateral to the rectum on the right side, consistent with disease was started 10 d after amputation; at that time, multiple red- recurrence. A second RT treatment was performed and met- dish nodules (at least 6) and some hemorrhagic papules were ronomic therapy was restarted. Photon beam 3-dimensional visible in the medial inguinal region adjacent to the caudal conformal RT was delivered consisting of 8 fractions of 3.8 Gy margin of the scrotum. The region underwent electron beam applied on a Monday–Wednesday–Friday schedule. No acute radiation treatment delivered using a 6 megavolt (MV) linear side effects were observed. Twelve months after the second RT accelerator (Clinac DMX System; Varian, Palo Alto, California, treatment, the dog was presented because of hematochezia and USA). Treatment planning was performed by hand calculation, tenesmus. Colonoscopy revealed a peduncolated rectal mass pro- field size was 20 3 20 cm, set to include the entire scar and truding in the lumen. An excisional biopsy was performed and the right inguinal region and a minimum of 3 cm of lateral histopathology revealed a rectal hemangiosarcoma. For staging tissue. To spare the urethra, the penis was gently stretched and purposes, a CT-scan was performed, showing partial remission fixed toward the left. Beam energy was 9 MeV, source surface of the obturator muscle lesion, mild right medial iliac lymph- distance was 100 cm. A bolus of tissue equivalent material adenopathy, and a 3.6 3 2.6 3 3.1 cm rectal mass. Moreover, 1.5 cm thick was used to improve dose distribution uniformity pulmonary nodules compatible with metastases were observed. to the surface. The 90% isodose line was chosen to encompass A dose-intense chemotherapy protocol consisting of intravenous the target volume and for dose normalization (5). Radiation doxorubicin given at 25 mg/m2 every 21 d in combination with therapy consisted of a finely fractionated protocol with a total oral toceranib at 2.75 mg/kg BW on a Monday–Wednesday– dose of 51 Gy, delivered in 17 fractions of 3 Gy over 4 wk Friday schedule was initiated. However, the clinical conditions (5 consecutive daily fractions the first wk and 4 fractions/wk progressively worsened, and the dog was euthanized 66 mo after over 3 wk). Metronomic therapy was continued during and after the initial presentation. RT as previously described. Clinical re-check 3 wk after RT and monthly thereafter, showed complete remission of the scrotal Case 2 lesions. Self-limiting grade II acute RT toxicity was observed, A 7-year-old male, 32-kg mixed breed dog was referred for RT consisting of alopecia, erythema, dry alternated by patchy moist because of PCA of the left hind limb, consisting of a nodule desquamation. Thoracic radiographs and abdominal ultrasound at the medial aspect of the right tarsal region associated with

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subcutaneous swelling. On CT, a proliferation of small tortu- case of circumferential involvement and is typically associated ous subcutaneous vessels involving the metatarsal and tarsal with side effects, including suture dehiscence, tissue necrosis, region at 360° and extending proximally in the caudal adipose or infection. Coagulation laser has recently been recommended tissue of the popliteal region was observed (Figure 2). The pop- as an alternative to conventional surgery in dogs with the aim liteal lymph node and the bony structures were within normal of treating the macroscopic disease (1,3). This local treatment,

limits. A biopsy was taken, and histopathology revealed PCA. however, is not effective in preventing disease recurrence and REPORT CASE Conservative surgery was ruled out based on the extensive monthly re-check and multiple treatments are necessary to and circumferential limb involvement and the owner refused control the progression. amputation. Radiation therapy is used for the management of progressive At presentation, the dog was intermittently lame with mild vascular diseases in humans; additionally, vascular disorders muscle atrophy and a moderate thickening of the dorsal, medial, are included among the indications provided by the consensus and lateral tarsal surface extending proximally to the medial guidelines for RT treatment of benign diseases (10–13). The popliteal region. The involved skin had a dark-reddish appear- biologic mechanism of ionizing irradiation in benign diseases ance and was painful on palpation. Positioning CT was carried is incompletely understood, and it is thought to result from a out with the dog immobilized in an individually shaped vacuum combination of several biologic mechanisms, including regula- cushion (SecureVac; Bionix, Toledo, Ohio, USA) and with a tion of tissue perfusion, release of cytokine and other inflamma- custom-made byte block (6). The dog was treated with photon tory mediators, impact on the autonomous nervous system and 3-dimensional conformal RT providing a total dose of 30 Gy electrochemical milieu, and finally an anti-proliferative effect divided in 5 bi-weekly fractions of 6 Gy. Oral metronomic (13). Vascular endothelial cells are considered a sensitive target chemotherapy was prescribed as previously described, consisting and vascular fibrosis that causes an impairment of circulation of thalidomide (Fagron Italia s.r.l., Quarto Inferiore), 2 mg/kg and reduction of abnormal vessels is suggested to play a key BW, q24h, piroxicam (Pfizer Italia s.r.l.), 0.3 mg/kg BW, q24h, role in the control of vascular proliferation (14–17). Reported and cyclophosphamide (Baxter s.r.l., Lurago d’Erba), 7 mg/m2, RT protocols are variable with respect to delivered total dose q24h. The dog was clinically rechecked after 3 wk and self- (from 7 to 40 Gy) and fractionation (daily fraction of 1.5 to limiting grade I acute toxicity was observed. Further clinical 2.5 Gy). Low total dose (between 4 and 10 Gy) is recommended follow-up was performed after 3, 6, 9, and 12 mo; the dog was in children because of the higher risk of growth disturbance and free of lameness, the subcutaneous lesion partially regressed secondary malignancies (11,12). and remained stable after 1 y. Alopecia was the only observed To the authors’ knowledge, RT has never been reported for late side effect. the treatment of benign vascular diseases in veterinary medicine. In 2 dogs herein, RT combined with metronomic therapy was Discussion effective to locally treat cutaneous angiomatosis. In the first The diagnosis of PCA is based on clinical, imaging, and histo- case, complete regression of the cutaneous nodules was obtained logical features. The presence of progressively enlarging cutane- after delivering a finely fractionated protocol (total dose of ous nodules or plaques primarily affecting the digits or distal 51 Gy) with a disease-free interval of 31 mo. Because of disease limbs spreading proximally along the vascular path, painful on recurrence, a second low-dose treatment (30 Gy administered palpation, associated with lameness and possible bleeding should in 8 fractions of 3.9 Gy) was completed 28 mo after the first suggest this condition (1–3). Skeletal structures are sometimes treatment, with a further period of clinical control of 12 mo. involved; therefore, radiographic examination of the limb can The second dog received a total dose of 30 Gy with a bi-weekly be useful to evaluate the presence of bony changes; however, CT 6 Gy fraction protocol, and stable disease was achieved for at is required to precisely define the soft tissue involvement (4). least 12 mo. Both RT protocols lead to PCA regression and Computed tomography findings have not been previously medium/long-term disease control; however, consideration of reported in the literature. In these 2 cases, CT showed diffuse the best RT strategy to treat this disease is not possible, because soft tissue thickening and a vascular proliferation enhancing in only 2 dogs with different dose fractionation were treated. The the venous phase, resulting in a thick net of tortuous structures finely fractionated protocol was associated with acute grade 2 spreading proximally and following the path of the main limb self-limiting toxicity, whereas the low-dose treatments did not vasculature. Computed tomography was useful in assessing the cause any acute toxicity. Moreover, the addition of metronomic extent of the disease, showing areas of disease involvement that therapy might have influenced the RT effect. were not evident on clinical examination. Biopsy is necessary Hemangiosarcoma developing from hemangioma or other to differentiate PCA from other benign or low-grade malignant vascular malformation sites has been reported in human medi- vascular tumors. Histologically, this condition is characterized cine as a rare event (18). Most of the reported cases have been by well-circumscribed dermal and subcutaneous nodules of considered to arise spontaneously; however, at least 2 cases of dilated fully enclosed blood-filled spaces lined by single layers recognized radiation-induced hemangiosarcoma are described. of endothelial cells aligned on thin fibrous walls, with minimal The first case occurred in the canthus of the eye of a patient mitotic activity (1,2,7–9). 20 y after radiation for a large face hemangioma and the sec- Wide surgical resection or limb amputation is the preferred ond occurred from skeletal hemangiomatosis of the pelvis in a treatment option in cases of extensive skin involvement. Wide Japanese patient exposed to atomic bomb irradiation over 50 y skin resection may be technically difficult, especially in the earlier (19,20). Exposure to ionizing radiation is known to

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increase the incidence of cancer, with a latent period of years or 8. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Skin Diseases of the Dog decades following exposure (21). and the Cat. Clinical and Histopathologic Diagnosis. 2nd ed. Oxford, UK: Blackwell Publishing, 2005:735–758. In the first case herein, a rectal hemangiosarcoma was diag- 9. Avallone G, Crippa L, Iussich S, et al. Canine cutaneous angiomatosis: nosed 36 mo after the first and 12 mo after the second RT treat- Clinical and histopathological characterization. Proceedings of the ment. Since the hemangiosarcoma occurred in the irradiated 3rd National Congress AIPVet, Pisa (Italy), 2006:31 pp. 10. Yildiz F, Yilmaz M, Cengiz M, et al. Radiotherapy in the management field, it is possible that it represents a case of malignant trans- of Klippel-Trénaunay-Weber syndrome: Report of two cases. Ann Vasc formation of a benign vascular process; however, pre- and post- Surg 2005;19:566–571. induction histology would have been necessary to confirm this 11. Atahan IL, Cengiz M, Ozyar E, Gürkaynak M. Radiotherapy in the management of Kasabach-Merritt syndrome: A case report. Pediatr and it was not available in this dog. Therefore, the hypothesis of Hematol Oncol 2001;18:471–476. a spontaneous occurring hemangiosarcoma cannot be ruled out. 12. Hesselmann S, Micke O, Marquardt T, et al. Case report: Kasabach- Both cases were treated with metronomic therapy in addition Merritt syndrome: A review of the therapeutic options and a case report

RAPPORTCAS DE of successful treatment with radiotherapy and interferon alpha. Br J to RT. Metronomic therapy refers to the practice of administer- Radiol 2002;75:180–184. ing cytotoxic drugs without prolonged drug-free breaks and at 13. Micke O, Seegenschmiedt MH. The German Working Group on doses significantly lower than traditional chemotherapy, with Radiotherapy of Benign Diseases. Consensus guidelines for radiation therapy of benign diseases: A multicenter approach in Germany. Int J the therapeutic outcome of both anti-angiogenic and immune- Radiation Oncology Biol Phys 2002;52:496–513. modulatory effects (22). Metronomic therapy consisting of 14. Heyd R, Seegenschmiedt MH, Rades D, et al, German Cooperative piroxicam, cyclophosphamide, etoposide, and/or thalidomide Group on Radiotherapy for Benign Diseases. Radiotherapy for symp- tomatic vertebral hemangiomas: Results of a multicenter study and has proven to be efficacious in canine hemangiosarcoma, among literature review. Int J Radiat Oncol Biol Phys 2010;77:217–225. other histotypes (23–25). Also, by normalizing tumor blood 15. Handl-Zeller L, Hohenberg G. Radiotherapy of Morbus Gorham-Stout: vessels, thereby resulting in improved tumor perfusion, it may The biological value of low irradiation dose. Br J Radiol 1990 Mar; 63:206–208. be hypothesized that the addition of radiation therapy to met- 16. Glanzmann C, Rust M, Horst W. Irradiation therapy of vertebral ronomic treatment may lead to a better clinical efficacy, because angionomas: Results in 62 patients during the years 1939 to 1975. anti-angiogenic therapy increases oxygenation and radiosensitiv- Strahlentherapie 1977;153:522–525. [Article in German]. 17. Faria SL, Schlupp WR, Chiminazzo H, Jr. Radiotherapy in the treat- ity, augmenting radiation efficacy (26,27). ment of vertebral hemangiomas. Int J Radiat Oncol Biol Phys 1985;11: In conclusion, combined RT and metronomic therapy was 387–390. an effective treatment for PCA in these 2 dogs, leading to long- 18. Rossi S, Fletcher CD. Angiosarcoma arising in hemangioma/vascular malformation: Report of four cases and review of the literature. Am J lasting control of disease and pain. Further cases are required to Surg Pathol 2002;26:1319–1329. confirm these preliminary results in a large cohort of dogs and 19. Yamamoto T, Iwasaki Y, Kurosaka M, Minami R. Angiosarcoma arising to establish the best protocol. from skeletal haemangiomatosis in an atomic bomb survivor. J Clin Pathol 2001;54:716–717. 20. Handfield-Jones SE, Kennedy CTC, Bradfield JB. Angiosarcoma aris- Acknowledgment ing in an angiomatous naevus following irradiation in childhood. Br J Dermatol 1988;118:109–112. The authors thank Dr. Bux who kindly contributed case material 21. Reichl B, Block A, Schäfer U, et al. German Cooperative Group on and provided clinical follow-up of the second case. CVJ Radiotherapy for Benign Diseases (GCG-BD). DEGRO practical guidelines for radiotherapy of non-malignant disorders: Part I: Physical principles, radiobiological mechanisms, and radiogenic risk. Strahlenther References Onkol 2015;191:701–709. . 1 Peavy GM, Walder EJ, Nelson JS, Rosenberg M. Use of laser photo- 22. Kareva I, Waxman DJ, Klement GL. Metronomic chemotherapy: An coagulation for treatment of cutaneous angiomatosis in one dog and attractive alternative to maximum tolerated dose therapy that can acti- two cats. J Am Vet Med Assoc 2001;219:1094–1097, 1073. vate anti-tumor immunity and minimize therapeutic resistance. Cancer 2. Kim Y, Reinecke S, Malarkey E. Cutaneous angiomatosis in a young Letts 2015;358:100–106. dog. Vet Pathol 2005;42:378–381. 23. Lana S, U’ren L, Plaza S, et al. Continuous low-dose oral chemotherapy 3. Olivieri L, Nardini G, Pengo G, Abramo F. Cutaneous progressive for adjuvant therapy of splenic hemangiosarcoma in dogs. J Vet Intern angiomatosis on the muzzle of a dog, treated by laser photocoagulation Med 2007;21:764–769. therapy. Vet Dermatol 2010;21:517–521. 24. Finotello R, Henriques J, Sabattini S, et al. A retrospective analysis of 4. Kuroki K, Britt LG, Franklin SP, Henry CJ. Skeletal–extraskeletal chemotherapy switch suggests improved outcome in surgically removed, angiomatosis in a dog. Vet Pathol 2010;47:944–947. biologically aggressive canine haemangiosarcoma. Vet Comp Oncol 5. Das Ij, Cheng CW, Healey GA. Optimum field size and choice of 2017;15:493–503. isodose lines in electron beam treatment. Int J Radiot Oncol Biol Phys 25. Bray JP, Orbell G, Cave N, Munday JS. Does thalidomide prolong sur- 1995;3:157–163. vival in dogs with splenic haemangiosarcoma? J Small Anim Pract 2018; 6. Rohrer Bley C, Blattmann H, Roos M, Sumova A, Kaser-Hotz B. 59:85–91. Assessment of a radiotherapy patient immobilization device using single 26. Kobayashi H, Lin PC. Antiangiogenic and radiotherapy for cancer plane port radiographs and a remote computed tomography scanner. treatment. Histol Histopathol 2006;21:1125–1134. Vet Radiol Ultras 2003;44:470–475. 27. Kleibeuker EA, Griffioen AW, Verheul HM, Slotman BJ, Thijssen VL. 7. Affolter VK, Gross TL, Walder EJ. Characterization of cutaneous Combining angiogenesis inhibition and radiotherapy: A double-edged angiomatosis in dogs and cats. Vet Dermatol 2004;15:71 [Abstract]. sword. Drug Resist Updat 2012;15:173–182.

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Successful surgical resolution of a ceco-cecal intussusception in a 15-month-old Angus heifer

Gustavo Ferlini Agne, Ricardo M. Stockler, Thomas Passler, Herris Maxwell, Robert Cole

Abstract — A 15-month-old Angus heifer was presented for anorexia and abdominal discomfort. Transabdominal ultrasound was suggestive of a ceco-cecal intussusception. Exploratory laparotomy confirmed the diagnosis and a cecectomy was performed. The heifer recovered well and continued to gain weight after discharge. This is the first report of a heifer with ceco-cecal intussusception in North America.

Résumé — Correction chirurgicale réussie d’une intussusception caeco-cæcale chez une génisse de race Angus âgée de 15 mois. Une génisse de race Angus âgée de 15 mois est présentée pour une anorexie et des signes d’inconfort abdominal. Une échographie transabdominale révèle la présence d’une intussusception caeco-caecale. Le diagnostic est confirmé par laparotomie exploratrice et une typhlectomie est réalisée. La génisse a bien récupéré après l’opération et a continué à prendre du poids après sa sortie de l’hôpital. Ceci est le premier rapport de cas d’une génisse atteinte d’une intussusception caeco-caecale en Amérique du Nord. (Traduit par Dr Thibaud Kuca) Can Vet J 2018;59:1071–1074

Case description intestinal mucosa. Initial blood analysis revealed a packed cell volume (PCV) of 28% and total solids of 50 g/L. A complete 15-month-old, 363-kg Angus replacement heifer was pre- blood (cell) count (CBC) demonstrated a mild leukocytosis sented to the Auburn University Large Animal Teaching A (12.22 3 103/ mL, RR: 5.00 to 10.00 3 103/ mL) with a mild Hospital for evaluation of anorexia and mild abdominal discom- neutrophilia (5.62 3 103/mL, RR: 0.60 to 4.00 3 103/ mL) fort which had started approximately 24 h earlier. The owner and normal lymphocyte count (5.13 3 103/ mL, RR: 2.50 to stated that no other animals in the herd were affected. 7.50 3 103/mL). A mild hypoalbuminemia and mild electrolyte On admission, the heifer was in good body condition derangements characterized by hyponatremia and hypochloremia (BCS 6 of 9). Upon physical examination, the heifer was were detected on serum biochemistry analysis (Table 1). A fecal lethargic and febrile [39.8°C, reference range (RR): 37.5°C egg count performed by a modified McMaster’s method indi- to 38.5°C]. The heifer had a heart rate of 100 beats/min (RR: cated the presence of Trichostrongyle (950 eggs/g) and moderate 60 to 90 beats/min) with no murmurs or arrhythmias noted numbers of coccidia. upon cardiac auscultation. The respiratory rate was 32 breaths/ Approximately 12 h after admission to the hospital, the min (RR: 10 to 30 breaths/min) with normal bronchovesicular heifer developed profuse, fibrino-mucoid, and hemorrhagic sounds and respiratory effort noted during auscultation of the diarrhea. A fecal sample was submitted for Salmonella culture, thorax. The mucous membranes were moist and of normal color, which eventually yielded a negative result 7 d later. Initial with a capillary refill time of 2.5 s, and the heifer was estimated medical therapy consisted of pain control with a single dose of to be 5% dehydrated. The nostrils were free of discharge and the non-steroidal anti-inflammatory drug flunixin meglumine there was no coughing. Ruminal sounds were increased with a (Banamine; Schering Plough Animal Health, Union, New Jersey, total of 5 ruminal contractions/min. USA), 1.1 mg/kg body weight (BW), IV. Intravenous fluid Findings from transrectal palpation of the abdomen were therapy consisted of 7.2% hypertonic saline (VetOne, Boise, unremarkable. Feces were dark and suggestive of sloughed Idaho, USA), 5 mL/kg BW, over 20 min (1) in order to provide rapid plasma volume expansion, along with an electrolyte solu- Department of Clinical Sciences, College of Veterinary tion (yeast, magnesium, calcium, and potassium, 500 mg in Medicine, Auburn University, Auburn, Alabama 36849, USA. 20 L of water — YMCP; TechMix, Stewart, Minnesota, USA) Address all correspondence to Dr. Gustavo Agne; e-mail: via orogastric intubation, administered once. [email protected] On day 2, transabdominal ultrasound examination revealed Use of this article is limited to a single copy for personal study. increased peristalsis of the small intestines without luminal Anyone interested in obtaining reprints should contact the distention or increased wall thickness of the small intestines. CVMA office ([email protected]) for additional Transabdominal ultrasound imaging of the abdomen at the right copies or permission to use this material elsewhere. para-lumbar fossa indicated an intussusception with a typical

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Table 1. Serum blood chemistry analysis of a 15-month-old heifer with a ceco-cecal intussusception. Reference range Total protein 46.6 g/L 58.0 to 85.0 Albumin 18 g/L 30 to 48 Globulin 29 g/L 34 to 48 Sodium 135 mmol/L 137 to 151 Potassium 4.8 mmol/L 2.5 to 5.9 Chloride 89 mmol/L 98 to 107 Anion GAP 29.7 mOsm/kg 10.0 to 27.0 Bicarbonate 21.1 mmol/L 16.0 to 40.0 RAPPORTCAS DE target sign lesion consisting of alternating concentric echogenic Figure 1. Transabdominal ultrasound imaging was performed and hypoechogenic rings of thickened intestinal wall (10 mm) in the right para-lumbar fossa, showing a sagittal view of the (Figures 1, 2). Given the anatomic location of the target sign cecum. Concentric rings (arrowhead) representing the target sign or “bulls eye” appearance of the intussusception (asterisk) lesion, and the lack of small intestinal distention, a ceco-cecal or are present. ceco-colic intussusception was suspected. No other abnormalities were observed during transabdominal ultrasound examination. Based on the history, physical examination, and diagnostic procedures performed (i.e., abdominal discomfort and transabdominal ultrasound findings consistent with a cecal intussusception) an exploratory laparotomy was performed. A standing right flank approach was initially selected. After loco-regional anesthesia of the paralumbar fossa using 2% lidocaine hydrochloride in a proximal paravertebral block, a 30-cm vertical skin incision was made in the right paralumbar fossa, midway between the last rib and the tuber coxae. The abdominal wall was incised, the abdomen was manually explored, and the ceco- cecal intussusception was easily palpable but could not be fully exteriorized. The decision to continue the surgery in left lateral Figure 2. Transabdominal ultrasound imaging was performed recumbency was made. The incision was temporarily closed with in the right para-lumbar fossa to obtain a longitudinal view of the cecal apex (asterisk) with multilayered appearance within the the use of Backhaus towel clamps, a high volume caudal epidural thickened cecal wall (arrowhead). (2% lidocaine; Vetone, Boise, Idaho, USA), 1 mL/5 kg BW was administered as previously described (2), and the animal and prognosis of intussusceptions in calves and adult cattle, all was placed in left lateral recumbency. The abdominal incision animals were presented with signs of anorexia and changes in was re-opened and the intussusception was exteriorized. A tear fecal quality and output, but only half of the animals presented in the cecal wall occurred during an attempt to manually cor- with signs of pain (3). In the heifer described here evidence of rect the intussusception (Figure 3). The affected portion of the lethargy and decreased appetite were observed but fecal output cecum was amputated at the base of the cecum and the result- was not reduced and abdominal discomfort was mild. ing enterotomy closed with 2-0 PDS (polydiaxanone; Ethicon, The heifer initially had mild tachycardia and pyrexia. Johnson and Johnson, Somerville, New Jersey, USA) utilizing Potential causes for the increased heart rate and temperature an inverting pattern (Cushing pattern). included: pain related to a gastrointestinal abnormality, perito- Post-surgical treatment consisted of anti-inflammatory ther- nitis, cardiac disease, pneumonia, and dehydration. The heifer apy (flunixin meglumine; Schering Plough Animal Health), was not coughing and there was no evidence of nasal discharge, 1.1 mg/kg BW, IV, q24h, for 3 d, pain management with ventral edema, increased jugular pulse or abnormalities noted butorphanol tartrate (Torbugesic; Zoetis, Parsippany-Troy Hills, during auscultation of the thorax; therefore, cardiac disease or New Jersey, USA), 0.04 mg/kg BW, SC, once, and antimicrobial a respiratory disease were considered unlikely contributors to therapy (ampicillin; Polyflex; Boehringer Ingelheim Vetmedica, the tachycardia and pyrexia noted. The heifer was estimated St. Joseph, Missouri, USA), 11 mg/kg BW, IM, q24h, for 7 d. to be 5% dehydrated, and although there was a mild decrease Recovery from surgery was uneventful, the heifer continued to in the heart rate after fluid therapy and rapid plasma expansion eat normally and pass normal feces, and was discharged from the with the use of a hypertonic solution, the heart rate remained hospital 10 d after surgery. At follow-up with the owner 5 mo elevated, indicating that abdominal pain was likely one of the after discharge, the heifer was doing well and had gained weight. causes for the tachycardia. Findings of the CBC were consistent with an inflammatory leukogram, likely due to ischemic necrosis Discussion of the intussesceptum. Serum biochemistry analysis was consis- Abdominal discomfort with lethargy, loss of appetite, and reduc- tent with protein loss and electrolyte derangements, which along tion of fecal output are common presenting complaints in rumi- with an increase in body temperature, were likely secondary to nant practice. In a retrospective study evaluating the prevalence a protein losing enteropathy and focal peritonitis.

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Figure 3. A — Ceco-cecal intussusception in a 15-month-old Angus heifer. B — Exteriorized intussusceptum with evidence of ischemia at the apex of the cecum (arrow). Note the tear in the cecal wall caused by attempts to manually resolve the intussusception (arrowhead).

Transrectal palpation of the abdomen did not confirm the were consistent with a similar report in a Simmental heifer (11). diagnosis of intussusception in this case. In a retrospective study Given the anatomical location, ultrasonographic appearance of intussusception in cows, about 50% of the cases had small on longitudinal view and lack of small intestinal distention, intestinal distention that was palpable per rectum and only the intussusception was determined to be involving only the 23% of the intussusceptions were noted during palpation of the cecum (ceco-cecal). abdomen per rectum (4). In our case, dark feces with mucus and Cecal intussusceptions are uncommon in cattle and, although sloughing of the mucosa were noted, with an appearance similar previously described in calves, to the authors’ knowledge this is to “raspberry jam,” which was consistent with previous reports the second report of a ceco-cecal intussusception in a heifer and of intussusception in cattle (5). the first described in North America. In a retrospective study of As described in other studies (6,7), the presumptive diagnosis 336 cases of intussusceptions in cattle, only 12 cases involved in the present case was obtained after transabdominal ultrasound the cecum and all were defined as ceco-colic intussusceptions examination findings consistent with intussusception of the (10). In the same study, calves less than 2 mo of age were the intestinal tract. In our case, transabdominal ultrasound examina- most affected. Our hypothesis is that ceco-cecal intussusception was only performed on the second day, due to persistence tions are not commonly observed in calves because the size of of clinical signs. A transabdominal ultrasound examination at the cecum in younger animals allows it to telescope completely admission could have provided an earlier diagnosis and surgical into the colon as previously described (12). In older animals intervention, which could have lessened the need for complete such as the heifer herein, the cecal diameter is likely too large cecal removal and decreased the chances of possible secondary to telescope into the colon; therefore, if invagination of the complications after surgery. Intussusception occurs when an orad cecum occurs, it is limited to a ceco-cecal intussusception due segment of the intestinal tract (the intussesceptum) telescopes to anatomical proportions. inside an aborad segment (the intussuscipiens) (8–10). Small The diagnosis of a ceco-cecal intussusception was obtained intestine distention may occur and is usually seen proximal to during exploratory laparotomy. The initial surgical approach was the intussusception. Small intestine distention was not observed performed standing, which allowed palpation of the intussuscep- in our case, which was likely because the ileocecocolic junction tion but did not permit exteriorization and visualization of the was not obstructed. area. This was likely due to excessive tension of the mesentery The cross-section ultra-sonographic pattern of an intus- and therefore, it was decided to place the heifer in left lateral susception is usually characterized by a multilayered mass with recumbency. Although the incision was temporarily closed with circular rings of varying echogenicity. In a study evaluating the Backhaus towel clamps, altering from a standing to a lateral ultrasonographic appearance of intussusceptions in cows, cross- recumbency increased the time of surgery and the risk of con- section ultrasound view of the intussuscipiens was assumed by tamination of the abdominal cavity. As previously reported (10), echogenic layers combined with hypoechoic portions (likely excessive tension of the mesentery while performing standing related to presence of edema), while the cross-section ultrasound gastrointestinal surgery might induce the animal to lay down pattern of the intussesceptum was often hypoechoic with a during the procedure. Therefore, it is the authors’ opinion that hypo to anechoic core (7). In the same study, the longitudinal the surgical approach for the assessment and correction of cecal view was characterized by echogenic parallel lines separated abnormalities such as a ceco-cecal intussusception should be by hypoechoic lines, giving a multilayered appearance to the performed through an incision in the right paralumbar fossa intussusception. In our case, the cross-section and longitudinal with the animal in left lateral recumbency. Due to edema and views were similar to those in previous reports, except that in tissue friability, an attempt to reverse the intussusception in this the longitudinal view, the central luminal area was hyperechoic case resulted in rupture of the cecal wall. It is our opinion that and conical in shape (intussesceptum) and seen within multiple manual resolution of a ceco-cecal intussusception is difficult layers of hyperechoic lines, interposed by hypoechoic lines, and will likely result in tissue damage, increasing the risks of forming a horse shoe shape (intussuscipiens). These findings contamination of the abdominal cavity with intestinal contents.

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In the present case, the cecum was removed with preserva- analgesia. The authors recommend conducting the procedure tion of the ileocecocolic junction. The effect of complete cecal in left lateral recumbency. No significant complications were excision including the ileocecocolic junction on digestibility and noted after surgical intervention. Cecectomy, when performed weight gain has been reported (13). There was no significant early in the disease process, appears to have a good long-term difference in digestibility and mean daily weight gain between prognosis. Initial weight loss and changes in fecal consistency cecectomized and sham-operated steers, indicating that the might be observed but removal of the cecum did not appear to cecum may not be a critical organ for fiber and protein diges- affect weight gain in the heifer described in this report. CVJ tion in cattle. In the same study, fecal consistency was loose and, in some cases, diarrhea was noted up to 4 wk after surgery. At References 8 wk following cecectomy, the feces of all steers had returned to . 1 Constable PD. Hypertonic saline. Vet Clin North Am Food Anim Pract 1999;15:559–585. almost normal consistency, indicating that the colon was likely 2. Anderson DE, Edmondson MA. Prevention and management of RAPPORTCAS DE compensating for the loss of the cecum. It was proposed that ini- surgical pain in cattle. Vet Clin North Am Food Anim Pract 2013;29: tial softening of the manure was related to antimicrobial therapy 157–184. 3. Sartelet A, Guyot H, Vandeputte S, Touati K. Intestinal intussusceptions and to absence of the ileal papilla. The ileal papilla prevents in cattle: A retrospective study (22 cases). Presentation at XXVth World backflow of ingesta from the large intestines to the ileum and Buiatrics Congress, Budapest, Hungary, July 10, 2008. if absent, colonic bacteria could colonize the small intestines, 4. Constable P, St. Jean G, Hull B, Rings D, Morin D, Nelson D. Intus susception in cattle: 336 cases (1964–1993). J Am Vet Med Assoc 1997; leading to diarrhea due to bacterial bile salt deconjugation (13). 210:531–536. In our case, the ileocecocolic junction was preserved; therefore, 5. Van Metre DC, Callan RJ, Holt TN, Garry FB. Abdominal emergencies the soft feces observed while in the hospital were likely related in cattle. Vet Clin North Am Food Anim Pract 2005;21:655–696. 6. Braun U, Marmier O, Pusterla N. Ultrasonographic examination of the to postsurgical antimicrobial therapy. Fecal consistency follow- small intestine of cows with ileus of the duodenum, jejunum or ileum. ing discharge was unknown in our case but the heifer continued Vet Rec 1995;137:209–215. to gain weight and diarrhea was not evident to the owners. 7. Imran S, Tyagi S, Kumar A, Kumar A, Sharma A, Sharma S. Usefulness and limitation of ultrasonography in the diagnosis of intestinal intus- Similarly, diarrhea was not noted after complete cecal removal susception in cows. Vet Med Int 2011; doi: 10.4061/2011/584387. in a Simmental heifer in Germany (11). 8. Dabas V, Jhala S, Suthar D. Management of intussusception in a cow. Cecal intussusceptions in cattle are rare, and to the authors’ Intas Polivet 2011;12:44–45. 9. Pravettoni D, Morandi N, Rondena M, et al. Repeated occurrence of knowledge this is the first case reported in North America. jejuno-jejunal intussusception in a calf. Can Vet J 2009;50:287–290. Transabdominal ultrasound examination is useful in detecting 10. Anderson DE, Ewoldt JMI. Intestinal surgery of adult cattle. Vet Clin ceco-cecal intussusceptions and its findings should be inter- North Am Food Anim Pract 2005;21:133–154. 11. Lejeune B, Kramer A, Meylan M. Ceco-cecal intussusception in a preted in conjunction with additional diagnostic tests, physical Simmental heifer. Schweiz Archiv Tierheilk 2015;157:401–405. examination, and history. Manual reduction of the intussuscep- 12. Julian RJ, Hawke TW. Cecalcolic intussusception in calf. Can Vet J tion may not be possible and might lead to cecal wall rupture; 1963;4:54–55. 13. Maala C, Smith D, Hintz H, Sack W. Removal of the cecum, including therefore, the surgeon should be prepared for removal of the the ileocecocolic junction, and its effects on digestibility in cattle. Am cecum. This can be performed with sedation and regional J Vet Res 1983;44:2237–2243.

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1074 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Case Report Rapport de cas

Occult tonsillar squamous cell carcinoma in 2 dogs presenting for treatment of primary oral squamous cell carcinoma

Nicholas J. Rancilio, Christopher M. Fulkerson

Abstract — Canine non-tonsillar oral squamous cell carcinoma (OSCC) is generally regarded as locally invasive with low rates of metastasis. Two cases of canine non-tonsillar OSCC with occult tonsillar squamous cell carcinoma (TSCC) detected with tonsillar biopsies are reported. Tonsillar biopsies and detection of occult TSCC changed the therapeutic plan and may have contributed to long-term tumor control.

Résumé — Carcinome squameux tonsillaire occulte chez 2 chiens présentés pour le traitement d’un carcinome squameux buccal primaire. Le carcinome squameux buccal (CSB) non tonsillaire canin est généralement considéré comme localement invasif avec de faibles taux de métastase. Deux cas de CSB non tonsillaire canin avec un carcinome squameux tonsillaire (CST) occulte détectés lors de biopsies tonsillaires ont été signalés. Les biopsies tonsillaires et la détection du CST occulte ont modifié le régime thérapeutique et peuvent avoir contribué au contrôle de la tumeur à long terme. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1075–1078

quamous cell carcinoma is the second most common oral Regional lymph node metastasis is reported in up to 73% of S tumor in the dog (1). The location of oral squamous cell dogs, pulmonary metastasis in 42% to 63% of cases, and 1-year carcinoma (OSCC) is predictive of its biological behavior. In survival rates range from 10% to 40% (2–5,9–11). Treatment locations other than the tonsil, OSCC is typically locally inva- with surgery alone has a median survival time of 137 d (10). sive, and when amenable to wide resection is associated with Median survival times ranging from 211 to 496 d have been good long-term clinical outcome. There are infrequent reports reported with combinations of surgery, radiation, and chemo- of locoregional and distant metastasis at diagnosis or following therapy (3,9–11). aggressive local treatment of non-tonsillar OSCC. Regional Staging for dogs with OSCC typically consists of computed lymph node metastasis is reported in , 10% of cases, pulmo- tomography (CT) of the head, thoracic radiography, abdominal nary metastasis in 3% to 36% of cases, and 1-year survival rates ultrasonography, and cytologic or histopathologic evaluation of range from 40% to 93.5% (2–10). Complete surgical excision locoregional lymph nodes (6). Here we discuss 2 cases presented is reported to result in a median disease-free interval of 722 d for treatment of primary OSCC with occult TSCC detected and low risk of local tumor recurrence (8). at the time of staging. To the authors’ knowledge, these cases In contrast, tonsillar squamous cell carcinoma (TSCC) has represent the first reported occurrence of occult TSCC concur- a biologically aggressive behavior both locally and distantly. rently with non-tonsillar OSCC in the dog. Case descriptions Purdue University College of Veterinary Medicine, Department Case 1 of Veterinary Clinical Sciences, Lynn Hall of Veterinary Medicine, 625 Harrison Street, West Lafayette, Indiana 47907, A 9-year-old spayed female 27.1-kg mixed breed dog was USA. presented for evaluation 1 mo after a non-tonsillar OSCC was surgically resected with incomplete margins from the buccal Address all correspondence to Dr. Christopher M. Fulkerson; mucosa of the right maxillary lip. A focal erosion was observed e-mail: [email protected] that was interpreted as minor surgical dehiscense at the time of Dr. Rancilio’s current address is Auburn University College presentation (Figure 1A). Complete staging included 3-view of Veterinary Medicine, Department of Clinical Sciences, thoracic radiographs, abdominal ultrasound, and CT with 1220 Wire Road, Auburn, Alabama 36849, USA. contrast of the head and neck for radiation treatment planning Dr. Rancilio and Dr. Fulkerson shared equally in the preparation (Figure 1C). The right mandibular lymph node was enlarged of this manuscript. on CT-scan; therefore, a fine-needle aspirate (FNA) was taken. Use of this article is limited to a single copy for personal study. Cytologic evaluation of the right mandibular lymph node Anyone interested in obtaining reprints should contact the revealed a mild to moderate reactive lymph node with no evi- CVMA office ([email protected]) for additional dence of metastatic carcinoma. Due to the presence of moderate copies or permission to use this material elsewhere. dental calculi, a prophylactic dental cleaning was completed by

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✹ ✹ ✹ ✹

Figure 1. A — Case 1. Lesion on buccal mucosa of right maxillary lip surface (arrow) before starting definitive chemoradiotherapy. B — Case 2. Scar on right maxillary lip after 19 fractions of 3 Gy (arrow). C — Case 1. Axial slice CT-scan at the level of the tonsils (stars) demonstrating normal tonsils prior to treatment. D — Case 2. Axial slice CT-scan at the level of the tonsils (stars) demonstrating normal tonsils prior to treatment.

a Board-certified veterinary dentist before initiation of radiation sional mitotic figures, and invasion into the basement membrane therapy. During the dental prophylaxis, maxillary incisor 202 zone, consistent with squamous cell carcinoma (SCC). was extracted. Definitive chemoradiotherapy was prescribed consisting of Although the tonsils were grossly normal and cytology from irradiation of the primary mass and tonsils with 19 fractions the right mandibular lymph node was consistent with a reactive of 3 Gy, medial retropharyngeal lymph nodes, and mandibular lymph node likely secondary to dental disease, a biopsy of the lymph nodes with 19 fractions of 2.52 Gy, and carboplatin. All right tonsil was performed at the recommendation of the den- radiation treatments were delivered by a linear accelerator with tist. A pair of 4 mm 3 28 mm Jackson Uterine Biopsy Forceps 6 MV photons using intensity modulated radiation therapy (Jorgensen Labs, Loveland, Colorado, USA) was used to biopsy treatment planning (Varian Clinac 6 Ex Accelerator and Eclipse the grossly normal right tonsil. With the aid of a cotton-tipped v.11; Varian Medical Systems, Palo Alto, California, USA) applicator, the tonsil was identified within the tonsillar crypt, on consecutive weekdays. Carboplatin (Hospira, Lake Forest, the forceps were positioned such that the tonsil was located Illinois, USA), 300 mg/m2, was administered by intravenous within the open jaws and then closed to obtain multiple tissue injection prior to fraction 8 of radiation therapy. A complete samples. Hemorrhage was controlled with direct digital pressure. blood (cell) count (CBC) was carried out 14 d after administra- Histopathology of the right tonsil revealed multifocal areas of tion of carboplatin. Physical examination and laboratory results marked cellular atypia within the squamous epithelium, occa- were consistent with afebrile and clinically silent Veterinary

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Cooperative Oncology Group common terminology criteria nodes, and medial retropharyngeal lymph nodes with 19 frac- for adverse events (VCOG-CTCAE) grade 3 neutropenia tions of 3 Gy using the same equipment described in the previ- (900 neutrophils/mL). Trimethoprim sulfa (Amneal, Patterson, ous case, and carboplatin. Carboplatin (Hospira), 300 mg/m2, New Jersey, USA), 37 mg/kg body weight (BW), PO, q12h, was administered by intravenous injection before fraction 2 of was prescribed (12). No delay in radiation delivery occurred radiation therapy. A CBC was performed 14 d after admin-

and neutropenia resolved without incident as expected. During istration of carboplatin. Physical examination and laboratory REPORT CASE radiation therapy the patient developed expected acute side results were consistent with afebrile and clinically silent VCOG- effects in the oral cavity and skin including Veterinary Radiation CTCAE grade 4 neutropenia (100 neutrophils/mL) and grade Therapy Oncology Group (VTROG) Acute Morbidity Score 3 thrombocytopenia (, 50 000 platelets/mL) (12). The patient grade II–III mucositis, and grade II–III desquamation which was started on cefpodoxime (Simplicef; Zoetis), 7.6 mg/kg BW, resolved without incident (13). Carprofen (Rimadyl; Zoetis, PO, q24h and the neutropenia and thrombocytopenia resolved Parsippany-Troy Hill, New Jersey, USA), 1.84 mg/kg BW, PO, as expected without radiation therapy delay. After completing q12h, was prescribed when acute radiation side effects were first radiation therapy, carprofen was discontinued and piroxicam noted and was continued thereafter. (Medisca, Plattsburgh, New York, USA), 0.3 mg/kg BW, PO, Due to the unusual presentation of this case, the patient was was started after a 5-day washout period. Four subsequent returned 20 d after completing definitive radiation therapy for doses of carboplatin were given at an extended dose interval of diagnostic biopsies of the head and neck lymphocentrums to once every 28 d and at a 20% dose reduction (240 mg/m2) for confirm remission. Bilateral tonsillectomies, extirpation of the a total of 5 doses. VRTOG Grade II–III moist desquamation right-sided mandibular lymph node chain, and extirpation of and mucositis also developed on the right muzzle and right identifiable cervical lymph nodes (bilateral medial retropharyn- maxillary buccal lip (13). All acute radiation side effects resolved geal lymph nodes and right deep cervical lymph nodes) were as expected. The regional lymph nodes and tonsils were not performed. No evidence of SCC was detected in either tonsil extirpated following chemoradiotherapy due to owner financial or any of the resected lymph nodes. After completing radia- constraints. The patient was euthanatized for unknown reasons tion therapy and recovering from surgery, carboplatin chemo- 1 y and 11 mo after initiating definitive chemoradiotherapy. therapy was resumed. The second dose of carboplatin (Hospira) Based on consultation with the primary veterinarian and review was administered 49 d after the first at a 5% dose reduction of the patient’s medical record, there was no apparent evidence (285 mg/m2). Clinically silent VCOG-CTCAE grade 4 throm- of SCC at the time of euthanasia. bocytopenia (11 000 platelets/mL) was detected 14 d after the second dose of carboplatin (12). Three subsequent doses of Discussion carboplatin were administered at a further 10% dose reduction To the authors’ knowledge, these are the first reported cases of (257 mg/m2) for a total of 5 doses. The patient was alive, and occult TSCC concurrent with OSCC in the dog. While primary reportedly well, after consultation with the owner 3 1/2 y after and occult bilateral TSCC have been documented (2,10), non- the initiation of definitive chemoradiotherapy. tonsillar OSCC uncommonly metastasizes to regional lymph nodes such as the mandibular and medial retropharyngeal lymph Case 2 nodes, and has not been reported to metastasize to the tonsils A 10-year-old spayed female 26.9-kg mixed breed dog was (2,3,7,8). Tonsillar metastasis from other oral tumors such as presented for evaluation 1 mo after a non-tonsillar OSCC was malignant melanoma have been infrequently documented (14). surgically resected with incomplete margins from the right While the authors suspect that the occult tonsillar SCC reported maxillary lip margin (Figure 1B). Following the initial sur- in these cases represent metastasis from the primary non- gery, the primary veterinarian prescribed carprofen (Rimadyl; tonsillar OSCC, concurrent development of TSCC (a second Zoetis), 3.7 mg/kg BW, PO, q24h. Complete staging was malignancy), or possibly field cancerization due to carcinogen performed including 3-view thoracic radiographs and abdomi- exposure within the oral cavity should also be considered. nal ultrasound. Computed tomography of the head and neck The cases herein demonstrate that aggressive management with contrast was performed for radiation treatment plan- of loco-regionally advanced non-tonsillar OSCC may result ning (Figure 1D). Other than an area of focal contrast uptake in long-term survival. In these cases, radiation therapy would on the right maxillary lip, no other imaging abnormalities typically have been prescribed to avoid the tonsils in order to were reported. On oral examination, the left and right tonsils diminish the potential for additional acute radiation side effects. were found to be grossly normal in size and shape. Due to If tonsillar biopsies had not been performed before treatment, the authors’ experience with the previous case, both tonsils it is likely that the TSCC would have progressed and been were biopsied using the same technique as in the first case. recognized as a treatment failure. Given the low metastatic Histopathology of both tonsils revealed irregular thickening potential of non-tonsillar OSCC and previously reported suc- of the mucosal stratified squamous epithelium with abnormal cessful long-term results with adequate local therapy (2–8,10), maturation, loss of a distinct basal cell layer or basement mem- the authors may not have incorporated chemotherapy into brane, and neoplastic invasion of the underlying lymphoid the treatment protocol if occult TSCC had not been detected tissue, consistent with SCC. (2,4,6–8). Retrospective studies of OSCC and TSCC often Definitive chemoradiotherapy was prescribed consisting of suggest that multi-modal therapy including combinations of irradiation of the primary mass, tonsils, mandibular lymph surgery, radiation therapy, and chemotherapy may provide a

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survival benefit, but are confounded by selection bias — owners References who elect multi-modal therapy may be more inclined to pursue . 1 Hoyt RF, Withrow SJ. Oral malignancy in the dog. J Am Anim Hosp therapy and less inclined to euthanize (3,9–11). Retrospective Assoc 1984;20:83–92. studies have demonstrated that chemotherapy protocols includ- 2. Brodey RS. The biological behaviour of canine oral and pharyngeal neoplasms. J Small Anim Pract 1970;11:45–53. ing either cisplatin or carboplatin have activity against OSCC 3. Brooks MB, Matus RE, Leifer CE, Alfieri AA, Patnaik AK. and TSCC in the dog, but long-term results remain unsatisfac- Chemotherapy versus chemotherapy plus radiotherapy in the treat- tory (3,5,9–11,15). Due to cisplatin’s nephrotoxicity, carboplatin ment of tonsillar squamous cell carcinoma in the dog. J Vet Intern Med 1988;2:206–211. is often the chemotherapy drug of choice, if chemotherapy is 4. Théon AP, Rodriguez C, Madewell BR. Analysis of prognostic factors elected. Non-steroidal anti-inflammatory drugs (NSAIDs) also and patterns of failure in dogs with malignant oral tumors treated with have activity against OSCC and TSCC either alone (16) or in megavoltage irradiation. J Am Vet Med Assoc 1997;210:778–784. 5. de Vos JP, Burm AGD, Focker AP, Boschloo H, Karsijns M, van der combination with platinum chemotherapy drugs (5,17). While Waal I. Piroxicam and carboplatin as a combination treatment of RAPPORTCAS DE chemotherapy and NSAIDs were used in the treatment of the canine oral non-tonsillar squamous cell carcinoma: A pilot study and a 2 cases described here, their contribution to the long-term literature review of a canine model of human head and neck squamous cell carcinoma. Vet Comp Oncol 2005;3:16–24. outcome versus treatment with aggressive local therapy alone 6. Grier CK, Mayer MN. Radiation therapy of canine nontonsillar squa- is unknown. Prospective or randomized studies evaluating the mous cell carcinoma. Can Vet J 2007;48:1189–1191. role of chemotherapy in the treatment of OSCC or TSCC fol- 7. Fulton AJ, Nemec A, Murphy BG, Kass PH, Verstraete FJM. Risk factors associated with survival in dogs with nontonsillar oral squamous lowing definitive local therapy with either surgery or radiation cell carcinoma 31 cases (1990–2010). J Am Vet Med Assoc 2013;243: therapy are lacking. 696–702. Tonsillar biopsies can be easily performed using the Jackson 8. Sarowitz BN, Davis GJ, Kim S. Outcome and prognostic factors following curative-intent surgery for oral tumours in dogs: 234 cases (2004 to Uterine Biopsy Forceps described in this article with minimal 2014). J Small Anim Pract 2017;58:146–153. additional patient morbidity. This instrument is relatively inex- 9. Mas A, Blackwood L, Cripps P, et al. Canine tonsillar squamous cell pensive and is reusable after steam sterilization. When used to carcinoma — A multi-centre retrospective review of 44 clinical cases. J Small Anim Pract 2011;52:359–364. biopsy the tonsils, the instrument effectively cuts and crushes 10. Grant J, North S. Evaluation of the factors contributing to long-term tissue within the jaws resulting in rapid hemostasis, minimal survival in canine tonsillar squamous cell carcinoma. Aust Vet J 2016; patient morbidity, and rapid acquisition of tissue samples. Any 94:197–202. 11. Murphy S, Hayes A, Adams V, et al. Role of carboplatin in multi- hemorrhage that occurs can typically be controlled with direct modality treatment of canine tonsillar squamous cell carcinoma — A digital pressure (in medium or larger dogs) or use of a cotton- case series of five dogs. J Small Anim Pract 2006;47:216–220. tipped applicator (in small dogs or cats) on the tonsillar crypt. 12. Veterinary Cooperative Oncology Group — Common terminology criteria for adverse events (VCOG-CTCAE) following chemotherapy As with any small biopsy, the authors recommend combinations or biological antineoplastic therapy in dogs and cats v1.1. Vet Comp of NSAIDs, tramadol, and/or opioids for post-operative pain Oncol 2016;14:417–446. management. Given the small size of a grossly normal tonsil, 13. Ladue T, Klein MK. Veterinary Radiation Therapy Oncology Group. Toxicity criteria of the veterinary radiation therapy oncology group. Vet tissue biopsy may be more likely to yield a definitive diagnosis Radiol Ultrasound 2001;42:475–476. compared with fine-needle aspirate, particularly in cases in 14. Tuohy JL, Selmic LE, Worley DR, Ehrhart NP, Withrow SJ. Outcome which only microscopic foci of neoplasia are present. following curative-intent surgery for oral melanoma in dogs: 70 cases (1998–2011). J Am Vet Med Assoc 2014;245:1266–1273. Typical staging recommendations for non-tonsillar OSCC in 15. Mestrinho LA, Bernardo E, Niza MMRE, Lloret A, Buracco P. the dog do not include sampling the tonsils (6). Based on these Neoadjuvant chemoradiotherapy and surgery as treatment for oral max- case reports and the relatively low patient morbidity associated illary squamous cell carcinoma in a dog. Aust Vet J 2012;90:264–268. 16. Schmidt BR, Glickman NW, DeNicola DB, de Gortari AE, Knapp DW. with tonsillar biopsies, the authors recommend that veterinar- Evaluation of piroxicam for the treatment of oral squamous cell carci- ians consider tonsillar biopsies for cases of non-tonsillar OSCC noma in dogs. J Am Vet Med Assoc 2001;218:1783–1786. even when the tonsils are not grossly enlarged. The detection of 17. Boria PA, Murry DJ, Bennett PF, et al. Evaluation of cisplatin combined with piroxicam for the treatment of oral malignant melanoma and occult TSCC would likely alter the planned course of treatment oral squamous cell carcinoma in dogs. J Am Vet Med Assoc 2004;224: with regard to local therapy, but further prospective studies 388–394. are necessary to determine if the addition of chemotherapy or NSAIDs is of any additional therapeutic benefit. CVJ

1078 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Case Report Rapport de cas

Successful management of doxorubicin overdose and extravasation in a dog with lymphoma

Kristin S. Kicenuik, Nicole C. Northrup, Dawn M. Clarke, Lisa J. Bazzle

Abstract — A dog was hospitalized after accidental overdose and extravasation of doxorubicin. With supportive care and dexrazoxane, systemic toxicity resolved by Day 9 and extravasation injury by Day 36. This case demonstrates that, with treatment, dogs can survive doxorubicin overdose and extravasation. The report also highlights the importance of checking the dose of chemotherapeutic agents and preventing extravasation.

Résumé — Gestion réussie d’une surdose à la doxorubicine et de l’extravasation chez un chien atteint d’un lymphome. Un chien a été hospitalisé après une surdose accidentelle et l’extravasation de doxorubicine. Avec des soins de soutien et de la dexrazoxane, la toxicité systémique s’est résorbée au Jour 9 et la blessure d’extravasation au Jour 36. Ce cas démontre que, avec un traitement, les chiens peuvent survivre à une surdose de doxorubicine et à l’extravasation. Ce rapport souligne aussi l’importance de la vérification de la dose d’agents chimiothérapeutiques et de la prévention de l’extravasation. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1079–1084

13-year-old spayed female mixed breed dog weighing 14.5 kg ated with prednisone (Prednisone; West-Ward, Eatontown, A (body surface area: 0.59 m2) was presented to the University New Jersey, USA), 1.3 mg/kg body weight (BW), PO, of Georgia Veterinary Teaching Hospital (UGA-VTH) for man- q24h, and L-asparaginase (L-asparaginase; KRS Global agement of accidental overdose of doxorubicin (Doxorubicin; Biotechnology, Boca Raton, Florida, USA), 10 000 U/m2, Pfizer, New York, New York, USA), 30 mg, 51 mg/m2, and SC. Five days later, partial response was observed based on extravasation of an unknown quantity of doxorubicin. lymph node measurements (1). Chemotherapy was contin- Twenty-nine days before presentation, the dog was diag- ued with a single agent doxorubicin protocol (30 mg/m2, IV, nosed with multicentric large cell lymphoma with moder- q3wk). The dog was treated with an IV infusion of 18.6 mg of ate nonregenerative anemia, thrombocytopenia, and a doxorubicin diluted in 35 mL of 0.9% NaCl. Prednisone was monoclonal gammopathy. The diagnosis was based on decreased to 1 mg/kg BW, PO, q24h. Eight days after doxo- cytological evaluation of a lymph node aspirate and a nega- rubicin administration, the dog was lethargic and inappetent, tive enzyme-linked immunosorbent assay (ELISA) screen- with febrile neutropenia. Rectal temperature was 39.2C and ing test for vector-borne organisms (SNAP 4Dx Plus Test; grade 2 neutropenia [1080/L, reference range (RR): 2940 to IDEXX, Westbrook, Maine, USA). Treatment was initi- 12 570/L] was diagnosed. The dog was treated with IV fluids, amoxicillin trihydrate/clavulanate potassium (Clavamox; Zoetis, Kalamazoo, Michigan, USA) and enrofloxacin (Baytril; Bayer Department of Small Animal Medicine and Surgery, College Healthcare, Shawnee, Kansas, USA). of Veterinary Medicine, University of Georgia, Athens Georgia The primary care veterinarian re-examined the dog 23 d after 30602, USA. the first treatment with doxorubicin. Stable disease was noted Address all correspondence to Dr. Nicole Northrup; e-mail: on lymph node palpation. A complete blood (cell) count (CBC) [email protected] showed that the neutrophil count had returned to the normal Dr. Kicenuik’s current address is Hope Veterinary Specialists, range. A reduction in dosage of doxorubicin to 25 mg/m2 was 40 Three Tun Road, Malvern, Pennsylvania 19355, USA. planned because of the adverse events with the first dose. The Dr. Bazzle’s current address is Veterinary Specialty Hospital, dog weighed 14.5 kg (body surface area: 0.59 m2). Due to a 10435 Sorrento Valley Road, San Diego, California 92121, miscalculation of dosage involving conversion of weight to body USA. surface area based on body weight in lb instead of kg, 30 mg of Use of this article is limited to a single copy for personal study. doxorubicin (body surface area: 51 mg/m2) was administered. Anyone interested in obtaining reprints should contact the Doxorubicin was administered through a 22-guage IV cath- CVMA office ([email protected]) for additional eter in the right cephalic vein using an IV fluid pump. The dog copies or permission to use this material elsewhere. received simultaneous infusions of 0.9% NaCl at 20 mL/h and

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Table 1. Neutrophil and platelet counts following doxorubicin overdose (51 mg/m2; intended dose 25 mg/m2) in a dog with lymphoma. The dog was treated with filgrastim (rh-G-CSF) starting 24 h after the overdose. Neutrophil count Platelet count Days after overdose (cells/L)a (cells/L)b 0 10 212 346 000 1 4368 288 000 2 6400 302 000 4 357 266 000 5 15 187 000 6 84 93 000 7 1848 46 000 RAPPORTCAS DE 8 5467 57 000 9 10 746 121 000 13 8400 724 000

a Reference range: 2.9  103 to 12.0  103/L. b Reference range: 235  103 to 694  103/L.

doxorubicin at 5 mL/h (planned administration time 3 h). The administration site was examined every 5 to 10 min. At approximately 1.5 h into the infusion, subcutaneous swelling was noted proximal to the tape at the catheter site. The infusion was discontinued and the catheter was removed. A cold compress was applied to the area and the swelling lessened. The infusion was then completed using a 22-guage IV catheter in the left cephalic vein. The veterinarian contacted the Oncology Service at UGA-VTH upon recognizing the potential for extravasation of doxorubicin. At that time, the miscalculation was discovered. After discussion about the potential for life-threatening toxic- Figure 1. Right antebrachium 48 h after doxorubicin ity, the dog was transferred to UGA-VTH. Due to owner travel extravasation. There was mild erythema and a scab at the catheter site. time to the dog’s location and the distance from the primary hospital to the UGA-VTH, 10 h elapsed between the overdose and extravasation and the time of arrival at UGA-VTH. admission (11 h after extravasation) and repeated 24 and 48 h On examination, mild erythema and swelling were pres- later. The site was treated with cold compresses for 15 to 20 min ent on the right antebrachium. A CBC and serum chemistry every 6 h and topical dimethyl sulfoxide (DMSO) 90% solution showed anemia (30.4%, RR: 36.6% to 59.6%), normal platelet (DMSO 90% solution; Neogen, Tulsa, Oklahoma, USA), q8h. count (346  103/L, RR: 235 to 694  103/L), normal Serial monitoring of clinicopathologic data consisted of daily neutrophil count (10.2  103/L, RR: 2.9 to 12  103/L), evaluation of the packed cell volume and total solids (PCV/TS) hyperproteinemia (88 g/L, RR: 50 to 73 g/L), hyperglobu- and CBC and serum chemistry every 1 to 3 d (Table 1). linemia (58 g/L, RR: 27 to 44 g/L), and increases in alkaline The day after the overdose (Day 1), the dog developed diar- phosphatase (596 U/L, RR: 11 to 131 U/L) and alanine ami- rhea and decreased appetite. As significant adverse events were notransferase (269 U/L, RR: 9 to 105 U/L). The dog was hos- expected, trophic (trickle) feeding through a nasoesophageal pitalized for supportive therapy. A 7-French double lumen IV (NE) tube was initiated with a continuous rate infusion of catheter was placed in the right jugular vein to allow IV therapy a complete and balanced liquid diet (Clinicare; Zoetis) with and repeat blood sampling without repeated venipuncture. L-glutamine (L-glutamine; Spectrum Chemical Manufacturing Treatment consisted of Lactated Ringer’s solution (Lactated Company, Gardena, California, USA, compounded to Ringer’s Injection, USP; Baxter Healthcare, Deerfield, Illinois, 250 mg/mL) at 12 mL/kg BW per day. Ondansetron hydrochlo- USA) at 90 mL/kg BW, IV/d, maropitant citrate (Cerenia; ride (Ondansetron; Aurobindo Pharma, Hyderabad-500 090, Zoetis, Kalamazoo, Michigan, USA), 1 mg/kg BW, IV, q24h, India), 0.5 mg/kg BW, IV, q12h and metronidazole (Metronida pantoprazole (Protonix; Wyeth Pharmaceuticals, Philadelphia, zole; Unichem, Ghuziabad, India), 15 mg/kg BW, IV, q12h, Pennsylvania, USA), 1 mg/kg BW, IV, q12h, sucralfate were administered. Treatment with filgrastim [recombinant (Sucralfate; PLIVA Hrvatska, Teva, North Wales, Pennsylvania, human granulocyte colony stimulating factor (rhG-CSF); USA), 1 g, PO, q8h, and dexamethasone (Dexamethasone Neupogen; Amgen, Thousand Oaks, California, USA], 5 g/kg sodium phosphate; Dexaject SP, Bimeda-MTC Animal Health, BW, SC, q24h, was initiated 24 h after the overdose. Cambridge, Ontario) 0.034 mg/kg BW, IV, q24h. The dog was On Day 2, the dog’s right forelimb was erythematous (grade 2 fed a gastroenteric diet (Purina EN; St. Louis, Missouri, USA). infusion site reaction, Figure 1). On Day 3, gastrointestinal Dexrazoxane (Zinecard; Pfizer, New York, New York, USA), (GI) toxicity progressed to grade 3 with anorexia, regurgita- 300 mg/m2, IV, over 15 min, was administered within 1 h of tion (9 episodes in 13 h), and diarrhea (liquid stool passed

1080 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 3. Right thoracic limb 13 d after doxorubicin extravasation. The skin was diffusely thickened and corrugated, with erythema and desquamation.

Figure 2. Right thoracic limb at time of discharge from the hospital 9 d after doxorubicin extravasation. Diffuse erythema and a small spot of scale were present.

every 1 to 4 h). A constant rate infusion of metoclopramide hydrochloride (Metoclopramide; PLIVA Hrvatska, Teva, North Wales, Pennsylvania, USA), 1 mg/kg BW per day, was initiated and trophic feeding was discontinued. On day 4, regurgita- tion stopped. Grade 4 neutropenia (357 neutrophils/L, RR: 2.9 to 12  103/L, Table 1) and fever (39.6C) were identified. Ampicillin sulbactam (Ampicillin sulbactam; Sagent, Schaumburg, Illinois, USA), 22 mg/kg BW, IV, q8h, and enrofloxacin (Bayer Healthcare), 10 mg/kg BW, IV, q24h, were administered. On day 5, the neutrophil count dropped to 15 cells/L (Table 1). Figure 4. Right thoracic limb 22 d after doxorubicin On Day 6, feces were soft/formed and the dog ate gastro- extravasation. Erythema had resolved and skin texture was enteric diet. On Day 7, the dog’s temperature normalized. normal. Only mild scale and hyperpigmentation remained.

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Grade 3 thrombocytopenia (46  103 cells/L, Table 1) was Therapy aimed at mitigating GI toxicity was instituted as identified. On day 8, the neutrophil count was normal and quickly as possible following recognition that the dog herein filgrastim was discontinued. By day 9, the dog was eating and had received an overdose of doxorubicin. Treatment consisted drinking normally. Consequently, the dog was discharged with of intravenous fluids to prevent hypovolemia and/or dehydra- 3 days of omeprazole, sucralfate, metronidazole, maropitant, tion secondary to vomiting and diarrhea. Maropitant citrate, and enrofloxacin. Erythema at the extravasation site had spread an NK-1 antagonist, was administered to lessen the severity of proximally (Figure 2). nausea, vomiting, and diarrhea (10). Pantoprazole, a proton On Day 13, the dog had no gastrointestinal abnormalities pump inhibitor, was administered to increase gastric pH in an and lymph node measurements indicated a partial response. effort to facilitate healing of injured gastric epithelium (11). A CBC was normal. The skin over the right thoracic limb was Trophic feeding via a constant rate infusion through an NE tube diffusely erythematous, thick, and corrugated, with dry desqua- was initiated as soon as the dog’s appetite decreased because, in RAPPORTCAS DE mation (Figure 3). Application of cold compresses and topical humans, low volume enteral nutrition can prevent atrophy of DMSO was discontinued. On Day 22, the skin over the right GI mucosa-associated lymphoid tissues (MALT) and reduce the thoracic limb had returned to normal texture with only small risk of bacterial translocation and sepsis (12). The commercially areas of scale and erythema (Figure 4). The owner declined fur- available diet was supplemented with L-glutamine. Prophylactic ther chemotherapy. On Day 62, the dog was euthanized due to glutamine has trophic effects on GI epithelium, plays a role in progression of lymphoma. At the time of euthanasia, the owner support of MALT, and significantly decreases the duration of and primary care veterinarian reported that the skin of the right chemotherapy-induced diarrhea in humans (13). thoracic limb was normal. As the dog reported here experienced grade 2 neutropenia with fever after a standard dosage of doxorubicin, it was Discussion anticipated that profound neutropenia would develop follow- The case described here provides valuable experiential informa- ing the overdose. The American Society of Clinical Oncology tion supporting the survivability of a life-threatening medical 2013 guidelines recommend prophylactic use of hematopoietic error in dosing of doxorubicin compounded by extravasation colony-stimulating factors (CSFs) when the risk of febrile of doxorubicin, a complication associated with morbidity and neutropenia is  20% (14). Prophylactic granulocyte-colony- even potential mortality. Moreover, this case report highlights stimulating factor (G-CSF) in humans reduces the risk of febrile 2 important issues facing veterinarians administering cancer neutropenia, duration of antibiotic usage, duration of neutro- chemotherapeutics: the need to ensure correct calculation of the penia, and number of days of hospitalization (15,16). In dogs, dose and the need to prevent extravasation of chemotherapeutic use of G-CSF is limited by the lack of a canine-specific colony agents administered by the IV route. stimulating factor and the risk of formation of cross-reactive neu- An adverse event is defined as any unfavorable and unintended tralizing antibodies with recombinant human G-CSF (rh-G-CSF). clinical sign, clinicopathologic finding, or disease temporally In this setting of overdose, we believed the risk of short-term associated with the use of a medical treatment (2). The veterinary use was outweighed by the potential benefit. Consequently, literature is replete with information focused on GI and cardiac rh-G-CSF (filgrastim) was used starting 24 h after treatment adverse events associated with doxorubicin. Doxorubicin’s acute with doxorubicin as per the recommendation in humans. The dose-limiting toxicities in the dog include GI toxicity 2 to 5 d dog developed febrile neutropenia 4 d after overdose (earlier after treatment and neutropenia 7 to 10 d after treatment (3,4). than expected with standard doses of doxorubicin), with the Dose-related cumulative cardiotoxicity resulting in arrhythmias, neutrophil nadir at Day 5. Filgrastim was continued and the dilated cardiomyopathy, and congestive heart failure, is possible, neutrophil count returned to normal by Day 8. It is unknown typically at doses  180 to 240 mg/m2 (4,5). However, cardiac whether the nadir would have been more severe and of longer toxicity has been reported in dogs receiving as little as 60 mg/m2 of duration without filgrastim, but rh-G-CSF decreases the severity doxorubicin (5). Following the first cycle of doxorubicin at a stan- and duration of neutropenia in dogs treated with myelosup- dard dose, the dog presented here experienced febrile neutropenia. pressive radiation therapy (17) and recombinant canine G-CSF Worse toxicity was anticipated following the overdose. In humans, decreases the severity and duration of neutropenia in dogs with overdose of doxorubicin has been associated with severe myelo- parvovirus infection (18). suppression, mucositis, and GI toxicity (6). Normal dosages for At the time of extravasation, the veterinarian treating the dog doxorubicin as a single agent in humans are 60 to 75 mg/m2, IV. was unsure whether the swelling at the catheter site was related In 1991, a letter to the editor from a representative of Adria Labs to the tape securing the catheter or due to drug leakage. The (Columbus, Ohio) stated that 12 accidental doxorubicin overdoses infusion site reaction that followed was evidence of extravasa- of 3 to 10 times the planned dosage had been reported to Adria tion of an unknown amount of doxorubicin. Doxorubicin is Labs between 1977 and 1991. Five of the 12 patients died. These a potent vesicant, causing severe tissue ulceration and necrosis. patients received 150 to 333 mg/m2 of doxorubicin (7). Another Dexrazoxane is the most effective treatment for anthracycline report described a 57-year-old man and a 17-year-old girl who extravasation (16–26) and should be administered within 3 to 6 h survived doxorubicin doses of 300 mg/m2 and 436 mg/m2, after extravasation, followed by subsequent dosing 24 and 48 h

respectively (8). In dogs, the reported LD50 for doxorubicin is later (19–22). Doxorubicin extravasation was successfully treated 2.4 mg/kg BW (9). For a dog the size of the dog in this report in 3 dogs given 1 to 3 doses of dexrazoxane with the initial that would be 34.8 mg. dose administered within 2 h of extravasation (23). A fourth

1082 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY dog in that series, treated 48 h after extravasation, developed and resulted in discontinuation of treatment. This serves as a severe tissue necrosis necessitating limb amputation (23). In the reminder of the importance of careful dose calculation and present case, dexrazoxane was not administered until 11 h after close monitoring during drug delivery. extravasation. Despite this delay, tissue injury did not progress to ulceration or necrosis of the skin and underlying tissue. Acknowledgments

While speculative, it is possible that dexrazoxane administra- We thank the owner of this dog and the primary care veterinar- REPORT CASE tion delayed beyond the current recommended time of 3 to ians involved for providing case information to allow completion 6 h following extravasation still provided a therapeutic benefit. of this report. We also thank Dr. Marc Kent for his editorial Dexrazoxane may add to myelosuppression by cancer chemo- assistance with this manuscript. CVJ therapeutic agents (24), however, in dogs, the combination of doxorubicin and dexrazoxane appears to be well-tolerated with References signs of GI and hematologic toxicity being similar to those of 1. Vail DM, Michels GM, Khanna C, et al. Response evaluation criteria for doxorubicin alone (23,25). The use of DMSO with dexrazoxane peripheral nodal lymphoma in dogs (v1.0) — A Veterinary Cooperative Oncology Group (VCOG) consensus document. Vet Comp Oncol is controversial as there may be potential for decreased efficacy 2010;10:28–37. of dexrazoxane (26). The current recommendation in humans is 2. Veterinary Cooperative Oncology Group — Common terminology to avoid use of DMSO with dexrazoxane for extravasation (27). criteria for adverse events (VCOG-CTCAE) following chemotherapy or biological antineoplastic therapy in dogs and cats v1.1. Vet Comp Beyond the care of this individual dog, this case highlights Oncol 2016;14:417–446. the risk for serious medical errors with chemotherapy admin- 3. Vail DM. Supporting the veterinary cancer patient on chemo- istration. Medical errors are the third leading cause of death therapy: Neutropenia and GI toxicity. Top Companion Anim Med 2009;24:122–129. for Americans (28). An important type of medical error in the 4. Gustafson DL, Page RL. Cancer chemotherapy. In: Withrow SJ, Vail care of humans is dosing errors. While the incidence of medical DM, Page RL, eds. Withrow and MacEwen’s Small Animal Clinical errors in veterinary medicine is not reported, it is important Oncology. 5th ed. St. Louis, Missouri: Elsevier Saunders, 2013:167–168. 5. Mauldin GE, Fox PR, Patnaik AK, Bond BR, Mooney SC, Matus RE. to recognize that treatment with cancer chemotherapeutics Doxorubicin-induced cardiotoxicosis: Clinical features in 32 dogs. J Vet is associated with potential for serious harm. Veterinarians Intern Med 1992;6:82–88. using these drugs should have standard procedures in place to 6. Uner A, Ozet A, Arpaci F, Unsal D. Long-term clinical outcome after accidental overdose of multiple chemotherapy agents. Pharmacotherapy minimize the risk of errors, including prescribing errors, and to 2005;25:1011–1016. manage complications should they arise. Information on che- 7. Curran CR. Acute doxorubicin overdoses. Ann Intern Med 1991;115: motherapy administration is available in veterinary oncology 913–914. 8. Bäck H, Gustavsson A, Ecksbor S, Rödier S. Accidental doxorubicin textbooks (4) and guidelines are available in reputable journals overdosage. Acta Oncol 1995;34:533–536. (29,30). The American Society of Clinical Oncology (ASCO) 9. Lewis RJ, ed. Sax’s Dangerous Properties of Industrial Materials. 11th and the Oncology Nursing Society (ONS) have defined stan- ed. Hoboken, New Jersey: Wiley-Interscience, Wiley & Sons, 2004:88. 10. Rau SE, Barber LG, Burgess KE. Efficacy of maropitant in the preven- dards for the safe administration of chemotherapy for humans tion of delayed vomiting associated with administration of doxorubi- undergoing cancer treatment (31,32). These comprehensive cin to dogs. J Vet Intern Med 2010;24:1452–1457. standards include the prescription, preparation, and admin- 11. Tolbert MK, Odunayo A, Howell RS, Peters EE, Reed A. Efficacy of intravenous administration of combined acid suppressants in healthy istration of cancer chemotherapeutics by qualified personnel. dogs. J Vet Intern Med 2015;29:556–560. Independent verification of the proposed cancer chemothera- 12. Kudsk KA. Beneficial effect of enteral feeding. Gastrointest Endosc Clin peutic by a second person (either a clinician or other qualified North Am 2007;17:647–662. 13. Sun J, Wang H, Hu H. Glutamine for chemotherapy-induced diarrhea: personnel) confirming the correct drug, dosage, calculation A meta-analysis. Asia Pac J Clin Nut 2012;21:380–385. used for dosing the patient, route of administration, and rate 14. Smith TJ, Bohlke K, Lyman GH, et al. Recommendations for the use of administration will minimize medication errors. Guidelines of WBC growth factors: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2015;33:199–212. also have been established to lessen the risk of extravasation 15. Garcia-Carbonero R, Mayordomo JI, Tornamira MV, et al. Granulocyte by emphasizing the importance of appropriate vascular access colony-stimulating factor in the treatment of high-risk febrile neutrope- (adequate vein and proper catheter placement), continuous nia: A multicenter randomized trial. J Natl Cancer Inst 2001;93:31–38. 16. Rusthoven J, Bramwell V, Stephenson B. Use of granulocyte colony- monitoring of the catheter site at the beginning and through- stimulating factor (G-CSF) in patients receiving myelosuppressive che- out the infusion, having protocols in place for management motherapy for the treatment of cancer. Provincial Systemic Treatment of extravasation, and having antidotes readily accessible (32). Disease Site Group. Cancer Prev Control 1998;2:179–190. 17. Yu ZY, Li M, Han AR, et al. RhG-CSF improves radiation-induced While the primary veterinarian involved in this case did not myelosuppression and survival in the canine exposed to fission neutron have dexrazoxane available onsite, rapid recognition of the irradiation. J Radiat Res 2011;52:472–480. swelling at the catheter site enabled immediate actions that 18. Duffy A, Dow S, Ogilvie G, Rao S, Hackett T. Hematologic improvement in dogs with parvovirus infection treated with recombinant minimized the amount of extravasated drug and initiated canine granulocyte-colony stimulating factor. J Vet Pharmacol Ther transfer to a referral hospital. 2010;33:352–356. In summary, the dog in this report recovered from a life- 19. Langer SW. Dexrazoxane for the treatment of chemotherapy-related side effects. Cancer Manag Res 2014;915:357–363. threatening doxorubicin overdose without suffering potentially 20. Schulmeister L. Extravasation management: Clinical update. Semin severe infusion site reaction secondary to extravasation. With Oncol Nurs 2011;27:82–90. intensive management, survival is possible in cases of overdose 21. Kane RC, McGuinn WD Jr, Dagher R, Justice R, Pazdur R. Dexrazoxane (Totect): FDA review and approval for the treatment of and extravasation of doxorubicin. The dog experienced signifi- accidental extravasation following intravenous anthracycline chemo- cant adverse effects that negatively impacted her quality of life therapy. Oncologist 2008;13:445–450.

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22. Mouridsen HT, Langer SW, Buter J, et al. Treatment of anthracycline 28. Makary MA, Daniel M. Medical error — The third leading cause of extravasation with Savene (dexrazoxane): Results from two prospective death in the US. BMJ 2016;353:i2139. clinical multicentre studies. Ann Oncol 2007;18:546–550. 29. MacDonald V. Chemotherapy: Managing side effects and safe handling. 23. Venable RO, Saba CF, Endicott MM, Northrup NC. Dexrazoxane Can Vet J 2009;50:665–668. treatment of doxorubicin extravasation injury in four dogs. J Am Vet 30. Biller B, Berg J, Garrett L, et al. 2016 AAHA Oncology Guidelines for Med Assoc 2012;240:304–307. Dogs and Cats. J Am Anim Hosp Assoc 2016;52:181–204. 24. Plumb DC, ed. Plumb’s Veterinary Drug Handbook. 8th ed. Ames, 31. Neuss MN, Gilmore TR, Belderson KM, et al. Updated American Iowa: Wiley-Blackwell, 2015:419–420. Society of Clinical Oncology/Oncology Nursing Society chemotherapy 25. FitzPatrick WM, Dervisis NG, Kitchell BE. Safety of concurrent admin- administration safety standards, including standards for pediatric oncol- istration of dexrazoxane and doxorubicin in the canine cancer patient. ogy. Oncol Nurs Forum 2016;44:31–43. Vet Comp Oncol 2010;8:273–282. 32. Polovich M, White J, Kelleher L, eds. Chemotherapy and Biotherapy 26. Langer SW, Thougaard AV, Sehested M, Jensen PB. Treatment of anthra- Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh, cycline extravasation in mice with dexrazoxane with or without DMSO Pennsylvania: Oncology Nursing Society, 2005. and hydrocortisone. Cancer Chemother Pharmacol 2006;57:125–128.

RAPPORTCAS DE 27. Wengström Y, Margulies A. European oncology nursing society extravasation guidelines. Eur J Oncol Nurs 2008;12:357–361.

Answers to Quiz Corner Les réponses du test éclair

1. D) The correct answer is D, acantholytic cell. The other cells are 4. C) The best method of assessing the equine erythroid regen- not common or numerous findings on cytology or histopa- erative response is determination of bone marrow M:E ratio thology of pemphigus foliaceus. and/or bone marrow reticulocyte count. D) La bonne réponse est D, cellule acantholysée. Les autres cellules C) La meilleure méthode pour évaluer la réponse régénérative ne sont pas communes ou rencontrées en grand nombre à la érythroïde des équins est la détermination du rapport M : cytologie ou à l’histopathologie du pemphigus foliacé. E de la moelle osseuse et/ou la numération des réticulocytes de la moelle osseuse. 2. A) Seizures are caused by abnormal activity in the cerebral cortex. 5. C) Haemonchus contortus, a nematode parasite of sheep, is A) Les crises d’épilepsie sont causées par l’activité anormale du associated with blood loss anemia and hypoproteinemia. The cortex cérébral. granular black abomasal contents signify digested blood. C) Hæmonchus contortus, un nématode parasite du mouton, est 3. C) Stored whole blood is given along with plasma products to associé à l’anémie par perte de sang et à l’hypoprotéinémie. provide coagulation factors. Le contenu granulaire de couleur noire dans l’abomasum C) Du sang entier entreposé est administré avec du plasma pour indique du sang digéré. fournir les facteurs de coagulation.

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1084 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Case Report Rapport de cas

Urinary bladder herniation through inguinal ring in a female cat

Miranda de la Vega, Katy L. Townsend, Jesse Terry, Sarah Nemanic

Abstract — A 7-month-old spayed female domestic shorthair cat was referred for lethargy, stranguria, and a fluctuant mass of varying size in the right inguinal region. Computed tomographic imaging revealed the urinary bladder partially herniated through the right inguinal canal. Primary herniorrhaphy was performed and re-placement of the urinary bladder was confirmed via laparotomy.

Résumé — Herniation de la vessie urinaire par le trou inguinal chez une chatte. Une chatte domestique stérilisée âgée de 7 mois a été recommandée pour de l’abattement, de la strangurie et une masse fluctuante de taille variable dans la région inguinale droite. Une imagerie obtenue par tomodensitométrie a révélé une vessie urinaire partiellement herniée dans le canal inguinal droit. Une herniographie primaire a été réalisée et le replacement de la vessie urinaire a été confirmé via laparotomie. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1085–1088

he inguinal canal is an opening in the abdominal wall hernias. Direct inguinal hernias occur when tissues or organs T extending between internal and external inguinal rings. pass through the inguinal rings adjacent to the normal evagina- The internal ring is bounded medially by the rectus abdominis tion of the vaginal process (5). muscle, cranially by the caudal edge of the internal abdominal Inguinal hernias can be congenital or acquired. Congenital oblique muscle and laterally by the inguinal ligament. The exter- inguinal hernias may occur more often in male dogs because nal ring is a longitudinal slit in the aponeurosis of the external of delayed inguinal canal narrowing from testicular descent abdominal oblique (1). Structures coursing through the inguinal and may spontaneously resolve by 12 wk of age when the rela- canal in both sexes include the genitofemoral nerve, artery and tive size of the inguinal rings decreases (5,6). In cats, there is vein, and external pudendal vessels. The vaginal process also a reported 0.02% to 0.025% incidence of congenital inguinal passes through the opening in dogs; it contains the spermatic hernias with no breed or gender predilection as described in cord in males or the round ligament in females (2). In a study dogs (7,8). Previous reports of inguinal hernias in cats have had involving 10 cats, in contrast with dogs, the vaginal process was a male predispostition (7–9). This reports describes a presumed not identified within the inguinal canal (3). congenital urinary bladder herniation through the inguinal ring Inguinal hernias occur when there is a defect in the inguinal in a female cat. ring through which abdominal contents protrude (4). Indirect inguinal hernias are the most common and are characterized by Case description tissues that herniate into the vaginal tunic in males and vaginal A 7-month-old spayed female domestic shorthair cat was process in females. Indirect hernias in males are called scrotal referred because of a 4-day history of lethargy, stranguria, and a fluctuant mass in the right inguinal region that varied in size Department of Clinical Sciences, Oregon State University, according to reports from the owner and referring veterinarian. 172 Magruder Hall, Corvallis, Oregon 97331, USA. The cat had been adopted 1 mo earlier with no history of illness or traumatic injury. On the day before presentation, the Address all correspondence to Dr. Katy Townsend; e-mail: referring veterinarian took a single caudal lateral abdominal [email protected] radiograph. On this image, the urinary bladder was not identi- Dr. de la Vega’s current address is Gulf Coast Veterinary fied in the caudoventral abdomen, instead, fat opacity was seen Specialists, 3800 Southwest Freeway, Suite 136, Houston, ventral to the descending colon and dorsal to a moderately Texas 77027, USA. thickened ventral body wall (Figure 1). In addition, there was Dr. Terry’s current address is WestVet Utah, 2465 N. Main an ovoid soft tissue opaque mass effect silhouetting with the Street, Suite 5, Sunset, Utah 84015, USA. thigh musculature and summating with the ventral abdominal Use of this article is limited to a single copy for personal study. fat that was presumed to be the bladder. Urinalysis obtained via Anyone interested in obtaining reprints should contact the cystocentesis of the fluctuant mass was unremarkable. CVMA office ([email protected]) for additional Upon presentation to Oregon State University, physical copies or permission to use this material elsewhere. examination revealed the cat was bright, alert, and responsive.

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Figure 1. A lateral abdominal radiograph shows an ovoid soft tissue opaque mass effect silhouetting with the thigh musculature and summating with the ventral abdominal fat, presumed to be the bladder (white arrows). The urinary bladder was not identified in the caudoventral abdomen, instead, fat opacity was seen ventral to the descending colon and dorsal to a moderately thickened ventral body wall (black arrow).

Palpation revealed an 8 cm 3 4 cm firm, smooth continuous structure that tapered towards the inguinal canal. Results of a complete blood cell count and biochemical profile were unremarkable. The cat was placed under general anesthesia for computed tomography (CT) imaging directly followed by surgery. She was premedicated with hydromorphone (West-Ward, Eatontown, New Jersey, USA), 0.1 mg/kg body weight (BW), IM, and Figure 2. Computed tomography scan (5-mm maximum acepromazine (VetOne, Boise, Idaho, USA), 0.1 mg/kg BW, intensity projection image, dorsal plane mid-abdomen, soft IM; anesthesia was induced with propofol (PropoFlo; Zoetis, tissue algorithm, 8-minute post-contrast; W 320, L 40) showing the bladder partially herniated through the right inguinal ring. Parsippany, New Jersey, USA), 6 mg/kg BW, IV. Anesthesia was The arrows show the ureters entering the bladder at a normal maintained with isoflurane in 100% oxygen. Fentanyl (West- location. Ward) continuous rate infusion (CRI) at 0.3 to 0.5 mg/kg BW per minute was given for analgesia. Prophylactic antibiotic administration (cefazolin; Fresnius Kabi USA, Lake Zurich, (Figures 2, 3). The urinary bladder neck was positioned to the Illinois, USA), 22 mg/kg BW, IV, was given in the periopera- right of the right rectus abdominus muscle and exited the peri- tive period. toneal cavity ventral to the external iliac artery and vein, within An abdominal CT-scan was taken on a 64 detector CT scan- the right inguinal ring. The right rectus abdominus muscle was ner (Toshiba Acquilion; Canon Medical Systems, Otawara, decreased in width but increased in height, being approximately Tochigi, Japan) before and after IV injection of iodinated the same cross-sectional area as the left. Both ureters entered contrast medium (2 mL/kg of Iopamidol — Omipaque; the trigone of the urinary bladder at a normal position and the GE Healthcare, Waukesha, Wisconsin, USA). Following con- urethra exited the cranially directed trigone and turned 180° trast medium administration, CT images were acquired in a from cranial to caudal in the abdomen (Figure 4). Caudal to this venous vascular phase and an 8-minute post-contrast medium turn, the location and path of the urethra was normal within the phase. Images were acquired as a volume and 0.5-mm volume pelvic inlet and perineal tissues. The ureters were not dilated. No images were reconstructed in bone and soft tissue algorithms fractures were seen, and the fat surrounding the caudal abdomen with a 0.5-mm reconstruction interval as isotropic voxels with was normal in attenuation. both 3-mm and 1-mm slice thickness in transverse, sagittal, A caudal ventral midline incision was used to expose the and dorsal planes. For image acquisition, the following set- herniated urinary bladder. The urinary bladder was herniated tings were used: rotation speed 0.6 s; helical pitch of 0.53, through the right inguinal canal, confirming a direct inguinal matrix 512 3 512; current 300 mA and voltage peak 120 kV. hernia. The urinary bladder was partially emptied by cystocen- On CT images, the urinary bladder was malpositioned tesis (Figure 5), and gentle digital pressure was used to replace with the trigone located cranially at the level of the sacrum the urinary bladder into the abdomen. The urinary bladder and the apex located caudally at the level of the 7th coccygeal appeared grossly normal, without evidence of thickening, hem- vertebra, within the inguinal fat ventral to the gracilis muscle orrhage, or bruising. The external inguinal ring was measured to

1086 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 3. Computed tomography 15-mm maximum intensity projection image (sagittal plane, parasagittal plane, 8-minute post-contrast, soft tissue algorithm, W 400, L 40) showing the bladder is partially herniated through the inguinal ring. The arrow shows the right ureter entering the urinary bladder at a normal location. Note the contrast medium in the bladder.

Figure 5. Intraoperative view of the urinary bladder after caudal ventral midline incision. Cranial is to the right of the photograph. The bladder is herniated through the inguinal ring and cystocentesis is used to empty the bladder.

Figure 6. Intraoperative view of the enlarged inguinal ring after the bladder has been reduced into the peritoneal cavity. Note that the cotton tipped applicator is within the peritoneal cavity, through the inguinal ring. Figure 4. Computed tomography image of the urethra (oblique dorsal plane, 8-minute post-contrast, soft tissue algorithm, W 400, L 40) showing the 180° turn of the urethra (black arrow) then transitioned to 0.02 mg/kg BW buprenorphine (Par from the trigone of the urinary bladder (white arrow) to a midline Pharmaceuticals, Chestnut Ridge, New York, USA) transmuco- position in the pelvic inlet, between the left pubic bone and right pubic bone (dark gray arrow) and to the right of the descending sally every 8 h the following day. One day after surgery, the cat colon (light gray arrow). was bright, alert, eating well, and urinating normally without evidence of stranguria or grossly detected hematuria. The cat was be 2.5 cm at the largest diameter, and it was difficult to identify presented 2 wk later for suture removal, and physical examina- the internal inguinal ring (Figure 6). The linea alba was incised, tion revealed a healed surgical incision with subcutaneous suture and the bladder was retroflexed to visualize the ureters and con- reaction and normal urination. She was lost to follow-up after firm correct placement. The left external and internal inguinal recheck at 2 wk. rings appeared grossly normal. The right external inguinal ring was closed with 2-0 polydioxanone (PDS; Ethicon/Johnson & Discussion Johnson, Bridgewater, New Jersey, USA) in a simple interrupted A non-strangulating, direct, unilateral inguinal herniation of the pattern. The linea alba was closed with 2-0 PDS in a simple urinary bladder in a female cat is described. The urinary bladder continuous pattern. The subcutaneous layer was closed with herniated through the right inguinal canal and varied in size 4-0 poliglecaprone (Monocryl; Ethicon/Johnson & Johnson) based on voiding of urine, but was never completely reduced. in a simple continuous pattern. The skin was apposed with It is unclear if the urinary bladder had previously herniated 4-0 Monocryl in a continuous intradermal pattern, and the and reduced prior to adoption as there was no medical history skin was closed with 4-0 nylon (Ethilon; Ethicon/Johnson & from the shelter. There was also no evidence of trauma, such as Johnson) in a simple continuous pattern. hemorrhage, and no gross changes were seen during surgery to Post-operative analgesia was maintained with a fentanyl suggest chronicity, such as adhesions or bladder wall thicken- CRI (2 to 5 mg/kg BW per hour) the night of surgery and ing or hemorrhage. Although the left inguinal canal appeared

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grossly normal and not enlarged at surgery, due to the young age Herniorrhaphy can be performed extra- or intra-abdominally, of the cat and lack of hormonal complications such as estrus, although extra-abdominal herniorrhaphy is more common pregnancy, intact status, or metabolic complications such as (12). Based on the presentation in this case, herniorrhaphy was nutritional disorders or obesity, we believe that a congenital extra-abdominal, and a caudal midline laparotomy confirmed origin of the hernia is most likely. correct placement of the bladder and ensured no torsion or To the authors’ knowledge, this is the first report of a pre- malplacement. In a previous case report with this condition in sumptive congenital inguinal hernia containing the bladder in a male cat, a cystopexy was conducted (9). A cystopexy was not a female cat. There is a report of urinary bladder herniation conducted after the bladder was repositioned in the abdominal through a congenitally enlarged inguinal canal in a male cat and cavity, as the surgeon did not suspect that the bladder would the authors proposed a predisposition in male cats due to tes- reherniate after primary repair of the defect. Hernia recurrence ticular descent through the inguinal canal (9). Other reports of is a known complication in inguinal hernia repair in dogs and RAPPORTCAS DE cats with inguinal hernias have a male predilection (7–9). This thought to occur in less than 3% in 1 case series (5). is the first report in which CT was used to diagnose an inguinal Congenital inguinal hernias in cats are rare, especially involv- hernia in a feline patient; this enabled 3-dimensional imaging of ing herniation of the bladder. This report describes a successful this rare defect in a cat. Ultrasound could also have been used surgical repair of a presumed congenital inguinal hernia involv- for diagnosis if CT had not been available, but would have given ing the bladder in a female cat. A differential diagnosis of an less complete information about the path and size of the ureters, inguinal hernia with bladder involvement should be considered because they were not enlarged, and the pelvic urethra, because when fluctuant masses are palpated in the inguinal region in of acoustic shadowing from the pelvic bones (10). young cats. Primary repair of the hernia provided a return to Due to anatomical differences, only direct herniation is normal urination. CVJ possible in female cats. A cadaveric study of 10 embalmed References female cats failed to identify a vaginal ring or process within . 1 Tobias KM, Johnston SA. Veterinary Surgery Small Animal. 1st ed. the inguinal canal; the only structure identified was the round St. Louis, Missouri: Elsevier Saunders, 2012. ligament of the uterus, which entered the inguinal canal and 2. Evans HE, de Lahunta A. Miller’s Anatomy of the Dog. 4th ed. transitioned into fascia just beyond the external inguinal ring St. Louis, Missouri: Elsevier Saunders, 2013:228. 3. Watson A. Vaginal ring and round ligament of the uterus in the female (3). The inguinal canal has been measured in 10 cats and was cat. Anat Hist Embryol 2009;38:319–320. found to be 5 mm in diameter (9). It is unknown whether these 4. Parks J. Herniation. In: Bojrab MJ, ed. Pathophysiology in Small Animal cats were male or female. The diameter of the inguinal ring in Surgery. Philadelphia, Pennsylvania: Lea and Febinger, 1981. 5. Waters DJ, Roy RG, Stone EA. A retrospective study of inguinal hernia the cat herein was 5 mm 3 17 mm 3 22 mm on CT, which is in 35 dogs. Vet Surg 1993;22:44–49. much larger than the reported normal size. 6. Fox MW. Inherited inguinal hernia and midline defects in the dog. J Am Inguinal herniation in dogs has been described with possible Vet Med Assoc 1963;143:602–604. 7. Priester WA, Glass AG, Waggoner NS. Congenital defects in domesticated contents including fat and omentum most commonly as well animals: General considerations. Am J Vet Res 1970;31:1871–1879. as small intestine, colon, bladder, spleen, uterus, and ovary. 8. Hayes HM. Congenital umbilical and inguinal hernias in cattle, horses, The left side is more commonly affected in female dogs (11). swine, dogs, and cats: Risk by breed and sex among hospital patients. Am J Vet Res 1974;35:839–842. Inguinal hernia contents have only recently been reported in 9. Zulauf D, Voss K, Reichler M. Herniation of the urinary bladder cats (9). through a congenitally enlarged inguinal canal in a cat. Schweiz Arch Several surgical approaches, termed herniorrhaphy, have Tierheilkd 2007;149:559–562. 10. Lamb CR. Ultrasonography of the ureters. Vet Clin North Am Small been described to correct inguinal hernias. Uncomplicated Anim Pract 1998;28:823–848. unilateral inguinal hernias can be approached over the ingui- 11. Bellenger CR. Inguinal and scrotal herniation in 61 dogs. Aust Vet Pract nal rings, whereas complicated inguinal hernias, such as those 1996;26:58–59. 12. Smeak D. Abdominal hernias. In: Slatter D, Saunders WB, eds. involving strangulation or concurrent abdominal trauma, are Textbook of Small Animal Surgery. 3rd ed. Vol 1. Philadelphia, approached through ventral midline laparotomy for exploration. Pennsylvania: Saunders, 2003:452–455.

1088 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Case Report Rapport de cas

Radiotherapy and pasireotide treatment of a growth hormone producing pituitary tumor in a diabetic dog

Francesco Zublena, Alice Tamborini, Carmel T. Mooney, Susan M. North, Monika A. Lobacz, Dan Andrew, Vanessa Woolhead, Heather Covey, Herbert A. Schmid, David B. Church, Stijn J.M. Niessen

Abstract — An 8-year-old castrated male border terrier dog was diagnosed with acromegaly resulting from a growth hormone secreting pituitary tumor. Sixteen daily fractions of radiation therapy were delivered followed, approximately 1 year later, by administration of pasireotide. The aforementioned treatment was considered effective and should be further evaluated in similar cases.

Résumé — Radiothérapie et traitement au pasiréotide pour une tumeur pituitaire produisant une hormone de croissance chez un chien diabétique. Un chien Terrier-Border castré âgé de 8 ans a été diagnostiqué avec de l’acromégalie découlant d’une tumeur pituitaire secrétant une hormone de croissance. Seize fractions quotidiennes de radiothérapie ont été administrées et ont été suivies, environ un an plus tard, de l’administration du pasiréotide. Le traitement précédemment mentionné a été considéré efficace et devrait être étudié de plus près dans des cas similaires. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1089–1093

Case description dexamethasone suppression test results within their reference intervals. Measurement of total thyroxine (TT4) was included in n 8-year-old castrated male border terrier dog was pre- the comprehensive biochemistry panel and hypothyroidism was sented to the primary veterinary surgeon for investi- A suspected because of a low TT4 concentration [, 3.0 nmol/L, gation of polyuria and polydipsia (PU/PD), lethargy, and reference interval (RI): 13.5 to 50 nmol/L]. Treatment with polyphagia of 8-weeks’ duration. Based on breed, age, and porcine insulin (Caninsulin; MSD Animal Health, Intervet, history, tests for both diabetes mellitus (DM) and hyperadre- Milton Keynes, UK), 0.25 IU/kg body weight (BW), SC, nocorticism were carried out. The former was diagnosed based q12h, and levothyroxine (Soloxine; Virbac Animal Health, Fort on persistent hyperglycemia (. 15 mmol/L) and glycosuria. Worth, Texas, USA), 30 mg/kg BW, PO, q24h, was initiated. Hyperadrenocorticism was considered unlikely based on adre- Eight weeks later, while the DM was apparently adequately nocorticotropin hormone (ACTH) stimulation and low dose controlled (as suggested by a 24-hour blood glucose curve), PU/PD, polyphagia, and lethargy persisted. Serum insulin-like Southfields Veterinary Specialists, formerly VRCC, growth factor 1 (IGF-1) concentration was evaluated and found Laindon, United Kingdom (Zublena, Tamborini, North, to be 1234 ng/mL (radioimmunoassay employing a human Lobacz); SeersCroft, North Norsham, United Kingdom anti-IGF-1 antibody validated for use in the dog; NationWide (Andrew); University Veterinary Hospital, Dublin, Ireland Specialist Laboratories, Sawston, UK), which prompted referral. (Mooney); Department of Clinical Science and Services, The At the time of referral, the skin around the head and neck Royal Veterinary College, Herts, United Kingdom (Woolhead, was noted to be thick and redundant, and the head appeared Covey, Church, Niessen); Novartis Institutes for BioMedical proportionally bigger than the rest of the body (Figure 1). There Research, Oncology Research, Novartis Pharma AG, Basel, were widened interdental spaces and macroglossia (Figure 1) Switzerland (Schmid). with obvious intermittent stertor. Address all correspondence to Dr. Alice Tamborini; e-mail: Urinalysis revealed isosthenuria (SG, 1.010 with no gly- [email protected] cosuria). Measurement of TT4 (45.8 nmol/L), canine thy- Conflict of interest declaration: Dr. Herbert A. Schmid is roid stimulating hormone (cTSH; , 0.03 ng/mL, reference employed by Novartis Pharma AG, Basel which manufactures value: , 0.6 ng/mL) 4 h after treatment, and fructosamine and markets pasireotide for the treatment of hyperadrenocorti- (345 mmol/L, RI: 300 to 450 mmol/L) suggested effective cism and hypersomatotropism in humans. treatment for DM and the previously assumed hypothyroid- Use of this article is limited to a single copy for personal study. ism. Given that there was no evidence of endogenous proges- Anyone interested in obtaining reprints should contact the terone production or exogenous progestagen administration, a CVMA office ([email protected]) for additional growth hormone (GH)-secreting pituitary macroadenoma was copies or permission to use this material elsewhere. suspected. The lethargy and polyphagia potentially could be

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Figure 1. The dog at presentation. The head appeared proportionally bigger than the rest of the body. Widened interdental spaces and macroglossia were also evident.

explained by a pituitary mass and the anabolic state induced A B by GH excess, respectively. The cause of the persistent PU/PD, despite effectively controlled diabetes mellitus, remained unclear but partial diabetes insipidus could not be ruled out. A helical computed tomography (CT) scan (SOMATOM Spirit, 2-slice; Siemens AG, Camberley, UK) of the skull was performed under general anesthesia and reconstructed in soft tissue and bone windows. It confirmed the presence of an oval, slightly irregularly shaped, 0.9 cm high 3 1.3 cm wide 3 0.9 cm long, soft tissue attenuating (61 HU), well-defined mass-like lesion in the region of the pituitary fossa (Figure 2A). Manual Figure 2. Transverse CT image reconstructed in soft tissue administration of intravenous contrast medium 2 mL/kg window at the level of the pituitary fossa. A — before contrast iohexol (Omnipaque 300 mg I/mL; GE Healthcare, Princeton, injection, well-defined large pituitary gland mass (white arrow) is visible. B — after contrast injection image with well-defined New Jersey, USA) demonstrated moderate contrast enhance- contrast uptaking mass (white arrow) and distorted pituitary ment (74 HU post-contrast) with visible pituitary flush mildly flush at the base to the left. displaced laterally to the left (Figure 2B). A definitive radiation protocol (RT) was started using a 6 MV administration was reduced in a stepwise manner to 0.05 IU/kg linear accelerator (CLINAC 600c; Varian Medical Systems, Palo BW, q12h over a 10-week period and then stopped in light of Alto, California, USA); a total dose of 48 Gy (4800 cGy) was persistent euglycemia, absent glycosuria, and fructosamine con- delivered at 3 Gy (300 cGy)/fraction on a Monday to Friday centration (292 mmol/L) within the reference interval. schedule basis for 16 fractions. The patient was anesthetised Sixteen weeks after RT, fructosamine concentration remained and positioned in ventral recumbency with the beam centered within reference interval (244 mmol/L), whereas TT4, 4 h after on the pituitary gland. The total dose was delivered in 4 field treatment, increased to 68.0 nmol/L. The dose of levothyroxine blocks. The radiation protocol was well tolerated and no side was decreased to 20 mg/kg BW, PO, q24h and 2 mo later to effects were noted. 10 mg/kg BW, PO, q24h. Two and half weeks after RT, mental status and lethargy had Thirty-eight weeks after RT, TT4 (4 h after treatment) and improved. TT4 (38.2 nmol/L) and cTSH (, 0.03 ng/mL), 4 h IGF-1 concentrations were 29.7 nmol/L and 1223 ng/mL, respec- after treatment, were within their reference intervals. A 24-hour tively. No glycosuria was noticed on dipstick. Levothyroxine blood glucose curve (measurements q2h) showed blood glucose administration was discontinued. In light of the reported return concentrations ranging from 4.1 to 7.9 mmol/L. Urinalysis of some clinical signs of particular concern to the owner, mainly revealed a specific gravity of 1.031 with no glycosuria. Insulin PU/PD (no SG available) and lethargy despite absence of DM,

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Table 1. Insulin-like growth factor 1 (IGF-1), total thyroxine (TT4), thyroid stimulating hormone (TSH), blood glucose (BG), glucosuria, fructosamine values, and BW (body weight) before and after treatment of the dog with the growth hormone secreting pituitary tumor. TT4 13.5 to TSH BG Glucosuria Fructosamine BW IGF-1 50 nmol/L , 0.6 ng/mL mmol/L Y/N mmol/L (kg) CASE REPORT CASE T0 — , 3 — . 15 Y — n/a T0 1 8 wk 1234 n/a T0 1 11 wk 45.8 , 0.03 — N 345 15.3 Radiotherapy start (R) — — — — — — 15.2 R 1 2.5 wk — 38.2 , 0.03 4.1 to 7.9 N 292 14.3 R 1 16 wk — 68 , 0.03 — N 244 n/a R 1 38 wk (2015) 1223 29.7 — — N — n/a R 1 50 wk 1210 — — — N 288 n/a R 1 62 wk — 13.1a 0.13b — — — n/a Pasireotide start (P) 1120 — — — — 310 15.2 P 1 4 wk 137 — — — — 222 n/a P 1 10 wk 144 — — — — 178 n/a P 1 16 wk 168 13.1 0.13 — — 249 n/a P 1 24 wk 187 — — — — — 14.85

The black and white arrows represent withdrawal of the insulin and levothyroxine administration, respectively. n/a — Not available. a Reference interval: 13 to 52 nmol/L. b Reference value , 0.41 ng/mL.

the PU/PD, increased activity, gradual disappearance of the soft tissue changes, and complete normalization of the skin of the head and neck. There was also a decrease in weight and size of the abdomen. The disproportionate appearance of the head persisted (Figure 3). No adverse effects were noted. Five months after the last levothyroxine administration, TT4 (13.1 nmol/L, RI: 13 to 52 nmol/L) and cTSH (0.13 ng/mL, reference value: , 0.41 ng/mL) were within their reference intervals. Discussion This report describes a GH-secreting pituitary macroadenoma Figure 3. The dog after 4 months of pasireotide treatment. The disproportionate appearance of the head persisted. in a dog with concurrent DM, which is thought to be a rare condition. The report also details the first documented use of RT and pasireotide treatment for this condition with consequent as well as the persistent soft tissue changes and elevated IGF-1 remission of DM, decrease in serum IGF-1 concentration, and concentrations, ongoing clinically relevant hypersomatotropism reversal of some of the acromegaly-associated soft tissue changes. was suspected. Therefore, hypophysectomy or treatment with Acromegaly is an endocrine disorder caused by excessive the novel somatostatin analog pasireotide (Signifor; Novartis secretion of GH, resulting in soft tissue, viscera, and bone Pharmaceuticals, Basel, Switzerland) was offered. The client overgrowth as well as insulin-resistance (1–3). Most affected opted for the latter. The dog was hospitalized and had IGF-1 cats and humans have a functional somatotroph adenoma in the measured on day 1, received subcutaneous injections q12h anterior pituitary gland that results in excessive GH production with short-acting pasireotide (0.03 mg/kg BW) on days 2 to 4, (3–5). In dogs, GH excess is usually associated with prolonged followed by repeat measurement of IGF-1 on day 5. During exposure to exogenous or endogenous progesterone that in turn this time, the IGF-1 concentration dropped from 1120 ng/mL stimulates GH hypersecretion from mammary tissue (3,6–9). To (day 1) to 536 ng/mL (day 5). The dog was discharged after the authors’ knowledge, only 2 cases of suspected and 1 of con- a subcutaneous injection of long-acting pasireotide (8 mg/kg firmed acromegaly due to a pituitary adenoma in dogs have been BW) with a view to repeating the treatment every 4 wk, whilst described and it is therefore considered a rare entity (10,11). gradually increasing the injection interval to establish the mini- In all species, including the dog, clinical signs result from mum injection frequency. The results are presented in Table 1. the combined catabolic effects of excess GH and the anabolic Serum IGF-1 remained markedly decreased compared to initial effects of GH-induced IGF-1 on soft tissue, viscera, and bone values. Concurrently, the owner reported a disappearance of (1–3). Thus unsurprisingly, enlargement of the head, widened

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interdental spaces, excess skin folds, and hypertrophy of the the case presented here was to achieve tumor size reduction and soft tissues of the head and neck (associated with stertor) were control the paraneoplastic effects, with minimal injury to sur- observed in the dog of the present case report. Polyuria and rounding healthy tissues (25). The remission of DM could be polydipsia were also evident and thought to result from the suggestive of declining GH concentrations and an effect of RT development of DM. In affected cats and humans, excess GH on tumor size. Previous reports of canine pituitary adenomas secretion is frequently associated with insulin resistance and treated with RT demonstrated improvement of clinical signs development of overt DM (1,3,12,13). Following RT, remission and some control of the disease, as in the dog described here of DM was evident, likely due to improvement of GH-induced (25–30). insulin resistance, although spontaneous remission enabled by A follow-up IGF-1 concentration remained elevated, 10 mo the start of exogenous insulin (and thus reduction of glucotoxic- after the last RT treatment. This is not surprising, as in most ity and endogenous demand) is also possible. The IGF-1 did, RT-treated acromegalic cats and humans, persistently high RAPPORTCAS DE however, not normalize and the soft tissue changes progressed IGF-1 concentrations are found. It is speculated that RT is in concordance with persistent elevation of IGF-1. Additionally, capable of only decreasing GH production to a limited extent continued polyphagia (with weight gain), was hypothesized to be sufficient to achieve remission of DM but without complete directly a result of persistent GH excess (3). In this case, despite reversal of all clinical signs as in the dog of this report. This remission of DM, the PU/PD recurred and it was speculated to has been well-demonstrated in acromegalic diabetic cats in result from mechanisms other than overt DM such as transient which DM improves or resolves despite persistently high diabetes insipidus, as described previously in diestrus-induced IGF-1 concentrations after RT treatment (31–35). As a con- acromegaly in dogs (14). Alternatively, possible diabetes insipi- sequence, hypophysectomy may be a preferred treatment for dus and the ongoing lethargy observed could have been associ- most acromegalic humans and cats but was not initially chosen ated with an expanding pituitary tumor. Unfortunately, because for this case. of financial constraints, a repeat CT-scan was not performed to Pasireotide is a novel multireceptor-targeted somatostatin investigate such a possibility. The subsequent improvement in (SST) analog with high binding affinity for SST receptor sub- demeanor on pasireotide treatment may have been related to a types 1, 2, 3 [SST(1,2,3)] and 5 [SST(5)]. Its use resulted in decrease in tumor size, as is reported occasionally in humans a significant and rapid decrease in serum IGF-1 concentration treated with this drug (15). within a matter of days together with more long-term reversal A diagnosis of acromegaly relies on demonstrating excess of many of the clinical signs of GH excess without any adverse circulating GH and/or IGF-1 concentrations. The latter is effects. The fact that all clinical signs did not resolve completely preferred as the assays are more widely available and IGF-1 in this dog is not unexpected as bony changes (contributing to concentration is much less prone to fluctuations (3,16). In this the disproportionate head size) are known to persist in previ- dog, increased circulating IGF-1 concentration in the absence ously acromegalic dogs (14). Pasireotide has also been shown to of progesterone/progestagen stimulation prompted CT imag- be effective in humans with hyperadrenocorticism and hyperso- ing of the pituitary gland (1,3,17,18). Hypothyroidism can matotropism, dogs with pituitary-dependent hyperadrenocorti- lead to changes in pituitary gland size, the pulsatile secretion cism, and cats with hypersomatotropism (36–38). This is the pattern of GH and to increased plasma IGF-1 concentrations; first report of an acromegalic dog being treated with pasireotide. thus elevated IGF-1 concentration in the presence of pituitary Finally, this case report suggests that, although pituitary enlargement is possible in dogs affected by either acromegaly tumor-derived GH excess in male dogs might be rare, the con- or hypothyroidism (19–22). In hypothyroidism, the pituitary dition should be considered as a possible differential diagnosis gland potentially enlarges because of transdifferentiation of in cases with physical examination signs compatible with acro- somatotropic pituitary cells to thyrosomatotropic cells (20,22). megaly. Optimal treatment in dogs with acromegaly resulting However, in this dog, the presence of a large oval-shaped soft from a GH-secreting pituitary tumor has not been standardized tissue attenuating lesion in the region of the pituitary fossa and various options are available subject to accessibility and despite confirmation of euthyroidism was more suggestive of a affordability. CVJ GH-secreting pituitary neoplasm rather than hypothyroidism- associated pituitary gland hyperplasia. It was thought that the References initial diagnosis of hypothyroidism was incorrect and that the . 1 Kooistra HS. Acromegaly and pituitary dwarfism. Ettinger and Feldman low TT4 value at that time was reflective of the non-thyroidal Textbook of Veterinary Internal Medicine. 6th ed. St. Louis, Missouri: illness syndrome rather than hypothyroidism per se. Indeed, Saunders, 2004:1498–1502. the persistence of clinical signs and high IGF-1 concentrations 2. Niessen SJM, Peterson ME, Church DB. Acromegaly. BSAVA Manual of Canine and Feline Endocrinology. 4th ed. Quedgeley, Gloucester, whilst on thyroxine supplementation and their reversal whilst UK: BSAVA Publications, 2012:35–42. on pasireotide treatment and off levothyroxine supplementation 3. Reusch CE. Disorders of growth hormone. Canine and Feline supports the diagnosis of a GH-secreting pituitary tumor rather Endocrinology. 4th ed. St. Louis, Missouri: Elsevier, 2015:56–76. 4. Nelson RW. Feline acromegaly. Nelson and Couto’s Small Animal than any association with hypothyroidism. Internal Medicine. 4th ed. St. Louis, Missouri: Elsevier, 2009:706–714. In dogs, both surgical transsphenoidal hypophysectomy 5. Niessen SJ, Petrie G, Gaudiano F, et al. Feline acromegaly: An under- and RT have been reported as treatment options for various diagnosed endocrinopathy? J Vet Intern Med 2007;21:899–905. 6. Selman PJ, Mol JA, Rutterman GR, van Garderen E, Rijnberk A. pituitary tumors, but there are no reports of the effect of RT Progestin-induced growth hormone excess in the dog originates in the on GH-secreting pituitary tumors (23–28). The goal of RT in mammary gland. Endocrinology 1994;134:287–292.

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. 7 Kooistra HS, Okkens AC. Secretion of prolactin and growth hor- 24. Fracassi F, Mandrioli L, Shehdula D, Diana A, Grinwis GC, Meij BP. mone in relation to ovarian activity in the dog. Reprod Domest Anim Complete surgical removal of a very enlarged pituitary corticotroph 2001;36:115–119. adenoma in a dog. J American Anim Hosp Assoc 2014;50:192–197. 8. Murai A, Nishii N, Morita T, Yuki M. GH-producing mammary tumors 25. Dow SW, LeCouteur RA, Rosychuk RAW, Powers BE, Kemppainen RJ. in two dogs with acromegaly. J Vet Med Sci 2012;74:771–774. Response of dogs with functional pituitary macroadenomas and mac- 9. Fracassi F, Zagnoli L, Rosenberg D, Furlanello T, Caldin M. Spontane rocarcinomas to radiation. J Small Anim Pract 1990;31:287–294. ous acromegaly: A retrospective case control study in German shepherd 26. Bley CR, Sumova A, Roos M, Kaser-Hotz B. Irradiation of brain tumors dogs. Vet J 2014;202:69–75. in dogs with neurologic disease. J Vet Intern Med 2006;19:849–854. REPORT CASE 10. Van Keulen LJM, Wesdorp JL, Kooistra HS. Diabetes mellitus in a 27. DeFornel P, Delisle F, Devauchelle P, Rosenberg D. Effects of radio- dog with a growth hormone-producing acidophilic adenoma of the therapy on pituitary corticotroph macrotumors in dogs: A retrospective adenohypophysis. Vet Pathol 1996;33:451–453. study of 12 cases. Can Vet J 2007;48:481–486. 11. Fracassi F, Gandini G, Diana A, et al. Acromegaly due to a somatotroph 28. Marcinowska A, Warland J, Brearley M, Dobson J. Comparison of adenoma in a dog. Domestic Anim Endocrinol 2007;32:43–54. two coarse fractionated radiation protocols for the management of 12. Elliot DA, Feldman EC, Koblik PD, Samii VF, Nelson RW. Prevalence canine pituitary macrotumor: An observational study of 24 dogs. Vet of pituitary tumors among diabetic cats with insulin resistance. J Am Radiol Ultrasound 2015;56:554–562. Vet Med Assoc 2000;11:1765–1768. 29. Brearley MJ, Polton GA, Litter RM, Niessen SJ. Coarse fractionated 13. Wass JAH, Peter J, Trainer PJ. Oxford Textbook of Endocrinology and radiation therapy for pituitary tumours in cats: A retrospective study Diabetes. 2nd ed. Oxford, UK: Oxford University Press, 2011:197–209. of 12 cases. Vet Comp Oncol 2006;4:209–217. 14. Schwedes CS. Transient diabetes insipidus in a dog with acromegaly. 30. Kaser-Hotz B, Rohrer CR, Stankeova S, Wergin M, Fidel J, Reusch C. J Small Anim Pract 1999;40:392–396. Radiotherapy of pituitary tumours in five cats. J Small Anim Pract 2002; 15. Petersenn S, Farral AJ, Block C, et al. Long-term efficacy and safety of 43:303–307. subcutaneous pasireotide in acromegaly: Results from an open-ended, 31. Littler RM, Polton GA, Brearley MJ. Resolution of diabetes mellitus multicentre, Phase II extension study. Pituitary 2014;17:132. but not acromegaly in a cat with pituitary macroadenoma treated with 16. Berg RIM, Nelson RW, Feldman EC, Kass PH, Pollard R, Refsal KR. hypofractionated radiation. J Small Anim Pract 2006;47:392–395. Serum insulin-like growth factor-I concentration in cats with diabetes 32. Dunning MD, Lowrie CS, Bexfield NH, Dobson JM, Herrtage ME. mellitus and acromegaly. J Vet Intern Med 2007;21:892–898. Exogenous insulin treatment after hypofractionated radiotherapy in 17. Pollard ER, Reilly M, Uerling MR, Wood FD, Feldman EC. Cross- cats with diabetes mellitus and acromegaly. J Vet Intern Med 2009;23: sectional imaging characteristics of pituitary adenomas, invasive adeno- 243–249. mas and adenocarcinomas in dogs: 33 cases (1988–2006). J Vet Intern 33. Keyte SV, Kenny PJ, Forcada Y, Church DB, Niessen SJ. Serum Med 2010;24:160–165. N-Terminal Type III Procollagen Propeptide: An indicator of growth 18. Love NE, Fisher P, Hudson L. The computed tomographic enhancement hormone excess and response to treatment in feline hypersomatotro- pattern of the normal canine pituitary gland. Vet Radiol Ultrasound pism. J Vet Intern Med 2016;30:973–982. 2000;41:507–510. 34. Jensen KB, Forcada Y, Church DB, Niessen SJ. Evaluation and diagnos- 19. Low WM, Diaz-Espineira MM, Mol JA, Rijnberk A, Kooistra HS. tic potential of serum ghrelin in feline hypersomatotropism and diabetes Primary hypothyroidism in dogs is associated with elevated GH release. mellitus. J Vet Intern Med 2015;29:14–20. J Endocrinol 2001;168:59–66. 35. Niessen SJ, Church DB, Forcada Y. Hypersomatotropism, acromegaly, 20. Diaz-Espineira MM, Mol JA, Rijnberk A, Kooistra HS. Adenohypophy and hyperadrenocorticism and feline diabetes mellitus. Vet Clin North seal function in dogs with primary hypothyroidism and nonthyroidal Am Small Anim Pract 2013;43:319–350. illness. J Vet Intern Med 2009;23:100–107. 36. Petersenn S, Scholpohl J, Barkan A, et al. Pasireotide (SOM230) dem- 21. Johnstone T, Terzo E, Mooney CT. Hypothyroidism associated with onstrates efficacy and safety in patients with acromegaly: A random- acromegaly and insulin-resistant diabetes mellitus in a Samoyed. Austr ized, multicenter, phase II trial. J Clin Endocrinol Metab 2010;95: Vet J 2014;92:437–442. 2781–2789. 22. Diaz-Espineira MM, Galac S, Mol JA, Rijnberk A, Kooistra HS. 37. Castillo V, Theodoropoulou M, Stalla J, et al. Effect of SOM230 Thyrotropin-releasing hormone-induced growth hormone secretion (pasireotide) oncorticotropic cells: Action in dogs with Cushing’s disease. in dogs with primary hypothyroidism. Domest Anim Endocrinol Neuroendocrinology 2011;94:124–136. 2008;34:176–181. 38. Scudder CJ, Gostelow R, Forcada Y, Schmid HA, Church D, Niessen SJ. 23. Hanson JM, Van’T HM, Voorhout G, Teske E, Kooistra HS, Meij BP. Pasireotide for the medical management of feline hypersomatotropism. Efficacy of transsphenoidal hypophysectomy in treatment of dogs with J Vet Intern Med 2015;29:1074–1080. pituitary-dependent hyperadrenocorticism. J Vet Intern Med 2005;19: 687–694.

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Fracture-associated osteosarcoma of the femur in a cat

Jared I. Baum, Owen T. Skinner, Sarah E. Boston

Abstract — This report describes a domestic shorthair cat with fracture-associated osteosarcoma 11 years after injury. A left hind limb amputation was performed using coxofemoral disarticulation. No intravenous cytotoxic chemotherapy was used after surgery. Pulmonary metastasis was identified 3 months after amputation. Fracture- associated osteosarcoma may occur in the cat more than 10 years after initial injury.

Résumé — Ostéosarcome du fémur associé à une fracture chez un chat. Ce rapport décrit un chat commun domestique atteint d’un ostéosarcome associé à une fracture 11 ans après la blessure. Une amputation du membre arrière gauche a été réalisée à l’aide de la désarticulation coxofémorale. Aucune chimiothérapie cytotoxique intraveineuse n’a été utilisée après la chirurgie. La métastase pulmonaire a été identifiée 3 mois après l’amputation. Un ostéosarcome associé à une fracture peut se produire chez le chat plus de 10 ans après la blessure initiale. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1096–1098

Introduction sarcoma (9). Further studies are still needed to help determine whether specific characteristics, such as radiographic, cytologic, eline osteosarcoma occurs with almost equal frequency in or histopathologic features, may help predict the biologic the axial and appendicular skeleton, and with no gender F behavior of feline osteosarcoma, and thereby guide clinical predilection (1). Osteosarcoma of the appendicular skeleton recommendations. typically affects the metaphyseal regions of the proximal and dis- The purpose of this case report is to discuss a unique pre- tal tibia, distal femur, proximal humerus, and distal radius (1,2). sentation of fracture-associated osteosarcoma with subsequent In dogs, metastasis is extremely common and can occur rapidly; aggressive biologic behavior in a cat. however, the metastatic rate for osteosarcoma in cats is much lower and has been reported to be between 8% and 16% (2,3). Case description Fracture-associated osteosarcoma is rare, but has been An 11-year-old, neutered male domestic shorthair cat weighing reported in both dogs and cats. In dogs, there is typically a lag 5.7 kg was presented for evaluation of a left distal femoral mass. period of $ 5 y before osteosarcoma arises following fracture The cat had a history of surgical stabilization of a left femoral repair (4,5). In cats, the lag period may be shorter and has been fracture when he was a kitten. Three days before presentation, reported to occur within 5 y of the initial surgery, with most the owner noticed a weight-bearing lameness of the left hind reported cases occurring within 6 to 15 mo (2,5–8). limb. At that time, the cat was taken to an emergency clinic, Studies have aimed to identify prognostic characteristics where radiographs were taken, with subsequent referral. of feline osteosarcoma. One such study found that histologic On physical examination, the cat was bright, alert, and grade and mitotic index seemed to be the most important responsive. The cat’s heart rate was within normal limits and histopathologic prognosticators for survival in cats with osteo- he was tachypneic (72 breaths/min). Thoracic auscultation was normal. Rectal temperature was normal. The cat had a marked Department of Small Animal Clinical Sciences, College of weight-bearing lameness affecting the left hind limb. Signs Veterinary Medicine, University of Florida, Gainesville, Florida of pain were elicited during palpation of a 4 3 3 cm, firm, 32608, USA. irregular mass at the caudal aspect of the distal portion of the Address all correspondence to Dr. Jared Baum; e-mail: left femur. Physical and orthopedic examination was otherwise [email protected] normal. The previously obtained radiographs from the referring Dr. Baum’s current address is Ontario Veterinary College, emergency clinic (Figure 1) were reviewed. University of Guelph, 28 College Avenue West, Guelph, Ontario An intramedullary pin was noted in the proximal and mid- N1G 2W1. thirds of the left femur that had been placed in normograde Use of this article is limited to a single copy for personal study. fashion, extending proximally in the soft tissues lateral to the Anyone interested in obtaining reprints should contact the femoral neck. Five cerclage wires were noted at the femoral CVMA office ([email protected]) for additional diaphysis with overlying cortical bone. Areas of radiolucency copies or permission to use this material elsewhere. were seen between the cortical bone and medullary cavity in the

1096 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 1. Lateral (A) and ventrodorsal (B) radiographic views of the left hind limb. Notice the expansile lesion at the left distal femoral metaphysis, at the distal edge of the implant, characterized by areas of moth-eaten to permeative osteolysis and a sunburst to amorphous pattern of periosteal proliferation (arrows).

mid-diaphyseal region. An expansile osseous lesion characterized for repeat staging; however, the owner did not return the cat for by areas of moth-eaten to permeative osteolysis and a sunburst this appointment. to amorphous pattern of periosteal proliferation and associated Approximately 3 mo after surgery, thoracic radiographs cortical erosion and ill-defined zone of transition was noted in taken by the primary veterinarian revealed multiple rounded, the mid- and distal-thirds of the femur, with proliferation pre- variably sized, soft tissue-opaque nodules within the pulmonary dominant caudally. The soft tissues surrounding the distal femur parenchyma, consistent with metastasis (Figure 2). Upon pre- were mildly thickened. The body of the left ischium was thick- sentation to an oncologist, the cat was treated with toceranib ened, with circumferential, mildly irregular osseous prolifera- phosphate (PALLADIA; Pfizer, New York, New York, USA), tion, which may have represented callus due to previous trauma 3.0 mg/kg body weight, PO, every Monday, Wednesday, and or, less likely, a low-grade aggressive lesion. Superimposition of Friday. Approximately 3 mo after initiating treatment with toc- the left iliac wing to the left sacral wing and asymmetry of the eranib phosphate, the cat was presented to an emergency clinic obturator foramina likely represented prior pelvic floor fracture for evaluation of vomiting, diarrhea, and anorexia of 24-hours and left sacroiliac subluxation, rather than a positional artifact. duration, and was euthanized due to suspected progressive Given the suspicion of a neoplastic lesion of the left femur, metastatic disease. staging with 3-view thoracic radiographs was performed. No evidence of pulmonary metastatic disease was seen. Differential Discussion diagnoses for the aggressive left femoral lesion included osteo- The radiographic findings in this case were consistent with sarcoma, other primary bone neoplasms, and, less likely, osteo- a primary bone tumor, with osteolytic and osteoproliferative myelitis or metastatic neoplasia. On cytologic examination, lesions and thickening of the surrounding soft tissue centered binucleation was frequently seen. Trinucleation, karyomegaly, on the distal femoral diaphysis at the previous fracture site. The nuclear molding, and abnormal mitotic figures were occasionally histopathologic findings confirmed osteosarcoma. Though the observed. Overall anisokaryosis and anisocytosis were moderate etiology of fracture-associated osteosarcoma is not fully under- to marked and the nucleus to cytoplasm ratio was moderate to stood, hypotheses include implant corrosion at the fracture high. Cytology identified the mass as a sarcoma, most likely site and inflammation at the fracture site with delayed healing, osteosarcoma. chronic inflammation, and infection (4,5). Although the cause A left hind limb amputation with coxofemoral disarticula- of osteosarcoma in this case is uncertain, one theory is that tion was carried out without complication. On histopathologic stabilization with an intramedullary rod and cerclage wires examination, anisocytosis and anisokaryosis were moderate to may have led to continued micro-motion. Associated chronic marked, there were frequent apoptotic cells, and 9 mitoses were inflammation and a continued stimulus for proliferation due to detected in 10 4003 fields. Histopathology identified the mass relative instability may have predisposed to subsequent tumor as an osteosarcoma. Chemotherapy was not advised, given the formation. Inflammatory mediators contribute to neoplasia by low rate of metastasis reported with feline osteosarcoma (1–3). inducing proneoplastic mutations, adaptive responses, resistance A 4-week recheck was recommended to repeat a complete blood to apoptosis, and environmental changes such as stimulation of cell count, serum biochemistry profile, and thoracic radiographs angiogenesis. All of these changes may confer survival advantages

CVJ / VOL 59 / OCTOBER 2018 1097 FOR PERSONAL USE ONLY RAPPORTCAS DE

Figure 2. Lateral (A) and ventrodorsal (B) radiographic views of the thorax. Metastatic nodules can be observed in both cranioventral and caudodorsal lung fields.

to affected cells (10). Given the effects of chronic inflammation, occasionally be aggressive, resulting in rapid onset of metastases. it may be possible in this case that fracture fixation technique Further studies are warranted to assess whether stabilization may have had significant clinical consequences many years technique may be associated with tumor development and to after initial management, even with apparent healing. As there identify cats at high risk of metastasis. CVJ are many reasons why osteosarcoma may have occurred at the fracture site, further studies would be necessary to confirm a References relationship between stabilization technique and subsequent . 1 Boston S. Musculoskeletal neoplasia and limb-sparing surgery. In: tumor development. Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animal. 1st ed. St. Louis, Missouri: Elsevier Saunders, 2012:1159–1177. This case was unique, given the presentation of late-onset 2. Kessler M, Tassani-Prell M, von Bomhard D, Matis U. Das Osteosarkom fracture-associated osteosarcoma and the rapid metastasis fol- der Katze: Epidemiologische, Klinische und Röntgenologische Befunde lowing amputation of the affected limb. It has been reported bei 78 Tieren (1990–1995). Tierarztl Prax 1997;25:275–283. 3. Garzotto C, Berg J. Oncology: Musculoskeletal system. In: Slatter D, ed. that the rate of metastasis of osteosarcoma is low in cats (5% to Textbook of Small Animal Surgery. 3rd ed. Philadelphia, Pennsylvania: 10%), with a median survival time of 64 mo (11,12). Serial Saunders, 2003:2460–2474. staging is therefore advisable, but adjuvant chemotherapy is 4. Stevenson S. Fracture-associated sarcomas. Vet Clin North Am Small Anim Pract 1991;21:859–872. not typically recommended. While the reported metastatic 5. Sonnenschein B, Dickomeit MJ, Bali MS. Late-onset fracture-associated rates and survival times in cats compare favorably to those seen osteosarcoma in a cat. Vet Comp Orthop Traumatol 2012;25:418–420. in dogs, these data are based on a limited population of cats 6. Bennett D, Campbell JR, Brown P. Osteosarcoma associated with healed fractures. J Small Anim Pract 1979;20:13–18. reported in studies several decades old (1–3,11,12). Predicting 7. Fry PD, Jukes HF. Fracture associated sarcoma in the cat. J Small Anim which cats may do well and which may succumb to metastasis Pract 1995;36:124–126. with osteosarcoma is not possible with the limited data cur- 8. Sinibaldi K, Pugh J, Rosen H, Liu SK. Osteomyelitis and neoplasia associated with the use of the Jonas intramedullary splint in small rently available. One study indicated that histologic grade and animals. J Am Vet Med Assoc 1982;181:885–890. mitotic index seem to be the most important prognostic factors 9. Dimopoulou M, Kirpensteijn J, Moens H, Kik M. Histologic prog- for survival (9). Further studies are necessary to help establish nosticators in feline osteosarcoma: A comparison with phenotypically similar canine osteosarcoma. Vet Surg 2008;37:466–471. prognostic factors for appendicular osteosarcoma in cats. Such 10. Shacter E, Weitzman SA. Chronic inflammation and cancer. Oncology factors may be helpful to stratify patients and determine at risk (Williston Park) 2002;16:217–226, 229–232. populations that may benefit from adjuvant therapy. 11. Liu S, Dorfman HD, Patnaik AK. Primary and secondary bone tumours in the cat. J Small Anim Pract 1974;15:141–156. In conclusion, fracture-associated osteosarcoma can occur 12. Bitetto WV, Patnaik AK, Schrader SC, Mooney SC. Osteosarcoma in over 10 y following fracture, and osteosarcoma in felines can cats: 22 cases (1974–1984). J Am Vet Med Assoc 1987;190:91–93.

1098 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Article

Antimicrobial resistance in mastitis, respiratory and enteric bacteria isolated from ruminant animals from the Atlantic Provinces of Canada from 1994–2013

Babafela B. Awosile, Luke C. Heider, Matthew E. Saab, J.T. McClure

Abstract — Diagnostic laboratory antimicrobial susceptibility data for bacteria isolated from clinical samples of cattle, sheep, and goats from 1994 to 2013 were evaluated retrospectively. Among bacteria from bovine mastitis, Staphylococcus aureus and Streptococcus uberis were the most commonly isolated organisms. Pasteurella multocida, Mannheimia haemolytica, and Histophilus somni were commonly isolated from the respiratory tract, while Escherichia coli isolates were frequently recovered from the intestinal tract. Isolates from mastitis were generally highly susceptible to the antimicrobials tested, except neomycin and oxytetracycline. Respiratory tract isolates were highly susceptible to trimethoprim-sulfamethoxazole, penicillin, florfenicol, and ceftiofur, while enteric bacteria were frequently susceptible to ceftiofur. Antimicrobial resistance trends over the study period were generally stable for small ruminant and cattle isolates. Multi-drug resistance was more common among respiratory isolates from small ruminants compared to those from cattle but more common in enteric bacteria from cattle compared to those from small ruminants. This information may guide clinicians when they are choosing empirical therapies for the treatment of ruminant animals in Atlantic Canada.

Résumé — Résistance antimicrobienne des bactéries respiratoires et entériques et de la mammite isolées des ruminants dans les provinces de l’Atlantique de 1994 à 2013. Les données de susceptibilité antimicrobienne des laboratoires diagnostiques, de 1994 à 2013, pour les bactéries isolées d’échantillons cliniques de bovins, de moutons et de chèvres, ont été évaluées rétrospectivement. Parmi les bactéries trouvées en lien avec la mammite bovine, Staphylococcus aureus et Streptococcus uberis ont été les organismes les plus communément isolés. Pasteurella multocida, Mannheimia haemolytica et Histophilus somni ont été communément isolés de l’appareil respiratoire, tandis que des isolats d’Escherichia coli étaient fréquemment récupérés du tractus intestinal. Les isolats de la mammite étaient généralement hautement susceptibles aux antimicrobiens testés, sauf pour la néomycine et l’oxytétracycline. Les isolats de l’appareil respiratoire étaient hautement susceptibles au triméthoprime- sulfaméthoxazole, à la pénicilline, au florfénicol et au ceftiofur, tandis que les bactéries entériques étaient fréquemment susceptibles au ceftiofur. Les tendances d’antibiorésistance pendant la période de l’étude étaient généralement stables pour les isolats des petits ruminants et des bovins. La multirésistance aux médicaments était plus commune pour les isolats respiratoires provenant des petits ruminants comparativement à ceux des bovins et plus commune dans les bactéries entériques des bovins par rapport à celles des petits ruminants. Ces données pourront guider les cliniciens qui choisissent des thérapies empiriques pour le traitement des ruminants dans les provinces de l’Atlantique. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1099–1104

Introduction resistance, in bacteria in food-producing species is a particular ntimicrobials are used in food animals for treatment and concern as these organisms may be transferred in food to humans A prevention of bacterial diseases (1). However, there is consid- and also may serve as a reservoir for AMR genes. These resistant erable evidence that antimicrobial use in food animal production bacteria may lead to treatment failures in humans and animals selects for resistance in commensal and pathogenic bacteria (2). and to increased costs of medical care and animal production (3). This is a growing concern in veterinary and human health. Devel For veterinarians, clinical microbiologists, public health opment of antimicrobial resistance (AMR), including multi-drug officials, and government agencies, knowledge of the common

Department of Health Management (Awosile, Heider, Saab, McClure), Diagnostic Services (Saab), Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue Charlottetown, Prince Edward Island C1A 4P3. Address all correspondence to Dr. Babafela B. Awosile; 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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bacterial causes of infection in food animal species and their modeled as a continuous variable, and antimicrobial resistance antimicrobial resistance patterns is important in selecting optimal (yes/no) for each bacterial-antimicrobial combination was the empirical and pathogen-specific therapy, guiding treatment pro- binary outcome. Linear relationship assumption between the tocols, and developing policy (4,5). Antimicrobial susceptibility year and the log odds of resistance was examined for each bacte- patterns and bacterial distribution vary from herd to herd and rium-antimicrobial combination by fitting quadratic polynomial from one region to another (4,5). It is therefore important to for the year. The antimicrobial resistance trends were presented acquire regional or local data (6). Additionally, surveillance is as odds ratios (OR). An OR  1 indicated an increased AMR important in identifying changes in AMR patterns as well as rec- trend over the study period, while an OR  1 represented a ognizing new or emerging bacterial diseases among food animals. decreased AMR trend over the study period (11). The Wald

ARTICLE There is a lack of published data on the dynamics of anti- test was used to determine the statistical significance of each microbial resistance in bacteria from food animals, particularly bacterial species-antimicrobial trend. The level of statistical over a long-term period. The objectives of this study were to significance was P  0.05. All statistical analyses were performed identify the most commonly isolated bacterial species and their using Stata 14 (StataCorp, College Station, Texas, USA). antimicrobial susceptibility from clinical samples from cattle, sheep, and goats submitted to a veterinary diagnostic laboratory Results in Atlantic Canada and to determine trends in their antimicro- Antimicrobial resistance in bacteria from bial susceptibilities over a 20-year period. mastitis in dairy cattle Staphylococcus aureus (n = 1532), Streptococcus uberis (n = 1171), Materials and methods and Escherichia coli (n = 716) were the most commonly iso- Antimicrobial susceptibility data for bacteria isolated from lated bacteria from mastitic milk samples. Overall, most of clinical samples from cattle, sheep, and goats from 1994 to the mastitis isolates were susceptible (90% to 100%) to all the 2013 were retrieved from the database of the Atlantic Veterinary antimicrobials tested (Table 1). Escherichia coli showed reduced College Diagnostic Services Bacteriology Laboratory (AVCDBL) susceptibility to cephalexin (43.3%) and neomycin (62.5%); in Charlottetown, Prince Edward Island. For each bacterial iso- 70% to 90% of all the isolates were susceptible to oxytetra- late, the host animal species was the only information available. cycline, while 96% of S. aureus isolates were susceptible to Other data, such as antimicrobial treatment, age, gender, and oxytetracycline. Among Gram-positive bacterial isolates 90% breed were not available. From each clinical sample, the bacteria to 98% were susceptible to pirlimycin, except for S. uberis, for were isolated using standard clinical microbiological isolation which only 82% of isolates were susceptible. Multi-drug resis- techniques, and antimicrobial susceptibility was determined by tance was not common among the mastitis bacterial pathogens; the Kirby-Bauer disk diffusion method. Zones of inhibition it was most observed in E. coli (12.7%) and least observed in were interpreted following Clinical and Laboratory Standards both S. dysgalactiae and S. aureus (0.3%). Institute standards (7). When CLSI zones of inhibition for The trends of antimicrobial resistance over the study bacteria-antimicrobial combinations in a particular host spe- period were stable for most bacteria and drug combinations. cies were not available, the zones of inhibition for other animal Significantly increased AMR trends (P  0.05) were observed species, humans, or different bacterial species were used. For for trimethoprim-sulfamethoxazole and E. coli [OR = 1.06, 95% bacteria isolated from mastitic milk samples from dairy cattle, confidence interval (CI): 1.01 to 1.12], oxytetracycline and antimicrobial susceptibility was determined to the follow- S. aureus (OR = 1.06, 95% CI: 1.01 to 1.11) and oxytetracy- ing antimicrobials: ceftiofur, cephalexin, cloxacillin, oxytet- cline and S. uberis (OR = 1.10, 95% CI: 1.07 to 1.13). A high racycline, penicillin-novobiocin, pirlimycin, neomycin, and proportion of E. coli isolates were resistant to cephalexin and trimethoprim-sulfamethoxazole. For bacteria isolated from the neomycin, but the resistance to cephalexin (OR = 0.97, 95% respiratory and intestinal tracts, susceptibility testing included CI: 0.94 to 0.99) and neomycin (OR = 0.73, 95% CI: 0.70 the following antimicrobials: ceftiofur, erythromycin, oxytet- to 0.77) significantly decreased (P  0.05) during the 20-year racycline, penicillin, streptomycin, florfenicol, tilmicosin, and period. Significant decreased resistance trends (P  0.05) were trimethoprim-sulfamethoxazole. observed in coagulase-negative staphylococci (OR = 0.76, 95% CI: 0.65 to 0.89) and S. aureus (OR = 0.79, 95% CI: 0.76 to Data management and statistical analyses 0.82) to neomycin, and in S. uberis to pirlimycin (OR = 1.04, Bacterial isolates and their antimicrobial susceptibility profiles 95% CI: 1.01 to 1.07) and trimethoprim-sulfamethoxazole (OR were selected from the AVCDBL database. Only bacteria that = 0.91, 95% CI: 0.86 to 0.96). commonly cause clinical disease in ruminant animals were selected. Data were tabulated using a computerized spread- Antimicrobial resistance in respiratory bacteria sheet (Microsoft Excel, 2010). Antimicrobial susceptibility from ruminants was presented as a proportion and only acquired resistance was In cattle, 87%, 84%, and 77% of the total Pasteurella multocida reported (8,9). A bacterial isolate that was resistant to at least 1 (n = 238), Mannheimia haemolytica (n = 187), and Histophilus antimicrobial in at least 3 antimicrobial classes was categorized somni (n = 87) isolates, respectively, were recovered from the as multi-drug resistant (MDR) (10). respiratory tract over the study period. In small ruminants, Logistic regression was used to detect the increased or 71.4% and 73.8% of M. haemolytica (n = 133), and P. multocida decreased antimicrobial resistance trend over time. Year was (n = 42), respectively, were isolated from the respiratory tract.

1100 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY

Antimicrobial susceptibilities among these bacteria are presented in Table 2. In both cattle and small ruminants, M. haemolytica .7 .3 .8 .3 .4 .0 and P. multocida were frequently resistant to erythromycin and DR (%) DR 1.1 to 2.6) to 1.1 0.1 to 2.2) to 0.1 1 0 0.1 to 0.7) to 0.1 11.8) to 0.2 1 1.3 to 4.4) to 1.3 0 2 4 ( ( ( ( ( (2.0 to 7.8) to (2.0 12.7

M (10.5 to 15.4) to (10.5 streptomycin, but were frequently susceptible (susceptibility ranged from 94% to 100%) to ceftiofur, oxytetracycline, penicil-

lin, trimethoprim-sulfamethoxazole, and florfenicol. However,

susceptibility was relatively less frequent to tilmicosin (suscep- ARTICLE

tibility ranged from 62% to 85%) in the respiratory isolates

5.1 9.7 9.5 3.7 5.6 2.0 MS 93.7 to 96.2) to 93.7 97.7 to 99.9) to 97.7 9 9 99.0 to 99.7) to 99.0 00.0 93.2 to 97.2) to 93.2 9 9 9 9 from cattle and small ruminants as well as to trimethoprim- ( ( ( ( (91.7 to 95.3) to (91.7 95.1) to (87.4 T 1 sulfamethoxazole in H. somni (86%) from cattle.

Multi-drug resistance was more common among the respira-

tory isolates from small ruminants compared with those from cattle. The frequency of MDR bacteria was higher in M. haemolytica

(17.1%) than in H. somni (14.9%) and P. multocida (11.8%) in 9.7 9.7 9.7 9.5 R R I I 99.2 to 99.9) 99.9) to 99.2 97.7 to 99.9) to 97.7 9 9 99.3 to 99.9) to 99.3 00.0 98.1 to 99.9) to 98.1 9 9 ( ( ( ( PNN

1 cattle. In small ruminants, MDR bacteria were more common in P. multocida (38.1%) than in M. haemolytica (22.6%). The

antimicrobial resistance trends in respiratory isolates from ruminants over the study period were stable, with the exception of a significant increased resistance trend (P  0.05) in P. multocida

6.4 to erythromycin (OR = 1.15, 95% CI: 1.06 to 1.23). R R IR I I 79.8 to 84.1) to 79.8 88.6 to 94.6) to 88.6 82.1 92.1 97.3 to 98.7) to 97.3 9 99.1) to 86.3 86.5 to 92.4) to 86.5 98.1 89.8 P ( ( ( ( ( Antimicrobial resistance in Escherichia coli and

Salmonella spp. In cattle, 85.4% of the total E. coli (n = 489) isolates and 71.4%

of the total Salmonella spp. isolates (n = 21) were recovered 1.3 5.1 5.7 XY 78.9 to 83.4) to 78.9 70.0 to 79.6) to 70.0 8 7 94.7 to 96.7) to 94.7 8 92.9) to 73.5 78.6 to 85.9) to 78.6 95.8 75.5 82.6 71.1 ( ( ( ( ( (72.2 to 78.5) to (72.2 77.0) to (64.4 O from the gastrointestinal tract with the remaining isolates recovered from blood, umbilicus, abscess, and respiratory tract.

In small ruminants, 83.8% of the E. coli isolates (n = 74) and 5 Salmonella isolates were recovered from the gastrointestinal usceptible % (95% CI) (95% % usceptible S

tract. A low proportion of ruminant isolates was susceptible

1.9 2.5 6.1 9.1 EO R R R I I I 79.9 to 83.8) to 79.9 93.8 to 97.6) to 93.8 8 6 9 7 ( ( (58.8 to 65.9) to (58.8 84.2) to (72.9 N to streptomycin and oxytetracycline. A high proportion of E. coli and Salmonella spp. isolates was susceptible to ceftiofur

(Table 3). Multi-drug resistance was more common in enteric bacteria from cattle compared to enteric bacteria in small

ruminants. The antimicrobial resistance trends in the enteric

7.6 9.7 8.2 9.8 9.3 R R XN bacteria were stable over the study period, except for significant I I 96.6 to 98.3) to 96.6 97.7 to 99.9) to 97.7 9 9 99.3 to 99.9) to 99.3 9 99.8) to 87.7 97.8 to 99.7) to 97.8 9 9 ( ( ( ( ( C increased resistance trends (P  0.05) in E. coli from cattle to

ceftiofur (OR = 1.08, 95% CI: 1.04 to 1.13), trimethoprim- sulfamethoxazole (OR = 1.05, 95% CI: 1.01 to 1.08) and florfenicol (OR = 1.16, 95% CI: 1.10 to 1.23). Significant

decreased resistance (P  0.05) to streptomycin in E. coli was 6.4 EX 98.5 to 99.6) to 98.5 97.8 to 99.9) to 97.8 99.2 99.6 99.1 to 99.8) to 99.1 9 99.1) to 86.3 97.1 to 99.5) to 97.1 99.6 43.3 98.7 90.5 ( ( ( ( ( (39.7 to 46.9) to (39.7 93.9) to (85.6 C observed in both cattle (OR = 0.94, 95% CI: 0.90 to 0.99) and small ruminants (OR = 0.78, 95% CI: 0.70 to 0.87) over the

study period.

a Discussion

6.8 8.2 9.9 7.4 9.0 6.5 EF 95.7 to 97.7) to 95.7 9 00.0 99.5 to 99.9) to 99.5 9 99.8) to 87.7 97.4 to 99.6) to 97.4 9 9 9 9 ( ( ( ( (95.9 to 98.3) to (95.9 98.3) to (92.8 C Retrospective antimicrobial susceptibility studies provide helpful 1 information to veterinarians in the selection of empirical anti-

microbial therapy (6). This study examined the antimicrobial 6 5 17 16 13 00

171 3 532 7 4 2 susceptibility patterns and trends in selected bacteria from clini-

N cal samples from cattle and small ruminants using data from a

regional veterinary diagnostic laboratory over a 20-year period.

Compared to previous studies, this study evaluated AMR data

negative Antimicrobial susceptibilities in bacteria from mastitis in dairy cattle over a 20-year period. 20-year a over cattle dairy in mastitis from bacteria in susceptibilities Antimicrobial and trends from ruminant bacterial pathogens over a relatively spp.

long period (6,11,12). beris ysgalactiae galactiae ureus taphylococci Staphylococcus aureus was the most frequently isolated agent u d a a s Available CLSI zone diameters. zone CLSI Available

Streptococcus

Streptococcus Streptococcus

Staphylococcus

Escherichia coli Escherichia CEF — Ceftiofur; CEX — Cephalexin; CXN — Cloxacillin; NEO — Neomycin; OXY — Oxytetracycline; PIR — Pirlimycin; PNN — Penicillin-novobiocin; TMS — Trimethoprim-sulfamethoxazole; IR —i ntrinsic resistance; ntrinsic —i IR Trimethoprim-sulfamethoxazole; — TMS Penicillin-novobiocin; — PNN Pirlimycin; — PIR Oxytetracycline; — OXY Neomycin; — NEO Cloxacillin; — CXN Cephalexin; — CEX Ceftiofur; — CEF Table 1. Table pathogens Mastitis Klebsiella Coagulase a interval. confidence — CI of bovine mastitis in this study and a high proportion of the

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Table 2. Antimicrobial susceptibilities in respiratory bacteria isolated from ruminants over a 20-year period. Susceptible % (95% CI) Cattle Small ruminants Mannheimia haemolytica Pasteurella multocida Histophilus somni Mannheimia haemolytica Pasteurella multocida Antimicrobials (n = 187) (n = 238) (n = 87) (n = 133) (n = 42) Ceftiofura 98.9 (95.8 to 99.7) 98.7 (96.1 to 99.6) 95.4 (88.3 to 98.3) 100.0 97.6 (84.5 to 99.7) Erythromycin 47.1 (39.7 to 54.5) 42.0 (34.5 to 50.0) 89.1 (77.2 to 95.1) 18.4 (12.5 to 26.3) 26.8 (15.1 to 43.0) Oxytetracycline 90.9 (85.7 to 94.3) 94.5 (90.7 to 96.8) 85.1 (75.7 to 91.2) 91.6 (85.7 to 95.3) 95.2 (81.9 to 98.9) Penicillin 94.1 (89.5 to 96.7) 97.9 (95.0 to 99.1) 96.6 (89.6 to 98.9) 97.7 (93.0 to 99.2) 97.6 (83.8 to 99.7)

ARTICLE Streptomycin 12.0 (7.9 to 17.6) 23.2 (18.2 to 29.1) 48.3 (37.8 to 58.9) 16.2 (10.7 to 23.6) 33.3 (20.4 to 49.4) Trimethoprim- 97.3 (93.7 to 98.9) 99.2 (96.7 to 99.8) 86.2 (77.0 to 92.1) 100.0 100.0 sulfamethoxazole Florfenicola 100.0 100.0 100.0 99.2 (94.4 to 99.9) 100.0 Tilmicosina 75.3 (68.3 to 81.1) 85.1 (79.7 to 89.2) 74.4 (63.6 to 82.8) 76.1 (67.1 to 83.3) 61.5 (44.8 to 75.9) Multi-drug resistant 17.1 (12.4 to 23.2) 11.8 (8.2 to 16.5) 14.9 (8.8 to 24.1) 22.6 (16.2 to 30.5) 38.1 (24.6 to 53.7)

a Available CLSI zone diameters.

isolates were susceptible to all the antimicrobials tested, includ- H. somni were the most common respiratory pathogens iso- ing penicillin, which is comparable to other published studies lated in this study. While P. multocida was frequently isolated (12–15). Streptococcal isolates were highly susceptible to all from cattle, M. haemolytica was more common in small rumi- antimicrobials except oxytetracycline. -lactams are the recom- nants. Histophilus somni was the least common respiratory mended antimicrobials for the treatment of intra-mammary pathogen in cattle and was not isolated in small ruminants. infections caused by Streptococcus agalactiae and environmental These 3 organisms are commonly isolated from cases of bovine streptococci (16,17). The proportion of mastitis pathogens that respiratory disease complex (26). A high proportion of these were MDR was low. Most isolates with multi-drug resistance bacteria was susceptible to ceftiofur, florfenicol, oxytetracycline, were Gram-negative organisms, especially E. coli, which is trimethoprim-sulfamethoxazole and penicillin in both cattle similar to previous findings from a Canada-wide study (18). and small ruminants. Similar antimicrobial susceptibility pat- Apart from the therapeutic implications of MDR E. coli, the terns have been reported in other studies in North America bacteria could also play a potential role in the transmission of (5,26–28) and in Europe (29). However, ceftiofur should be antimicrobial resistance genes to other udder pathogens (16). reserved for situations in ruminant respiratory diseases in which Resistance trends in most antimicrobial and mastitis patho- other antimicrobial options are not available. Third generation gen combinations were stable. In some instances, resistance cephalosporins are critically important in human medicine decreased over the 20-year period, although most of the anti- (30), but ceftiofur is a third generation cephalosporin that is microbials have been used to treat mastitis for decades (17). approved for both systemic and intramammary treatment in This stable trend is consistent with previous studies in North cattle in Canada (17). America (18–21). Increased resistance trends for trimethoprim- While there was variation in proportions of isolates that were sulfamethoxazole and E. coli as well as oxytetracycline and susceptible to the antimicrobials tested among both cattle and S. aureus and S. uberis were found in this study. This increased small ruminant bacteria, most antimicrobial resistance trends resistance trend to both antimicrobials for these bacteria could over the course of the study were stable. However, an increased be because these antimicrobial drugs are commonly used for sys- antimicrobial resistance trend was observed in P. multocida to temic treatments of dairy cattle on Canadian dairy farms (17). erythromycin and is in agreement with a similar older study over The findings from our study support the evidence presented by a 4-year period (1988–1992) in Michigan (26). Conversely, a the National Mastitis Council’s Expert Group that antimicro- study from Oklahoma (27) reported a decreased resistance trend bial resistance in mastitis pathogens is uncommon with little to erythromycin in both M. haemolytica and P. multocida over a evidence of increasing resistant trends (13). 9-year period (1994–2002). Respiratory isolates from cattle, sheep, and goats and their The multi-drug resistance in M. haemolytica and P. multocida antimicrobial susceptibility patterns were similar over the study in this study is consistent with the findings of a similar study period. However, AMR, as well as MDR bacteria trends over from Kansas State University, USA (5). The development of the study period, changed more in cattle compared to small multi-drug resistance in both bacteria is reported to be medi- ruminants. This may be because of differences in antimicrobial ated by small plasmid-derived DNA and conjugative and non- usage patterns in cattle compared to small ruminants. Dairy and conjugative transposons (31). Recently a chromosomal-based beef cattle are more likely to have bacterial disease challenges, mobile genetic element, referred to as an integrative conju- possibly due to management choices, such as increased animal gative element, was associated with multi-drug resistance in stocking density, and are more frequently exposed to antimicro- North American isolates (32). The development of multi-drug bial drugs compared to sheep and goats (22). resistance in either bacteria would be economically challenging Respiratory diseases are a major cause of morbidity and to ruminant animal production systems within this region, as mortality in dairy, beef, and small ruminant production sys- respiratory disease complex is a major disease of both cattle and tems (23–25). Mannheimia haemolytica, P. multocida, and small ruminants (28).

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Table 3. Antimicrobial susceptibilities in enteric bacteria from ruminants over a 20-year period. Susceptible % (95% CI) Cattle Small ruminants Antimicrobials Escherichia coli (n = 489) Salmonella spp. (n = 21) Escherichia coli (n = 74) Salmonella spp. (n = 5) Ceftiofur 86.4 (82.9 to 89.2) 95.0 (67.7 to 99.4) 95.8 (87.6 to 98.6) 100.0 Erythromycin IR IR IR IR ARTICLE Oxytetracycline 36.8 (17.3 to 61.9) 36.8 (17.3 to 61.9) 67.1 (55.3 to 77.1) 100.0 Penicillin IR IR IR IR Streptomycin 10.4 (7.9 to 13.6) 11.1 (2.4 to 38.9) 31.0 (21.1 to 42.9) 0.0 Trimethoprim- 51.6 (47.2 to 56.1) 95.2 (69.1 to 99.4) 95.9 (87.9 to 98.7) 100.0 sulfamethoxazole Florfenicol 72.0 (66.5 to 76.8) 53.3 (26.6 to 78.3) 88.1 (76.7 to 94.4) 100.0 Tilmicosin IR IR IR IR Multi-drug resistant 48.7 (44.3 to 53.1) 33.3 (16.5 to 55.9) 5.4 (2.0 to 13.7) 0.0

IR — intrinsic resistance.

Escherichia coli was the most commonly isolated enteric possibility of repeated clinical sample submission from the same organism from both cattle and small ruminants in this study, farm or by the same veterinarian. Some of the isolates may have which is consistent with other studies (33,34). Escherichia coli been from animals that were treated with antimicrobials prior to can be a primary pathogen, a commensal, or a cause of co- sampling, possibly selecting for more resistant pathogens, and infections with other bacteria and viruses. Furthermore, some increasing the proportion of resistant isolates and the frequency types of E. coli are important food-borne pathogens (35). of MDR. It should be noted that some isolates in this study may Enterotoxigenic strains of E. coli are a primary bacterial cause be normal microflora and not pathogenic, especially for bacterial of calf scours, while other strains are major causes of extra- species such as E. coli. intestinal infections in humans and animals (36). In this study, This study provides valuable information on antimicrobial enteric bacteria were frequently resistant to oxytetracycline and susceptibility patterns of commonly cultured mastitis, respira- streptomycin, which is similar to findings in Europe and North tory, and enteric bacteria from cattle, sheep, and goats from America (6,35,37), and may be due to the prescribing practices the Atlantic region of Canada. This information may guide and administration of these antimicrobials in ruminant animal clinicians in choosing empirical therapies for the management production in these regions. of these diseases of cattle and small ruminants in Atlantic A decreasing trend of resistance to streptomycin in E. coli Canada. We caution that selection of antimicrobials categorized from cattle and small ruminants was found in our study. This as highly important to human health should be based on strong may be because streptomycin is unavailable for use in Canada. scrutiny and in most cases as a last resort. In conclusion, a Since use of streptomycin in dairy production was prohibited high proportion of the bacteria isolated were susceptible to the in Canada 3 decades ago, the selective pressure exerted by antimicrobials tested over the study period, especially bacteria streptomycin is declining (35). Increased AMR trends were isolated from bovine mastitis and samples from small ruminants. seen to ceftiofur and florfenicol in E. coli. This is different from Generally, AMR trends in isolated bacteria were stable over the the stable or decreased AMR trends to ceftiofur and florfenicol study period in both cattle and small ruminants. Stable trends reported from 2 studies from the United States (35,38). The and higher susceptibility among specific pathogen and antimi- increased AMR trend to ceftiofur found in this study in E. coli crobial combinations may indicate predictable susceptibilities warrants continued monitoring. that should result in a high probability of therapeutic success The high proportion of MDR E. coli isolates from ruminants when these antimicrobials are used to treat infections without found in this study is similar to findings reported from western prior antimicrobial susceptibility testing. Canada (6), the USA (33,35), and Europe (39). This is not Acknowledgment surprising because E. coli is ubiquitous, colonizes a wide range of hosts, and easily acquires AMR genetic elements (33). We are grateful to Robert Page of University of Prince Edward The use of antimicrobial resistance data generated from the Island for the retrieval of the culture and susceptibility data. CVJ diagnostic laboratory has limitations. The Kirby-Bauer disk dif- References fusion method was used for antimicrobial susceptibility testing 1. McEwen SA, Fedorka-Cray PJ. Antimicrobial use and resistance in over the study period, rather than micro-broth dilution meth- animals. Clin Infect Dis 2002;34:S93–106. ods used in other surveillance studies. This may limit the use 2. Landers TF, Cohen B, Wittum TE, Larson EL. A review of antibiotic of these data for comparison with other studies, and may have use in food animals: Perspective, policy, and potential. Public Health Rep 2012;127:4–22. also limited the detection of smaller changes in antimicrobial 3. Bengtsson B, Greko C. Antibiotic resistance — Consequences for animal resistance. Also, as there are regional variations in antimicrobial health, welfare, and food production. Ups J Med Sci 2014;119:96–102. susceptibilities of common bacteria, comparison or extrapolation 4. Blondeau JM, Tillotson GS. Formula to help select rational antimicrobial therapy (FRAT): Its application to community- and of our findings to other studies or regions should be done cau- hospital-acquired urinary tract infections. Int J Antimicrob Agents tiously (4). Additional sources of bias in our study include the 1999;12:145–150.

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. 5 Lubbers BV, Hanzlicek GA. Antimicrobial multidrug resistance and 22. Cummings K, Warnick L, Alexander K, et al. The duration of fecal coresistance patterns of Mannheimia haemolytica isolated from bovine Salmonella spp. shedding following clinical disease among dairy cattle respiratory disease cases — A three-year (2009–2011) retrospective in the northeastern USA. Prev Vet Med 2009;92:134–139. analysis. J Vet Diagn Invest 2013;25:413–417. 23. Avery BP, Raji´c A, McFall M, et al. Antimicrobial use in the Alberta 6. Checkley SL, Campbell JR, Waldner CL, Dowling PM, Chirino-Trejo sheep industry. Can J Vet Res 2008;72:137–142. M. A retrospective diagnostic laboratory survey of antimicrobial resis- 24. Grissett G, White B, Larson R. Structured literature review of responses tance in fecal Escherichia coli isolated from spring calves in western of cattle to viral and bacterial pathogens causing bovine respiratory Canada. Can Vet J 2010;51:1283. disease complex. J Vet Intern Med 2015;29:770–780. 7. Performance Standards for Antimicrobial Disk and Dilution 25. Tahamtan Y, Hayati M. Multi drug resistance of Pasteurella spp. isolated Susceptibility Tests for Bacteria Isolated from Animals. 3rd ed. CLSI from sheep and goats in Iran. Res J Microbiol 2014;9:51–58. supplement VET01S (ISBN 1-56238-907-6). Clinical and Laboratory 26. Watts JL, Yancey RJ, Salmon SA, Case CA. A 4-year survey of antimi- Standards Institute, Wayne, Pennsylvania 19087 USA, 2015. crobial susceptibility trends for isolates from cattle with bovine respira-

ARTICLE 8. Bonnet R, Caron F, Cavallo JD, et al. Comité de l’Antibiogramme de tory disease in North America. J Clin Microbiol 1994;32:725–731. la Société Française de Microbiologie. Recomm 2012 [Internet]. 2012 27. Welsh RD, Dye LB, Payton ME, Confer AW. Isolation and antimi- [cited 2017 Jun 1]; Available from: https://www.resapath.anses.fr/ crobial susceptibilities of bacterial pathogens from bovine pneumonia: resapath_uploadfiles/files/Documents/2013_CASFM.pdf Last accessed 1994–2002. J Vet Diagn Invest 2004;16:426–431. June 10, 2018. 28. Portis E, Lindeman C, Johansen L, Stoltman G. A ten-year (2000–2009) 9. Leclercq R, Cantón R, Brown DFJ, et al. EUCAST expert rules in anti- study of antimicrobial susceptibility of bacteria that cause bovine microbial susceptibility testing. Clin Microbiol Infect 2013;19:141–160. respiratory disease complex — Mannheimia haemolytica, Pasteurella 10. Magiorakos A-P, Srinivasan A, Carey RB, et al. Multidrug-resistant, multocida, and Histophilus somni — in the United States and Canada. extensively drug-resistant and pandrug-resistant bacteria: An inter- J Vet Diagn Invest 2012;24:932–944. national expert proposal for interim standard definitions for acquired 29. de Jong A, Thomas V, Simjee S, et al. Antimicrobial susceptibility resistance. Clin Microbiol Infect 2012;18:268–281. monitoring of respiratory tract pathogens isolated from diseased 11. Ball KR, Rubin JE, Chirino-Trejo M, Dowling PM. Antimicrobial cattle and pigs across Europe: The VetPath study. Vet Microbiol resistance and prevalence of canine uropathogens at the Western College 2014;172:202–215. of Veterinary Medicine Veterinary Teaching Hospital, 2002–2007. Can 30. World Health Organization. WHO guidelines on use of medically Vet J 2008;49:985–990. important antimicrobials in food-producing animals [Internet]. WHO. 12. Sargeant JM, Scott HM, Leslie KE, Ireland MJ, Bashiri A. Clinical [cited 2017 Dec 11]. Available from: http://www.who.int/foodsafety/ mastitis in dairy cattle in Ontario: Frequency of occurrence and bacte- areas_work/antimicrobial-resistance/cia_guidelines/en/ Last accessed riological isolates. Can Vet J 1998;39:33–38. June 10, 2018. 13. Oliver SP, Murinda SE. Antimicrobial resistance of mastitis pathogens. 31. Kehrenberg C, Schulze-Tanzil G, Martel J-L, Chaslus-Dancla E, Schwarz Vet Clin North Am Food Anim Pract 2012;28:165–185. S. Antimicrobial resistance in Pasteurella spp. and Mannheimia spp.: 14. Anderson KL, Lyman RL, Bodeis-Jones SM, White DG. Genetic diver- Epidemiology and genetic basis. Vet Res 2001;32:323–339. sity and antimicrobial susceptibility profiles among mastitis-causing 32. Klima CL, Zaheer R, Cook SR, et al. Pathogens of bovine respiratory Staphylococcus aureus isolated from bovine milk samples. Am J Vet Res disease in North American feedlots conferring multidrug resistance via 2006;67:1185–1191. integrative conjugative elements. J Clin Microbiol 2014;52:438–448. 15. Persson Y, Nyman A-KJ, Grönlund-Andersson U. Etiology and anti- 33. Sawant AA, Hegde NV, Straley BA, et al. Antimicrobial-resistant enteric microbial susceptibility of udder pathogens from cases of subclinical bacteria from dairy cattle. Appl Environ Microbiol 2007;73:156–163. mastitis in dairy cows in Sweden. Acta Vet Scand 2011;53:36 doi: 34. Carballo M, Esperón F, Sacristán C, et al. Occurrence of tetracycline 10.1186/1751-0147-53-36. residues and antimicrobial resistance in gram negative bacteria isolates 16. Erskine RJ, Wagner S, DeGraves FJ. Mastitis therapy and pharmacology. from cattle farms in Spain. Adv Biosci Biotechnol 2013;4:295–303. Vet Clin Food Anim Pract 2003;19:109–138. 35. Tadesse DA, Zhao S, Tong E, et al. Antimicrobial drug resistance 17. Saini V, McClure JT, Léger D, et al. Antimicrobial use on Canadian in Escherichia coli from humans and food animals, United States, dairy farms. J Dairy Sci 2012;95:1209–1221. 1950–2002. Emerg Infect Dis 2012;18:741–749. 18. Saini V, McClure JT, Léger D, et al. Antimicrobial resistance profiles 36. Nataro JP, Kaper JB. Diarrheagenic Escherichia coli. Clin Microbiol Rev of common mastitis pathogens on Canadian dairy farms. J Dairy Sci 1998;11:142–201. 2012;95:4319–4332. 37. Guerra B. Phenotypic and genotypic characterization of antimicrobial 19. Lindeman CJ, Portis E, Johansen L, Mullins LM, Stoltman GA. resistance in German Escherichia coli isolates from cattle, swine and Susceptibility to antimicrobial agents among bovine mastitis pathogens poultry. J Antimicrob Chemother 2003;52:489–492. isolated from North American dairy cattle, 2002–2010. J Vet Diagn 38. Cummings KJ, Aprea VA, Altier C. Antimicrobial resistance trends Invest 2013;25:581–591. among Escherichia coli isolates obtained from dairy cattle in the 20. Erskine RJ, Walker RD, Bolin CA, Bartlett PC, White DG. Trends in Northeastern United States, 2004–2011. Foodborne Pathog Dis antibacterial susceptibility of mastitis pathogens during a seven-year 2013;11:61–67. period. J Dairy Sci 2002;85:1111–1118. 39. Hendriksen RS, Mevius DJ, Schroeter A, et al. Prevalence of antimi- 21. Makovec JA, Ruegg DPL. Antimicrobial resistance of bacteria isolated crobial resistance among bacterial pathogens isolated from cattle in from dairy cow milk samples submitted for bacterial culture: 8,905 different European countries: 2002–2004. Acta Vet Scand 2008;50:28 samples (1994–2001). J Am Vet Med Assoc 2003;222:1582–1589. doi: 10.1186/1751-0147-50-28.

1104 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Brief Communication Communication brève

Overlooked sources of Salmonella contamination in the pig production network: Slaughterhouse yard pathways and mudguards and carpets from transport trucks

Alexandra Elayiz Henry, Ann Letellier, Jean-Charles Côté, Gabriel Desmarais, Virginie Lachapelle, Nadia Bergeron, Sylvette L. Lewandowsky, Philippe Fravalo

Abstract — This report describes various Salmonella serovars which were found on often overlooked locations in a pig farm/slaughterhouse interface. These include slaughterhouse yard pathways and mudguards and carpets of transport trucks arriving at and departing from production sites.

Résumé — Sources négligées de contamination par Salmonella dans un réseau de production de porcs: les voies de circulation de l’abattoir et les garde-boues et les tapis de cabine des camions de transport. Nous montrons ici que Salmonella, l’agent causal de la salmonellose, peut être trouvé sur des sites très inhabituels et négligés dans l’interface ferme porcine/abattoir: les voies de circulation de la cour d’abattoir, et les garde-boues et tapis des camions de transport qui arrivent et partent vers les sites de production. (Traduit par les auteurs) Can Vet J 2018;59:1105–1108

almonellosis is an infection caused by the bacterium on the transportation trucks. Our aim was to study the presence S Salmonella. It is characterized by abdominal cramps, and distribution of Salmonella on often overlooked locations on diarrhea, vomiting, and fever (1). Domestically produced pork a pig slaughterhouse yard; in the dust collected from various is an important animal-food source of human salmonellosis pathways taken by transport trucks in the slaughterhouse yard; (2). Pork can be contaminated by the bacterium at any stage and on mudguards and carpets of the transport trucks when they in the farm-to-fork chain, at pre-harvest (pig farming), harvest arrive and when they leave the slaughterhouse. (slaughter, meat processing), and post-harvest (distribution, A slaughterhouse yard was visited 18 times over a 10-month cooking). Mitigation measures rely on several factors and specific period, from August 2011 to May 2012. Samples for micro- control measures have been implemented from the farm to the biological testing were collected using cleaned and disinfected slaughterhouse, including vaccination, changes in pig density, dustpans to superficially sweep a 1 m 3 1 m surface located on feed additives, and improved hygiene (3,4). the main gate pathway before the arrival of a pig transportation The transport of pigs from the farm to the slaughterhouse truck, after its arrival, and upon its departure. Samples were also is recognized as a source of Salmonella contamination (5). taken from a 1 m 3 1 m surface located on 2 separate pathways: Surprisingly, however, little information is available on the 1 used by the carcass rendering truck and the other used by the presence of Salmonella at the interface between the produc- non-edible matter truck. A subtotal of 90 (18 3 5) samples was tion farm and the slaughterhouse, and more specifically in the collected. In addition, mudguards from pig transport trucks slaughterhouse yard, a place of transit for various vehicles, or were sampled 3 times at the slaughterhouse: upon arrival at the entrance of the slaughterhouse yard, during pig delivery at the landing stage, and just upon leaving the slaughterhouse Chaire de recherche en salubrité des viandes, Faculté de méde- yard at the main gate. Here, a subtotal of 54 samples (18 3 3) cine vétérinaire, Université de Montréal, 3200 rue Sicotte, was collected. Samples (n = 18) were also collected from cabin Saint-Hyacinthe, Québec J2S 2M2 (Henry, Letellier, Côté, carpets of the trucks. Altogether, 162 (18 3 9) samples were Desmarais, Lachapelle, Bergeron, Lewandowsky, Fravalo); collected, carried to the laboratory, and analyzed within 5 h for Agence Canadienne d’Inspection des Aliments, 3190 rue Sicotte, the presence of Salmonella. Saint-Hyacinthe, Québec J2S 2M1 (Lachapelle). Salmonella was isolated according to ISO 6579:2002 (6). Address all correspondence to Dr. Philippe Fravalo; e-mail: Briefly, each sample was pre-enriched in buffered peptone [email protected] water and incubated at 37°C overnight (18 to 20 h). Next, a Use of this article is limited to a single copy for personal study. sample from the pre-enrichment broth culture was inoculated Anyone interested in obtaining reprints should contact the into Rappaport-Vassiliadis medium with soya (RSV broth) and CVMA office ([email protected]) for additional Muller-Kauffmann tetrathionate/novobiocin broth (MKTTn copies or permission to use this material elsewhere. broth, pH 8.0). The RSV and MKTTn broths were incubated

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Table 1. Distribution and identification of Salmonella serovars on selected slaughterhouse pathways, truck mudguards, and truck cabin carpets. Pathwaya used by the pig delivery truck Date Pathwayb used by the Pathwayc used by the YY-MM-DD Before its arrival After its arrival After its departure non-edible matter truck carcass rendering truck 11-08-30 Infantis Brandenburg, Infantis Brandenburg 11-09-07 Infantis, Typhimurium Brandenburg, Derby, Uganda Typhimurium PT 104b, PT U302 1,4,[5],12:i- Typhimurium PT U302 11-09-28 Derby Typhimurium PT 208 Brandenburg Typhimurium PT 132, Non-typable 11-10-05 Typhimurium PT 104b Give, Typhimurium Infantis, Worthington Typhimurium PT 104b PT UT5 11-10-05 Infantis Typhimurium PT 104b Infantis, Worthington Typhimurium PT 104b COMMUNICATIONBRÈVE 11-11-10 Brandenburg Brandenburg Derby 11-11-30 Brandenburg, Brandenburg Brandenburg, Infantis, Brandenburg, Infantis Derby, Schwarzengrund Typhimurium PT 104 Typhimurium PT 104b 11-12-01 Worthington Worthington Ohio Infantis, Typhimurium PT 104 11-12-20 Infantis 12-01-11 12-01-11 Infantis Typhimurium PT 104b 12-01-19 Infantis Typhi 12-01-26 Typhimurium PT 108 Auto-aggutinating Alachua 12-02-06 Derby Derby Infantis 12-04-18 Uganda 12-04-24 Infantis, Ohio Ohio Infantis Infantis Infantis 12-04-24 Benin Infantis Ohio 12-05-24 Give Brandenburg, Give Infantis Typhi Truck mudguard Cabin carpet Date YY-MM-DD Upon arrival During unloading Upon leaving 11-08-30 Brandenburg, Infantis 11-09-07 Infantis, Typhimurium PT 104b 11-09-28 Derby, Typhimurium PT 208 11-10-05 Typhimurium PT 104b Typhimurium PT 208 Typhimurium PT 104b, Typhimurium PT 104a, Typhimurium PT 208 Typhimurium PT 104b, Typhimurium PT 108 11-10-05 Typhimurium PT 208 Derby, Typhimurium PT 208 Derby, Typhimurium PT 208 11-11-10 Derby 11-11-30 Heidelberg, Typhimurium PT U302 Typhimurium PT 104 Brandenburg Derby, Typhimurium PT U302 11-12-01 Heidelberg, Worthington Ohio, Worthington Worthington Infantis 11-12-20 12-01-11 12-01-11 12-01-19 Brandenburg 12-01-26 12-02-06 Derby 12-04-18 Brandenburg 12-04-24 12-04-24 Derby Brandenburg 12-05-24 Brandenburg

a 1 m 3 1 m surface located on the main gate pathway. b 1 m 3 1 m surface located on the pathway used by the non-edible matter truck. c 1 m 3 1 m surface located on the pathway used by the carcass rendering truck. Empty areas indicate no Salmonella was isolated.

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overnight at 42°C and 37°C, respectively. Cultures were plated slaughterhouse yard. Interestingly, Salmonella was not detected on xylose lysine deoxycholate agar (XLD agar) and incubated on the mudguards during the winter period (December 20, at 37°C, overnight. In some cases, colonies on XLD agar were 2011 to April 6, 2012).

obtained from both RSV and MKTTn broths. In these cases, Twelve of the 18 samples (67%) collected from the cabin BRIEF COMMUNICATION colonies from both sources were further identified. Identity carpet were Salmonella-positive. They provided 19 isolates that of Salmonella isolates was confirmed by biochemical reactions comprised 3 serotypes and 5 phage types (Table 1). Salmonella including those identified on Triple Sugar Iron (TSI) agar (7), was detected throughout the period under study. Lysine Iron Agar (LIA) (7), urease medium (7), and API 20E Several risk factors are associated with pig contamination with (8). All confirmed Salmonella isolates were sent to “Laboratoire Salmonella in a farm/slaughterhouse interface: the farm status, d’épidémiosurveillance animale du Québec” (MAPAQ, Saint- pig transport conditions, lairage, which determine pre-existence Hyacinthe, Quebec) for serotyping (9). Salmonella Typhimurium of Salmonella on carcasses followed by cross-contamination, isolates were further characterized by phage typing (10) at the and dirty and “clean” zones of the slaughter line (5,11). It was National Microbiology Laboratory (Public Health Agency of found that pathways taken by the transportation trucks in the Canada, Winnipeg, Manitoba). slaughterhouse yard, and the mudguards and truck cabin carpets Fifty-five of the 90 dust samples collected from locations on can all be sources of Salmonella, which in turn could be spread the slaughterhouse pathways were Salmonella-positive. A total elsewhere in the slaughterhouse yard or presumably even be of 72 Salmonella isolates were obtained and serotyped. These transported back to the pig farms (5). Salmonella isolates encompassed 12 serovars, 1 non-typable Salmonella was frequently isolated throughout the duration of and 1 auto-agglutinating (rough variants of Salmonella that our study. The isolates showed a great diversity of serotypes and do not express O antigen) (Table 1). Salmonella Typhimurium phage types. The presence of common or different Salmonella on isolates were subtyped into 5 phage types by phage typing (10) various pathways from one sampling day to another (Table 1) (Table 1). The frequency of recovery of isolates varied accord- indicates either the survival of the bacteria or the deposition ing to the different slaughterhouse pathways. Salmonella was of new serotypes and phage types, some following the tran- found on the pathway used by the pig delivery truck before its sit of trucks. Interestingly, specific Salmonella serotypes and arrival (10 positive samples/18 samples tested, 56%; 13 iso- phage types were associated with specific pathways. Salmonella lates/72 total isolates, 18%), after its arrival (7/18, 39%; 8/72, Typhimurium and S. Derby were not found on pathways in 11%), and after its departure (13/18, 72%; 19/72, 26%). the slaughterhouse yard used by the non-edible matter collec- Somehow, this pathway had lost some Salmonella serotypes tor trucks (0 isolate/13 isolates, 0%; 0 isolate/18 samples, 0%). and acquired new ones on the same day between the arrival These pathways were not taken by trucks used in the transport of the pig delivery truck and after its departure. The location of live swine. These bacteria, however, were found on pathways on the pathway used by the non-edible matter truck was also used by trucks involved in primary production, i.e., the pig contaminated with Salmonella (10/18, 56%; 13/72, 18%). delivery trucks (12/40, 30%; 12/54, 22%), and the carcass The location on the pathway used by the carcass rendering rendering trucks (9/19, 47%; 9/18, 50%). Not surprisingly, truck, where leaching water from the slaughterhouse is usually serotypes Typhimurium and Derby are also often found in present, was the most contaminated location (15/18, 83%; primary pig production (11–15). 19/72, 26%). In conclusion, it was shown that Salmonella isolates are pres- Because samples were taken over a 10-month period, it was ent on different pathways taken by trucks in the slaughterhouse possible to follow the seasonal distribution of Salmonella at these yard, and on truck mudguards and truck cabin carpets. This locations on the slaughterhouse pathways. Of the 60 samples work emphasizes the importance of a thorough cleaning and taken when the temperature was warmer (from August 30 disinfection protocol for transport trucks upon leaving the to December 1, 2011 and from April 18 to May 24, 2012), slaughterhouse to prevent spread of Salmonella elsewhere in 44 (73%) contained Salmonella. They accounted for 61 (85%) the network of pig production farms visited by the same trucks. of the total number of isolates. Salmonella was also detected in CVJ the winter season on pathways covered with snow and ice. Of the 30 samples taken during the winter period (December 20, References 2011 to April 6, 2012), 11 (37%) contained Salmonella. They 1. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology. 8th ed. St. Louis, Missouri: Elsevier, 2015. accounted for 15% of the total number of isolates. Salmonella 2. Jackson BR, Griffin PM, Cole D, Walsh KA, Chai SJ. Outbreak- was detected at a lower frequency in winter (37% versus 73%; associated Salmonella enterica serotypes and food commodities, United Chi-square P , 0.01). States, 1998–2008. Emerg Infect Dis 2013;19:1239–1244. 3. European Food Safety Authority. Opinion of the Scientific Panel on Thirteen of the 54 samples collected from truck mudguards biological hazards (BIOHAZ) related to Risk assessment and mitigation were Salmonella-positive. They yielded 18 isolates that com- options of Salmonella in pig production. The EFSA J 2006;341:1–131. prised 6 serovars and 4 Salmonella Typhimurium phage types 4. Ojha S, Kostrzynska M. Approaches for reducing Salmonella in pork production. J Food Prot 2007;70:2676–2694. (Table 1). Distribution varied according to the time at which 5. Arguello H, Alvarez-Ordoñez A, Carvajal A, Rubio P, Prieto M. Role of mudguards were sampled. Salmonella was found on truck mud- slaughtering in Salmonella spreading and control in pork production. guards upon arrival (4 positive samples/18 samples tested, 22%; J Food Prot 2013;76:899–911. 6. International Organization for Standardization. ISO6579:2002. 6 isolates/18 total isolates, 33%); during unloading (5/18, 28%; Microbiology of food and animal feeding stuffs — Horizontal method 5/18, 28%), and upon leaving (7/18, 39%; 7/18, 39%) the for the detection of Salmonella spp. 2002. Standard revised by ISO

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6579-1:2017. Available from: https://www.iso.org/standard/56712.html 12. Jensen AN, Lodal J, Baggesen DL. High diversity of Salmonella serotypes Last accessed May 16, 2018. found in an experiment with outdoor pigs. NJAS — Wageningen J Life 7. Roberts D, Greenwood, M. Practical Food Microbiology, 3rd ed. Ames, Sci 2004;52:109–117. Iowa: Wiley-Blackwell, 2002. 13. Rajić A, Keenliside J, McFall ME, et al. Longitudinal study of 8. Biomérieux API® 20E — 18–24 hour identification of Enterobacteriacae Salmonella species in 90 Alberta swine finishing farms. Vet Microbiol and other non-fastidious gram negative bacteria. Biomérieux Canada, 2005;105:47–56. St. Laurent, Quebec. 14. Mainar-Jaime RC, Atashparvar N, Chirino-Trejo M, Rahn K. Survey 9. Grimont PAD, Weill F-X. Antigenic Formulae of the Salmonella on Salmonella prevalence in slaughter pigs from Saskatchewan. Can Vet Serovars. 9th ed. Cedex, France: Collaborating Center for Reference J 2008;49:793–796. and Research on Salmonella, Institut Pasteur, 2007. 15. Andres VM, Davies RH. Biosecurity measures to control Salmonella 10. Anderson E, Ward L, de Saxe M, de Sa JD. Bacteriophage-typing desig- and other infectious agents in pig farms: A review. Comp Rev Food Sci nations of Salmonella Typhimurium. J Hyg (Lond) 1977;78:297–300. Food Saf 2015;14:317–335. 11. De Busser EV, De Zutter L, Dewulf J, Houf K, Maes D. Salmonella control in live pigs and at slaughter. Vet J 2013;196:20–27. COMMUNICATIONBRÈVE

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1108 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Brief Communication Communication brève

Serological survey of canine vector-borne diseases in Saskatchewan, Canada

M. Casey Gaunt, Anthony P. Carr, Susan M. Taylor

Abstract — Whole blood samples were collected from 515 dogs in the practice region surrounding Saskatoon, Saskatchewan, Canada between 2008 and 2010 and evaluated for seroprevalence of vector-borne diseases. Of 515 samples, 12 (2.3%) were positive, with 7 (1.4%) positive for antibodies to Borrelia burgdorferi. These prevalences are higher than those previously reported for this region.

Résumé — Enquête sérologique des maladies canines à transmission vectorielle en Saskatchewan, au Canada. Des échantillons de sang total ont été prélevés auprès de 515 chiens dans des établissements vétérinaires des environs de Saskatoon, en Saskatchewan, au Canada, entre 2008 et 2010, et ont été évalués pour la séroprévalence des maladies à transmission vectorielle. Parmi les 515 échantillons, 12 (2,3 %) étaient positifs et 7 (1,4 %) étaient positifs pour les anticorps contre Borrelia burgdorferi. Ces prévalences sont supérieures à celles précédemment signalées pour cette région. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1109–1111

ector-borne diseases are an important and emerging health west to Saskatchewan found that 2.5% of tests were positive for V concern for humans and animals worldwide. A recent spe- Borrelia burgdorferi antibodies, while less than 0.5% of samples cial report in the Canadian Veterinary Journal highlighted the were positive for antibodies to Ehrlichia canis or Anaplasma increasing risk of Lyme disease in Canada (1). The geographic phagocytophilum. Despite this large number of samples, only distribution of vectors, reservoir hosts, and pathogens has been 186 samples came from Saskatchewan, with 0.5% of those shifting and expanding (2,3), necessitating up-to-date surveil- testing positive for antibodies to B. burgdorferi (8). While the lance studies to assess current risk. western Canadian provinces of British Columbia and Manitoba Several large seroprevalence studies have provided excellent have well-recognized pockets of endemic vector-borne diseases data on changing pathogen prevalence in North America and including heartworm and Lyme, Saskatchewan and Alberta the Caribbean; however, these studies lack strong data from continue to be underrepresented in the literature (7–9). the Canadian prairie provinces of Alberta, Saskatchewan, and Three dogs with clinical illness due to granulocytic anaplas- Manitoba (4–6). One recent short communication described mosis were identified in Saskatchewan in 2009 and seropreva- the seroprevalence of vector-borne diseases in a large number lence data identifying exposure to West Nile virus in dogs from of dogs from across Canada; however, less than 2% of the cases Saskatchewan were reported in 2015; however, other vector- came from the provinces of Saskatchewan and Alberta (7). A borne diseases such as ehrlichiosis and Rocky Mountain spot- more recent large survey that reviewed 115 636 SNAP 4DX ted fever are not usually considered endemic in Saskatchewan Plus test results collected in 2013–2014 from eastern Canada (10,11). While there are no known endemic populations of Ixodes scapularis within the province of Saskatchewan, the role 615, 5th Street East, Saskatoon, Saskatchewan S7H 1G4 of migratory birds in the delivery of competent vectors to the (Gaunt); Western College of Veterinary Medicine, Department region as well as the projected expansion of vector range due of Small Animal Clinical Sciences, 52 Campus Drive, Saskatoon, to climate change make further investigation critical to allow Saskatchewan S7N 5B4 (Carr, Taylor). for the development of appropriate screening and prevention Address all correspondence to Dr. Casey Gaunt; e-mail: strategies in this region (12–14). [email protected] The aim of this study was to determine prevalence of B. burg- Disclosure statement dorferi, A. phagocytophilum, E. canis, and Dirofilaria immitis; and IDEXX Labs Canada provided the SNAP 4Dx tests. There are to identify potential risk factors for exposure to vector-borne no competing financial interests. pathogens in dogs from Saskatchewan. Use of this article is limited to a single copy for personal study. Serum and whole blood samples were collected from 135 clin- Anyone interested in obtaining reprints should contact the ically healthy client-owned dogs presenting to the Veterinary CVMA office ([email protected]) for additional Medical Centre (VMC) in Saskatoon, Saskatchewan, Canada copies or permission to use this material elsewhere. between 2008 and 2010 for routine health care procedures.

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Table 1. SNAP 4Dx test results. Percent positive test results for dogs tested between 2008–2010 for antigen to Dirofilaria immitis and antibodies to B. burgdorferi, Anaplasma spp. and Ehrlichia spp. B. burgdorferi Group Total positive B. burgdorferi Anaplasma spp. Ehrlichia spp.  Anaplasma spp. All samples 12/515 (2.3%) 7/515 (1.4%) 3/515 (0.6%) 3/515 (0.6%) 1/515 (0.2%) Laboratory samplesa 7/366 (1.9%) 4/366 (1.1%) 1/366 (0.3%) 3/366 (0.8%) 1/366 (0.3%) Known totalb 5/149 (3.4%) 3/149 (2%) 2/149 (1.3%) — — Known healthyc 3/135 (2.2%) 1/135 (0.7%) 2/135 (1.5%) — — Known sickd 2/14 (14.3%) 2/14 (14.3%) — — —

a Samples collected from PDS with no known historical, travel, or clinical information. b Samples with known historical, travel, and clinical information. Healthy and sick dogs combined. c Samples with known historical, travel, and clinical information. Only clinically healthy dogs. d Samples with known historical, travel, and clinical information. Only clinically sick dogs. COMMUNICATIONBRÈVE Owners signed a consent form approved by the University of healthy dogs (1/135; 0.7%). None of the sick dogs were positive Saskatchewan Animal Use Committee to allow testing of their for A. phagocytophilum antibodies. However, 2/135 (1.5%) and samples. The seroprevalence of antibodies to West Nile virus 1/135 (0.7%) samples from healthy dogs were positive for A. in these dogs has previously been reported (11). In addition to phagocytophilum and B. burgdorferi antibodies, respectively. those 135 healthy dogs, samples were collected during the same Seven of the 366 (1.9%) dogs with unknown historical or time frame from 14 dogs presenting to the VMC for assessment clinical data collected from the PDS laboratory were positive of clinical illness with differential diagnoses including infectious for 1 or more pathogens on the SNAP 4Dx test. The positive or vector-borne diseases. The final diagnoses for these patients tests included 4/366 (1.1%) positive for B. burgdorferi antibod- included endocarditis (1/14), lameness/arthritis (2/14), Shar ies, 1/366 (0.3%) positive for A. phagocytophilum antibodies Pei fever (1/14), gastroenteritis (3/14), polyarthritis (5/14), and 3/366 (0.8%) positive for E. canis antibodies. One dog unspecified immune mediated disease (1/14), fever of unknown (0.3%) was positive for both B. burgdorferi and A. phagocyto- origin (2/14), arthritis (1/14), with 1 dog having both fever philum antibodies. and lameness. None of the 135 healthy client-owned dogs or The overall vector-borne disease seroprevalence of 2.3% is the 14 clinically ill dogs had left the province of Saskatchewan higher than has been previously reported for Saskatchewan, in the previous 2 y. with higher seroprevalence rates for B. burgdorferi (1.4%) and Additionally, 366 whole blood samples submitted for labora- A. phagocytophilum (0.6%) than those reported for the prov- tory testing to Prairie Diagnostic Services Laboratory, Saskatoon, ince in recent surveys. The failure to identify any heartworm Saskatchewan were evaluated for seroprevalence of the 4 previ- antigen is consistent with previous reports for the region (7,8). ously described pathogens. No historical data, travel, or medical Bowman et al (6) reported the prevalence of vector-borne dis- information was available for these samples. eases in the neighboring states of Montana and North Dakota The SNAP 4Dx (IDEXX Laboratories, Markham, Ontario) in 2008. Animals from Montana that were tested did not have was used to determine the presence of D. immitis antigen, antibodies to B. burgdorferi, A. phagocytophilum, or E. canis, but A. phagocytophilum antibody, B. burgdorferi antibody, and 0.6% had evidence of D. immitis antigen, while animals from E. canis antibody in each sample. There may be cross reactivity North Dakota had higher rates for both B. burgdorferi (3%) and with Anaplasma platys or Ehrlichia ewingii, though no further A. phagocytophilum (2.4%) (6). testing was performed to assess for this possibility. The sensi- Interestingly, Herrin et al (8) reported Saskatchewan as having tivity and specificity of each of these tests have been reported the highest seroprevalence of E. canis of any province in Canada by IDEXX Laboratories (package insert) and also reviewed with 3/186 (1.6%) samples positive. Our result of 0.6% is lower; previously (8). however, it is within their reported 95% confidence interval (CI) Twelve of the 515 samples that were tested (2.3%) had a and is still above the national average reported in that study positive result on the SNAP 4Dx, for 1 or more pathogens, with (0.14%). Herrin et al (8) did not include samples from Alberta 1 dog being positive for both B. burgdorferi and A. phagocyto- or British Colombia in their study, so the true current Canadian philum antibodies. Seven of the dogs (1.4%) were positive for national prevalence is unknown. B. burgdorferi antibodies, 3 (0.6%) tested positive for A. phago- Although B. burgdorferi and A. phagocytophilum infections cytophilum antibodies and 3 (0.6%) were positive for E. canis are transmitted by the same tick vector, Ixodes scapularis, a antibodies. No samples were positive for D. immitis antigen. much lower seroprevalence was observed for A. phagocytophi- The SNAP 4Dx results are summarized in Table 1. lum antibodies than for B. burgdorferi antibodies in this study. When dogs with a known clinical history were considered This finding is noteworthy given the previous report of clinical separately, 5/149 (3.4%) were seropositive for 1 or more patho- anaplasmosis in 3 dogs from Saskatchewan (10). Despite this gens on the SNAP 4Dx test. These included 3/149 (2.0%) test- low value, 0.6% prevalence for A. phagocytophilum antibodies is ing positive for B. burgdorferi antibodies and 2/149 (1.3%) test- still above what was recently reported to be the national average ing positive for A. phagocytophilum antibodies. Dogs classified as for Canada (8). sick were more likely to test positive for B. burgdorferi antibodies No statistically significant differences were identified between (2/14; 14.3%, both diagnosed with polyarthritis) than were patients with known versus unknown clinical histories or

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between sick versus healthy dogs, despite a tendency for dogs dog found to be positive in such a low prevalence environment with polyarthritis to be B. burgdorferi positive. No risk factors should be retested prior to clinical intervention (7). for seropositivity were identified. The association between The results from this study serve to expand the information

each evaluated risk factor of interest and serological outcomes on vector-borne disease in the province of Saskatchewan, and BRIEF COMMUNICATION was examined using logistic regression (SAS for Windows suggest that these diseases must remain in consideration when ver. 9.3; SAS, Cary, North Carolina, USA). The failure to clinical signs are present, despite lack of travel to a previously demonstrate a clear difference is likely a reflection of the low documented endemic area. positive rate and the small number of patients in the known Acknowledgment clinical history and sick patient groups. There are several important limitations to this study. Only The authors gratefully acknowledge the University of 149/515 dogs had known clinical and travel histories. As such, Saskatchewan Companion Animal Health Fund which provided it is impossible to know the reason for sampling in the 366 dogs financial support for this project. CVJ tested through the commercial laboratory. These samples may References have been submitted as part of routine screening in healthy 1. Bouchard CB, Leonard E, Koffi JK, et al. The increasing risk of Lyme patients or part of a clinical investigation into underlying dis- disease in Canada. Can Vet J 2015;56:693–699. ease. Additionally, for the dogs with unknown travel histories, 2. Chomel B. Tick-borne infections in dogs: An emerging infectious threat. Vet Parasitol 2001;179:294–301. it is possible that they were exposed to pathogens outside of 3. Ogden NH, Mechai S, Margod G. Changing geographic ranges of ticks Saskatchewan and not locally exposed. This being said, the and tick-borne pathogens: Drivers, mechanisms and consequences for seroprevalence rates in this population of dogs are comparable pathogen diversity. Front Cell Infect Microbiol 2013;3:46. 4. Yancey CB, Hegarty BC, Qurollo BA, et al. Regional seroreactivity to those found in the 2 recent Canadian studies (7,8) as well as and vector-borne disease co-exposure in dogs in the United States from the seroprevalence rates identified in dogs with a known clinical 2004–2010: Utility of canine surveillance. Vector-borne Zoonotic Dis 2014;14:724–732. history in the current study, suggesting they may be representa- 5. Qurollo BA, Chandrashekar R, Hegarty BC, et al. A serological survey tive of the population as a whole. of tick-borne pathogens in dogs in North America and the Caribbean The inclusion of samples from the 14 sick dogs may bias the as assessed by Anaplasma phagocytophilum, A. platys, Ehrlichia canis, E. chaffeensis, E. ewingii and Borrelia burgdorferi species-specific peptides. results towards a higher seroprevalence; however, the authors Infect Ecol Epidemiol 2014;4. doi: 10.3402/iee.v4.24699. felt it was appropriate to keep these data in the final analysis 6. Bowman D, Little SE, Lorentzen L, Shields J, Sullivan MP, Carlin EP. in light of the unknown clinical histories of 366 dogs tested Prevalence and geographic distribution of Dirofilaria immitis, Borrelia burgdorferi, Ehrlichia canis, and Anaplasma phagocytophilum in dogs in through a commercial laboratory. Moreover, when a final analy- the United States: Results of a national clinic-based serologic survey. sis was performed after removing data from the 14 sick dogs, the Vet Parasitol 2009;160:138–148. 7. Villeneuve A, Goring J, Marcotte L, Overvelde S. Seroprevalence of prevalence rate was higher than had been previously reported Borrelia burgdorferi, Anaplasma phagocytophilum, Ehrlichia canis, and for Saskatchewan. The small number of sick dogs with clinical Dirofilaria immitis among dogs in Canada. Can Vet J 2011;52:527–530. signs consistent with vector-borne diseases makes it impossible 8. Herrin BH, Peregrine AS, Goring J, Beall MJ, Little SE. Canine infection with Borrelia burgdorferi, Dirofilaria immitis, A. phagocytophilum, to draw conclusions about the true prevalence of these diseases and E. canis in Canada, 2013–2014. Parasit Vectors 2017;10:244 doi: in the region. Continued evaluation of the population of sick 10.1186/s13071-017-2184-7. dogs is necessary to gauge the real impact of vector-borne dis- 9. Banerjee S, Stephen C, Fernando K, Coffey S, Dong M. Evaluation of dogs as sero-indicators of the geographic distribution of Lyme borreliosis eases in the area. in British Columbia. Can Vet J 1996;37:168–169. This study used a convenience sample consisting of clinically 10. Cockwill KR, Taylor SM, Snead EC, et al. Granulocytic anaplasmosis in three dogs from Saskatoon, Saskatchewan. Can Vet J 2009;50:835–840. healthy dogs recruited through the Veterinary Medical Centre. 11. Gaunt MC, Waldner C, Taylor SM. Serological survey of West Nile Because it was not a random sample, it is not possible to say how Virus in pet dogs from Saskatchewan, Canada. Vector-borne Zoonotic well the results can be generalized to all dogs in the province. Dis 2015;15:755–758. 12. Anstead CA, Chilton NB. Ticks feeding on northern pocket gophers It is possible that the independence assumption was violated, (Thomomys talpoides) in central Saskatchewan and the unexpected because some dogs could have lived in the same household. detection of Ixodes scapularis larvae. J Vector Ecol 2011;36:355–360. However, given the average number of dogs per household in 13. Ogden NH, St-Onge L, Barker IK, et al. Risk maps for range expansion of the Lyme disease vector, Ixodes scapularis, in Canada the dataset would be substantially less than two, the impact on now and with climate change. Int J Health Geogr 2008;7:24. doi: study estimates of prevalence would be minimal (15). 10.1186/1476-072X-7-24. 14. Ogden NH, Barker IK, Francis CM, Heagy A, Lindsay LR, Hobson KA. Given the low prevalence of all of these diseases in How far north are migrant birds transporting the tick Ixodes scapularis Saskatchewan, it must be considered that some of these posi- in Canada? Insights from stable hydrogen isotope analysis of feathers. tive results could represent false positives. The positive predictive Ticks Tick Borne Dis 2015;6:715–720. 15. Dohoo I, Martin W, Stryhn H. Introduction to clustered data. In: value of the SNAP 4Dx test has, however, been suggested to be Veterinary Epidemiologic Research. 2nd ed. Charlottetown, PEI: VER acceptable in similar serosurveys. Despite this, any asymptomatic Inc., 2010:535.

CVJ / VOL 59 / OCTOBER 2018 1111 FOR PERSONAL USE ONLY Brief Communication Communication brève

Assessing the sharpness of hypodermic needles after repeated use

Kadin Majcher, Dustin Eichorn, Cheryl Waldner, James Johnston, Chris Clark, Murray Jelinski

Abstract — Four gauges (14G, 16G, 18G, 20G) of single use hypodermic needles were evaluated for sharpness by measuring the force required to puncture rehydrated bovine leather. The needles began to dull after 1 use with maximum bluntness occurring within 4 to 5 uses.

Résumé — Évaluation du tranchant des aiguilles hypodermiques après un usage répété. Quatre gabarits (14G, 16G, 18G, 20G) d’aiguilles hypodermiques à usage unique ont été évalués pour le tranchant en mesurant la force requise pour percer du cuir bovin réhydraté. Les aiguilles ont commencé à s’émousser après 1 usage et la capacité de tranchant maximale se produisait durant les 4 ou 5 premières utilisations. (Traduit par Isabelle Vallières) Can Vet J 2018;59:1112–1114

ingle use medical devices such as hypodermic needles are apply to using single use needles; balancing strict hygienic S routinely used in human and veterinary medicine to miti- practices with the time and cost associated with using a new gate the spread of infectious agents among patients. Within the needle for each injection. Apart from the potential for iatrogenic veterinary community there has been a number of documented disease, single use needles dull very quickly thus requiring more cases of iatrogenic transmission of infectious diseases due to the penetration force, making them more susceptible to bending and repeated use of needles (1,2). This concern coupled with needle breakage (7). Breakage is of concern because broken needles may stick injuries, and economic losses resulting from injection site become embedded within meat products. In Canada, a survey blemishes and broken needles found in meat products, have of beef processors found that 41% received at least 1 complaint been the impetus for developing needle-free injection devices annually of broken needles found in retail meat products (8). (3). This technology, however, has not been widely adopted and The International Organization of Standardization (ISO) hence single use needles remain in common use in veterinary provides standards and methods for testing single use hypoder- medicine. mic needles (9), as well as for the stainless steel tubing (needle Livestock producers routinely reuse the same needle on mul- stem) used in their manufacture (10). There is, however, a tiple animals. In fact, Canada’s Verified Beef Program advises paucity of information related to testing of hypodermic needles producers to change needles after 10 to 15 uses (4). A recent for use in veterinary medicine. In 1999, Hoff and Sundberg survey of producers in the United Kingdom found that 43% of (11) published the results of a study in which 2 lengths of producers changed needles when the needle broke or became 16 gauge (G) and 18G needles were tested for sharpness using blunt during vaccination procedures (5). Furthermore, a survey pig cadavers. Using a mechanical spring scale, they assessed the of food and mixed animal practitioners found that veterinarians force (pounds) needed to penetrate the pig cadavers at 0, 10, routinely use needles more than once (6). These studies under- 20, 30, and 40 repetitions or repeat penetrations. From these score the pragmatic approach that producers and veterinarians results it appeared that the 16G and 18G needles became dull after 20 repeated punctures. However, the force measurements were taken after every 10th needle penetration and the method of measuring force was relatively imprecise compared with College of Engineering (Majcher, Eichorn, Johnston), Large current technology. Animal Clinical Sciences, Western College of Veterinary The objective of this study was to indirectly assess the number Medicine (Waldner, Jelinski), Department of Veterinary of times a single use needle could be used before signs of dull- Biomedical Sciences, Western College of Veterinary Medicine ing. Dulling was determined by measuring the amount of force (Clark), University of Saskatchewan, Saskatoon, Saskatchewan. required to perforate tanned hide. The greater the change in Address all correspondence to Dr. Murray Jelinski; e-mail: required force, the greater the degree of dulling. [email protected] The testing medium was bovine vegetable tanned side leather Use of this article is limited to a single copy for personal study. (Tandy Leather, Fort Worth, Texas, USA). Prior to testing, the Anyone interested in obtaining reprints should contact the leather was rehydrated by soaking in a warm water bath for CVMA office ([email protected]) for additional a minimum of 30 min. Leather strips, averaging 2.8 mm in copies or permission to use this material elsewhere. thickness, were then cut from a single hide and examined for

1112 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY

120 Force actuator 100 * * 80

Load cell BRIEF COMMUNICATION 60 Hypodermic * needle 40 * 20

Test stage (Newtons) force Puncture 14G 16G 18G 20G 0 P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 Leather test strip Needle puncture

Figure 2. Mean peak penetration force (Newtons) plots for 4 single use hypodermic needles. The asterisk (*) represents the point at which the mean force required to penetrate the Figure 1. Each bovine leather sample was fixed to the leather was not different (P , 0.05) from force required for MTS Bionix testing system by clamping the sample between the preceding penetration. 2 aluminum plates. The test needle moved axially, penetrating the leather at a perpendicular angle. assessed with a Wald test and planned post hoc comparisons were assessed within each gauge following each puncture and among irregularities before testing. Single use, bevel tipped, stainless gauges for each puncture value. Model residuals were checked steel, hypodermic needles (Monoject; Covidien, Mansfield, graphically for normality and homogeneity of variance. Needle Maine, USA) of 4 different gauges (G14, G16, G18, and G20) dulling was considered to have peaked when the force required were tested. Each needle was forced to penetrate the leather to penetrate the leather did not change significantly from one 10 times, with the leather being repositioned 10 mm between puncture to the next. All levels of statistical significance were tests to ensure the needle penetrated intact leather. Testing P , 0.05. was conducted intermittently over a 6-week period, beginning The mean force (N) required by the 14G, 16G, and 18G with the smallest bore needles (G20). The ten 20G needles needles to penetrate the leather increased significantly between were tested on 2 separate days (5/d). All ten 18G needles were the 1st and 2nd puncture (P1–2) and 2nd and 3rd puncture tested the same day, while the ten 16G needles were tested (P2–3), but was not different between the 3rd and 4th puncture over 2 consecutive days (2 and 8 needles/d). Lastly, 4 of the (P3–4) (Figure 2). Specifically, the P-values for the 3 needles 14G needles were tested the same day, with the remaining 6 at P3–4 were as follows: 14G (P = 0.08); 16G (P = 0.31); 18G the following day. (P = 0.20). Apart from 1 exception, P5–6 for the 16G needles A servo-hydraulic material testing system (MTS Bionix; MTS (P = 0.001), there were no significant changes in mean force System Corporation, Eden Prairie, Minnesota, USA) controlled between successive penetration points for the remainder of the the axial displacement of the needles during testing, Figure 1. study. Since there was no difference in the mean peak penetra-

Two rigid aluminum plates fixed the position of the leather and tion force for the P3–4 interval, it can be concluded that the nee- ensured constant surface tension during penetration with an dle reached maximum dullness at the time of the 3rd puncture. exposed test diameter of 9.52 mm. In preparation for testing, The 20G needles appeared to dull sooner, with no sig-

the needle hub was separated from the stem and the tip visually nificant change in the mean force (P = 0.07) across the P2–3 inspected for deformation. A chuck was then used to secure the interval. Hence, maximum dullness occurred at the time of the needle stem in place, preventing any unwanted movement. Each 2nd puncture. needle penetrated the leather perpendicularly to the surface at a The mean increase in total force from the 1st puncture to rate of 2 mm/s until puncture occurred. Peak penetration force the puncture in which no further significant increases in force

(puncture force) was recorded at a frequency of 1000 Hz with occurred were: P2–3 for 14G [19.5 N; 95% confidence interval a data acquisition system (National Instruments Corporation, (CI): 10.6 to 28.3]; P2–3 for 16G (37.3 N; 95% CI: 28.5 to Austin, Texas, USA) and converted to Newtons (N). 46.1); P2–3 for 18G (13.8 N; 95% CI: 5.0 to 22.7); and P1–2 Descriptive statistical analysis of the mean peak penetration for 20G (13.1 N; 95% CI: 6.7 to 19.5). These represented force for each needle gauge was completed using commercial relative mean increases of 33.1% (14G), 64.7% (16G), 54.8% software (STATA/SE 14.0 for Windows; StataCorp LP., College (18G), and 43.6% (20G) above the force required for the initial Station, Texas, USA). A mixed model with a random intercept puncture. for each needle was used to examine the differences in peak In addition to differences in mean force between consecutive

penetration force among puncture number (P1 to P10) and the penetration time-points, the difference in mean forces across gauge of the needles (14G, 16G, 18G, and 20G). An auto the 4 needle gauges at each penetration point were exam- regressive (1) correlation structure was used to account for the ined. A repeating pattern emerged from this analysis. At each order of observations within each needle. The model contained of the 10 puncture points, there were no differences between an interaction between puncture number and gauge as well as the mean forces for the 14G and 16G needles (P $ 0.13), and each main effect. The significance of the interaction term was the mean forces for the 18G and 20G needles (P $ 0.32). The

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mean puncture forces for all other paired comparisons, at each increasing risk of needle fatigue at the stem-hub juncture with puncture point, were significantly different (P # 0.03). These increased repeat usage. This study could be conducted on both relationships are evident in Figure 2, with the lines representing single use and multi-use needles and with needles from different the 14G and 16G needles being very close together, as are the manufacturers. lines for the 18G and 20G needles. The results indicate that single use needles dull rapidly, All 4 needle gauges displayed the same general trend beginning after a single use. There were no significant differ-

throughout the study, with the mean peak penetration forces ences in mean peak force between P3 and P4, and all sequential being lowest at P1 and then steadily increasing at the 2nd and puncture points (P5 to P10) for the 14G, 16G, and 18G needles. 3rd puncturing events until the penetration force approached to However, mean peak forces tended to drift higher towards plateau (Figure 2). This plateau can be attributed to the cessa- the end of the test. This suggests that the needles may have tion of dulling in which the needle reached maximum bluntness. continued to fatigue, making them slightly less sharp and thus In the dulled state, the same amount of force was required for requiring greater force to penetrate the leather. For all intents

COMMUNICATIONBRÈVE each subsequent penetration. Conceivably, had the study been and purposes, single use needles, regardless of gauge, become extended, there may have been additional wear and dulling of dull within 2 to 3 uses, and should be considered blunt by the the needles. Furthermore, to facilitate testing, the needle stem 4th to 5th use. Finally, the results should not be construed as had been detached from the hub. Had the needle remained encouraging the repeated use of single use needles. Rather we intact, fatigue at the stem-hub junction may have resulted in draw attention to how rapidly these needles become dull, which needle breakage. It has been reported (11) that lateral forces increases the risk of bending and breaking. placed on the needle result in sheering at the stem-hub joint. Although there was a linear increase in the bore size of the Acknowledgments needles, this was not reflected in the amount of force required We thank Dr. Sarah Parker for her help interpreting the statis- to penetrate the leather. Presumably, the small bore 20G nee- tical outcomes and Drs. Lope Tabil and Majid Soleimani for dle would have required the least amount of force, with the lending laboratory testing equipment. CVJ 14G needle requiring the most. However, at P1 the 14G and 16G required similar amounts of force, as did the 18G and 20G. References Despite every effort being made to standardize the testing, the . 1 Brightling P, Radostits OM. Bovine leukosis virus infection in a dairy similarity in force measurements of the 14G and 16G needles herd in Saskatchewan. Can Vet J 1983;24:362–363. and the 18G and 20G needles (Figure 2) suggests that some bias 2. Reinbold JB, Coetzee JF, Hollis LC, et al. Comparison of iatrogenic transmission of Anaplasma marginale in Holstein steers via needle and may have occurred during testing. Perhaps there were differences needle-free injection techniques. Am J Vet Res 2010;71:1178–1188. in the relative moisture content of the leather or the leather 3. Rey MR, Undi M, Rodriguez-Lecompte JC, et al. A study of the was not homogenous. This may also explain why the 20G line effectiveness of needle-free injection device compared with a needle and syringe used to vaccinate calves against bovine viral diarrhea and crossed that of the 18G needle in Figure 2, and why it appeared infectious bovine rhinotracheitis viruses. Vet J 2013;198:235–238. to dull sooner than the other 3 needles. 4. Verified Beef Production Plus, Producer Resources, Injection techniques While the data are not shown, preliminary testing was also for beef cattle. Available from: http://verifiedbeefproductionplus.ca/files/ producer-resources/injection_site_technique_poster.pdf Last accessed performed on 3 reusable 16G stainless steel needles (Jorvet; June 18, 2018. Jorgensen Labs, Loveland, Colorado, USA). These needles were 5. Anderson DE, Silviera F. Survey of large animal veterinarians’ biosecu- inserted into the leather 15 times and appeared to maintain rity practices. Proc 41st American Association of Bovine Practitioners Conference, Charlotte, North Carolina, 2008:244. sharpness over the course of the trial; however, an insufficient 6. Thacker JG, Rodeheaver GT, Towler MA, Edlich RF. Surgical needle number of needles were tested for statistical analysis. These sharpness. Am J Surg 1989;157:334–339. findings are salient because the Verified Beef Program suggests 7. Cresswell E, Remnant J, Butterworth A, Wapenaar W. Injection-site lesion prevalence and potential risk factors in UK beef cattle. Vet Rec changing needles after 10 to 15 uses (4), or when they become 2017;180:70. bent, broken, or contaminated. Presumably, this recommenda- 8. Van Donkersgoed J. Canadian Cattlemen Quality Starts Here — Broken tion is based on the needles’ degree of sharpness and an increased needles in beef. Available from: https://www.google.ca/url?sa=t&rct=j &q=&esrc=s&source=web&cd=1&cad=rja&uact8&ved=0ahUKEwjG risk of bending and breakage. However, the recommendations pLyH3IfYAhVXGMKHWO3B80QFggnMAA&url=http%3A%2F% do not specifically identify whether the needles are single use or 2Fwww.agromedia.ca%2FAFMG%2FSection%25205%2520Quality multi-use needles. If the latter, then the preliminary data indicate %2520Assurance%2F5J2%2520Broken%2520Needles%2520in%25 20Beef.pdf&usg=AOvVaw1JJQ0h8FS5LjX3sQsxTgpn Last accessed that these needles should remain sharp for at least 15 injections. June 18, 2018. Future studies should consider using cadavers to more 9. International Organization of Standardization: Sterile hypodermic closely recreate the tissue layers in which a needle is inserted. needles for single use — Requirements and test methods. 4th ed. Reference number ISO 7864:2016. Furthermore, intact needles should be tested for sheering. This 10. International Organization of Standardization: Stainless steel needle could be accomplished by inserting the needle into a cadaver tubing for the manufacture of medical devices — Requirements and to the level of the hub and then applying lateral forces, which test methods. 2nd ed. Reference number ISO 9626:2016. 11. Hoff SJ, Sundberg P. Breakage and deformation characteristics of hypo- would approximate what occurs when an animal suddenly moves dermic devices under static and dynamic loading. Am J Vet Res 1999; while the needle is fully inserted into the tissue. Such a study 60:292–298. could provide a science-based recommendation related to the

1114 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Practitioners’ Corner Le coin des praticiens

What is your diagnosis?

Leila Bedos, Ruth Dennis, Adrien Aertsens

9-year-old neutered male golden retriever dog was referred performed, but aspiration was difficult and no effusion could be A for right pelvic limb lameness. The dog had been presented drawn. Little material was obtained despite multiple attempts; to the referring veterinary surgeon 4 wk previously for acute this revealed a low cellularity which was therefore not helpful. lameness. He had been rested and given a non-steroidal anti- Magnetic resonance imaging (MRI) of the stifle joint was inflammatory drug (NSAID) and subsequently the clinical carried out using a 1.5 Tesla magnet (GE Signa Echospeed; signs resolved. General Electric, Milwaukee, Wisconsin, USA) with the dog in General examination was unremarkable. The orthopedic right lateral recumbency on a spinal radiofrequency (RF) coil. examination revealed a 1/5 right pelvic limb lameness, muscular This revealed an extensive, lobulated soft tissue mass in the soft atrophy on the right pelvic limb, thickening at the medial aspect tissues surrounding the distal femur and proximal tibia which of the proximal tibia and distal femur, severe stifle effusion, extended over a total distance proximodistally of 20 cm. The and pain on stifle extension. The cranial drawer and the tibial mass was predominantly cranial to the femur and probably thrust signs were negative, and no meniscal click could be felt. located in fascial planes rather than invading muscles, but it The rest of the orthopedic and the appendicular neurologic also extended caudally at the level of the femoral condyles on examinations were within normal limits. Radiographs of the both lateral and medial aspects. It extended distally between right stifle were taken. the patella and the femoral trochlear groove into the stifle joint, compressing the fat pad as seen on the radiographs. There was a Diagnostic imaging: small, focal area of invasion into the caudal margin of the medial Findings and interpretation femoral condyle and possibly into the medial margin of the On the radiographs, there was almost complete obliteration lateral condyle via the intercondylar fossa. The mass extended of the infrapatellar fat pad and displacement of fascial planes only lateral to the tibia. caudally, caused by soft tissue with opacity (Figures 1A, B). The Aside from its lobular aspect, the mass appeared relatively distribution of the soft tissue cranial to the joint space was not homogeneous, hypointense to fat and hyperintense to muscle typical for a joint effusion, and raised the suspicion of a soft on T2W and proton density weighted (PDW) sequences, mark- tissue mass. edly hyperintense on Short TI Inversion Recovery (STIR), and Mild changes of osteoarthritis in the form of tiny osteophytes isointense on T1W sequences. There was heterogeneous contrast on the patella, proximal end of the trochlear groove, medial enhancement with some poorly enhancing areas, and a marked fabella, and medial and lateral tibial margins were present but joint effusion surrounded by inflamed synovium (Figure 2). the tibia and femur were aligned normally and there were no visible changes on the tibial plateau at the insertion site of the What steps would you take to cranial cruciate ligament (CCL). determine a diagnosis? The absence of obvious bony changes on the tibial plateau Additional tests, treatment, and outcome and the pattern of intracapsular soft tissue opacity suggested that Biopsies were taken from the affected stifle, and the results were CCL disease was not a likely radiographic diagnosis in this case consistent with lipoma. However, the appearance of the lesion and other causes of severe joint effusion or soft tissue mass in on MRI was consistent with a more aggressive process not con- the joint should be considered. Arthrocentesis of the joint was sisting of adipose tissue. Biopsies of the joint were consequently repeated through a craniocaudal approach, allowing excision of the intra-articular part of the mass together with a portion of the Western College of Veterinary Medicine, University of capsule. Soft tissue in the cranial tibial area was also biopsied. Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan The histopathologic findings were consistent with a malig- S7N 5B4 (Bedos, Aertsens); Animal Health Trust, Lanwades nant spindle cell mesenchymal neoplastic proliferation, most Business Park, Kennett, Newmarket CB8 7UU, UK (Dennis). likely compatible with a soft tissue sarcoma. Therefore, amputa- Address all correspondence to Dr. Leila Bedos; e-mail: tion of the limb was recommended. [email protected] Prior to surgery, the thorax and abdomen were staged using Use of this article is limited to a single copy for personal study. computed tomography, which revealed only mild right ingui- Anyone interested in obtaining reprints should contact the nal and medial iliac lymphadenopathy. Ultrasound-guided CVMA office ([email protected]) for additional fine-needle aspirates (FNAs) of the enlarged lymph nodes were copies or permission to use this material elsewhere. consistent with non-specific reactive lymphadenopathy with

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LE COINLE DES PRATICIENS C

Figure 1. Radiographic views of the right stifle of a 9-year-old neutered male golden retriever dog, with a history of acute onset of lameness. A — Mediolateral view with arrows pointing at the proximal and distal margins of an intra-articular area of increased opacity mimicking joint effusion. B — Craniocaudal view with arrows pointing at the most medial and lateral margins of increased opacity area. The medial area mimics medial buttress which is seen with chronic cranial cruciate ligament disease. C — Mediolateral view of the contralateral stifle with arrow pointing at the normal fat pad area.

no signs of metastatic spread of the tumor. Right pelvic limb the size and location of the tumor and include lameness, pain, amputation with disarticulation of the coxofemoral joint was swelling around the affected joint, and enlarged lymph nodes (3). performed as a potentially curative treatment. Although SCSs are locally invasive and aggressive tumors, they have a relatively low metastatic potential (32%) depend- Discussion ing on the grade. Metastasis most often occurs in the lungs and Tumors arising around joints in dogs include fibrosarcoma, occasionally in the regional lymph nodes (2). rhabdomyosarcoma, osteosarcoma, malignant fibrous histiocy- A presumptive diagnosis of synovial cell sarcoma is often toma (MFH), liposarcoma, hemangiosarcoma, myxoma, soft made based on the presence of compatible clinical signs. tissue malignant giant cell tumor, and undifferentiated sarcoma. Definitive diagnosis is only achieved with biopsies and histo- Synovial cell sarcoma (SCS) remains the most common neo- logic analysis (4). The surgical biopsies taken from the infiltrated plasm affecting joints (1). It is a malignant tumor that arises cranial tibial muscle were consistent with a malignant spindle from synoviocytes of the joint and the capsule of the tendon cell mesenchymal neoplastic proliferation, most likely compat- sheath. Histologically, these tumors are classified as biphasic ible with a soft tissue sarcoma. Immunohistochemistry is often when both spindle and epithelial cells are present or monophasic recommended in such cases in order to differentiate SCS from when there is a lack of epithelial cells (1). An SCS is graded from other joint tumors; however, various authors do not always 1 to 3 depending on nuclear pleomorphism, mitotic figures, agree with this approach (2). In our case immunohistochem- and necrosis (2). istry proved beneficial in this respect. The results showed the Although SCS has been reported to be the most common immunophenotype of the neoplastic population compatible joint tumor, a retrospective study including 35 dogs showed with synovial cell sarcoma; this was based on the presence of that 51.4% were histiocytic in origin (1). neoplastic cells positive to vimentin and cytokeratin (CK). Synovial cell sarcomas are rare in cats and dogs. In dogs, Initial work-up involves imaging of the area to assess the they tend to occur in large breeds, with a predisposition for extent of the tumor. Periosteal reactions, remodeling, and flat-coated retrievers and golden retrievers (2). These sarcomas osteolysis of the bone can be seen on the radiographs (3,5). typically involve large joints of the extremities, especially the Advanced cross-sectional imaging allows more precise visualiza- stifle, elbow, and shoulder (2). Clinical signs vary depending on tion of the local invasion.

1116 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY

B A PRACTITIONERS’ CORNER PRACTITIONERS’

Figure 2. A — transverse STIR image, 5-mm slice thickness; B — sagittal T2W image, 3-mm slice thickness. These images show an extensive soft tissue mass surrounding the femoral condyles and extending into the joint. The arrows point to the extension of the mass.

Wide surgical excision, most often consisting in amputation References of the whole limb, enables control of the tumor and the best 1. Craig LE, Julian ME, Ferracone JD. The diagnosis and prognosis of long-term outcome (1,6). Chemotherapy protocols should synovial tumors in dogs: 35 cases. Vet Pathol 2002;39:66–73. be considered for the treatment of grade III canine SCS after 2. Liptak JM, Forrest LJ. Soft tissue sarcomas. In: Withrow S, Vail D, eds. Withrow and MacEwen’s Small Animal Clinical Oncology. 4th ed. amputation (6). The effectiveness of adjuvant chemotherapy St. Louis, Missouri: WB Saunders, 2007:433–434. is unknown in dogs (6), but one study reports some response 3. Yamate J, Aota M, Kuwamura M, Kotani T, Shimada T. Synovial sar- with the use of doxorubicin HCl and cyclophosphamide (7). In coma of the tendon and tendon sheath in a dog. J Vet Med Sci 2006;68: 983–986. humans, the use of ifosfamide-based chemotherapy was associ- 4. Liptak JM, Dernell WS, Farese JP, Worley DR. Musculoskeletal system. ated with an improved disease-specific survival (8). In: Kudnig TS, Seguin B, eds. Veterinary Surgical Oncology. 1st ed. Radiation therapy is another optional treatment for large Hoboken, New Jersey: John Wiley & Sons, 2012:549–552. 5. Silva-Krott IU, Tucker RL, Meeks JC. Synovial sarcoma in a cat. J Am soft tissue sarcomas that cannot be surgically excised or for Vet Med Assoc 1993;203:1430–1431. preoperative treatment (9). However, in the case presented here, 6. Vail DM, Powers BE, Getzy DM, et al. Evaluation of prognostic factors considering the invasion of the joint, bone, and musculature for dogs with synovial sarcoma: 36 cases (1986–1991). J Am Vet Med Assoc 1994;205:1300–1307. surrounding the lesion, amputation was considered the best 7. Tilmant LL, Gorman NT, Ackerman N, Mays MB, Parker R. Che treatment option. Adjuvant chemotherapy was offered, but was motherapy of synovial cell sarcoma in a dog. J Am Vet Med Assoc 1986; declined by the client. 188:530–532. 8. Eilber FC, Brennan MF, Eilber FR, et al Chemotherapy is associated The long-term prognosis for dogs with synovial cell sarcoma with improved survival in adult patients with primary extremity synovial depends on many factors, including the histologic appearance, sarcoma. Ann Surg 2007;246:105–113. type of treatment, and evidence of metastatic disease. The 9. Ettinger SNE. Principles of treatment for soft-tissue sarcomas in the dog. Clin Tech Small Animal Pract 2003;18:118–122. median survival time for dogs affected with SCS treated with limb amputation is 850 d; only 455 d are reported with conservative excision (2).

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Industry News Nouvelles de l’industrie

Timeless Veterinary Systems® and ClienTrax® Expand Technology Partnership Timeless Veterinary Systems Inc., a specialized veteri- Rowe is very pleased to be launching this 2nd integration with nary technology company located in Prince Edward Island, ClienTrax and further expanding on their technology partner- and ClienTrax, a technology solutions company located in ship, noting “with the integration of the Timeless Veterinary Columbus, Ohio have further expanded on their technology Cloud PACS, ClienTrax in partnership with Timeless can now partnership and are pleased to announce another major integra- offer clinics a new and innovative approach to telemedicine that tion. The Timeless Veterinary Cloud PACS is now integrated is designed to simplify the entire referral process and improve with the ClienTrax Practice Management Software providing the referral experience saving clinics time by streamlining their an innovative way for clinics to quickly move images to the workflow”. radiologist instead of the radiologist to the images. This provides Jeff Good, Vice President of ClienTrax, commented that optimum reliability and performance with event-driven work- “ClienTrax is proud to launch a new Cloud PACS providing an flows that help keep clinics on task, custom-triggering notifica- integrated web-based solution for our clinics’ radiology imaging tions for study interpretation, transcription, report downloads, workflow all from within our practice management software. etc., until the loop is closed. More than just a PACS, it is a Our Clinics now can submit a case request without ever having comprehensive workflow solution that addresses the challenges to leave ClienTrax, and to add to the already seamless workflow, of today’s reading environments. Advanced DICOM interface the final case report is even automatically sent directly to the tools and HL7 integration make the Timeless Veterinary Cloud patient’s medical record in their ClienTrax Practice Management PACS a must-have integration that operates seamlessly within System, keeping all the patients’ information in the medical the ClienTrax Practice Management System. The Timeless record and saving the clinic more time.” Veterinary Cloud PACS provides advanced imaging tools with The ClienTrax Practice Management software is now fully an integrated downloadable desktop DICOM viewer and a integrated with the Timeless Veterinary Cloud PACS, and Zero-Footprint HTML5 DICOM Web Viewer that delivers access to the Timeless Veterinary Telemedicine global network simple, secure access to imaging results. of service providers adds to its already powerful list of features The Timeless Veterinary Cloud PACS offers even more to provide clinics with a truly all-in-one Veterinary manage- advanced features with instant access to the Timeless Veterinary ment solution. Telemedicine global network of service providers directly from within the ClienTrax Practice Management System. This pro- Contact: Timeless Veterinary Systems Inc., 614 North River Road, vides a seamless workflow for DVMs and Specialists to commu- Suite E, Charlottetown, PE C1A 1K2; phone: 1-855-247-2327; nicate and share patient information. Timeless President, John website: TimelessVeterinary.com

Lilly to Separate Elanco Animal Health with Initial Public Offering Eli Lilly and Company announced that its subsidiary, Elanco a number of factors and uncertainties, including business and Animal Health, has filed a registration statement with the market conditions. U.S. Securities and Exchange Commission (SEC) for an initial “With more than six decades of expertise in animal health, public offering (IPO) of common stock. we are prepared to take this step to become an independent The offering is expected to represent an ownership stake of company,” said Jeffrey Simmons, president of Elanco Animal less than 20 percent. The number of shares to be offered and Health. “With a sole focus on animal health, we will help our the price range for the offering have not yet been determined. customers address the greatest challenges of keeping animals The company expects to complete the IPO process during the healthy, and together advance a vision of food and companion- second half of 2018. ship enriching life.” For Lilly’s financial reporting, Lilly will continue to con- solidate Elanco in its financial results. Lilly plans to divest Contact: Elanco Animal Health, 150 Research Lane, Suite 120, its remaining ownership through a tax-efficient transaction. Guelph, ON N1G 4T2; phone: 1-800-265-5475; website: Execution of the IPO is dependent upon — and subject to — www.elanco.ca

1118 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Special Report Rapport spécial

West Nile virus in horses — What do you need to know to diagnose the disease?

Julie Paré, Alison Moore

est Nile virus (WNV) is an emerging arthropod-borne reportable/notifiable diseases [rabies, eastern equine encepha- W pathogen that causes disease in horses and humans, as litis (EEE)], which should be ruled out to confirm disease. well as in a variety of other animals. The virus is maintained Correct identification of WNV cases in horses is important within the avian wildlife population that acts as a natural reser- since surveillance indicates the presence of a pathogen and its voir and amplifier for the virus, which is transmitted mostly by vector in a geographic area, and the risk of infection to other mosquitoes (Culex spp.) (1). equines and humans. Cases of WNV infection in horses (and In humans, WNV infection is considered a serious zoonotic other domestic animals) are reported to the animal health and disease. The infection is asymptomatic in 80% of cases and public health federal-provincial-territorial entities. West Nile appears as a flu-like syndrome in 20% of cases. Neurological virus is also a notifiable disease to the World Organisation for disease develops in less than 1% of infections. In these, how- Animal Health (OIE). ever, case fatality may be as high as 20%, and chronic disease develops in most survivors. In Canada, the number of human A horse is classified as a positive case cases reported varied, from 21 to 190 in the past 5 years (1). based on clinical signs AND The first case of WNV in horses was diagnosed in Canada in laboratory testing 2002 (2). West Nile virus is an immediately notifiable disease The horse must have a clinical presentation of ataxia and at under the Health of Animals regulations in Canada (3) and is least 2 of the following: circling, hind limb weakness, inability also a notifiable disease in many provinces (British Columbia, to stand, multiple limb paralysis, muscle fasciculation, proprio- Alberta, Saskatchewan, Manitoba, Ontario, and Quebec). From ceptive deficits, blindness, lip droop/paralysis, teeth grinding, 2013 to 2017, the number of cases reported in horses in Canada fever, and acute death (4). via passive surveillance has been 57, 21, 19, 46, and 54 per year Clinical history, location of the horse, as well as vacci- respectively, reflecting a continued presence of the virus, and nation status on the submission form will help confirm the need for horse owner awareness of the risks and preventative diagnosis and determine the area at risk. measures. Laboratory testing involves identification of the virus or of Infection in horses can be asymptomatic; however, approxi- a specific immune response to WNV (4). The identification of mately 20% of horses infected will develop clinical signs. These WNV may involve isolation from tissue [preferred diagnostic signs include ataxia (stumbling, staggering, wobbly gait, or tissues are brain or spinal cord; blood or cerebrospinal fluid incoordination) combined with circling, hind limb weakness, (CSF)] or by a positive polymerase chain reaction (PCR) to inability to stand, multiple limb paralysis, muscle fasciculation, WNV genomic sequences in tissues and appropriate histological proprioceptive deficits, blindness, lip droop/paralysis, teeth changes or, a positive immuno-histochemistry (IHC) for WNV grinding, fever, or acute death. Horses that develop neuro- antigen in tissue and appropriate histological changes. logical disease may have up to 30% case-fatality, and another Serological diagnosis is useful for an animal with clinical 10% to 20% recover with residual neurologic deficits. The signs. Detection of IgM antibody to WNV by enzyme-linked clinical manifestation of WNV infection may resemble other immunosorbent assay (ELISA) testing in serum or CSF in a horse that is not known to have been recently vaccinated con- firms the diagnosis if associated with compatible clinical signs. Animal Health Science Directorate, Canadian Food Inspection Immunoglobulin M (IgM) antibody detection by ELISA is Agency, 3200 Sicotte Street, Saint-Hyacinthe, Quebec J2S 7C6 the test of choice since IgM antibodies are short-lived and (Paré); Animal Health and Welfare Branch, Ontario Ministry indicative of a recent infection. There is no need for paired of Agriculture, Food and Rural Affairs, 1 Stone Road West, samples to confirm the diagnosis. In some horses, vaccination Guelph, Ontario N1G 4Y2 (Moore). with specific vaccines has been reported to cause increases in Address all correspondence to Dr. Julie Paré; e-mail: IgM concentration for up to several weeks after vaccination; [email protected] therefore, the date of the most recent WNV vaccination, if Use of this article is limited to a single copy for personal study. known, should accompany the test request (5,6). Otherwise, Anyone interested in obtaining reprints should contact the confirmation of a case requires an associated 4-fold or greater CVMA office ([email protected]) for additional change in IgG ELISA test or serum neutralization (SN) test copies or permission to use this material elsewhere. antibody titer to WNV in paired sera, in which the first serum

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should be drawn as soon as possible after onset of clinical signs 3. Government of Canada [homepage on the Internet] Health of Animals and the second drawn at least 7 d after the first. Unless paired Regulations (C.R.C., c. 296) Part X, Section 91.2. Available from: http:// laws-lois.justice.gc.ca/eng/regulations/C.R.C.,_c._296/page-10.html# serum samples are submitted, the elevated titer to WNV anti- h-51 Last accessed August 9, 2018. body by SN test in serum or positive IgG ELISA test on a single 4. Government of Canada [homepage on the Internet] Health of Animals sample will only allow classification as a possible case (4). Regulations (C.R.C., c. 296) Part X, Section 91.2. Available from: http:// www.inspection.gc.ca/animals/terrestrial-animals/diseases/immediately- Clinical history and appropriate test selection contribute to notifiable/west-nile-virus/surveillance/eng/1346131121021/134613121 effective and efficient diagnosis of West Nile virus infection on 3336 Last accessed August 9, 2018. an individual basis and with a One Health perspective. 5. Jonquiere FJ, van der Heijden HMJF, van Maanen C, Sloet van Oldruitenborgh-Oosterbaan MM. West Nile virus vaccination in horses — IgM and IgG responses after injection in different muscles. References Pferdeheilkunde 2011;27:412–416. 1. Gray TJ, Webb CE. A review of the epidemiological and clinical aspects 6. Khatibzadeh SM, Gold CB, Keggan AE, et al. West Nile virus–specific of West Nile virus. Int J Gen Med 2014;7:193–203. immunoglobulin isotype responses in vaccinated and infected horses. Am RAPPORT SPÉCIAL 2. Weese JS, Baird JD, DeLay J, et al. West Nile virus encephalomyelitis in J Vet Res 2015;76:92–100. horses in Ontario: 28 cases. Can Vet J 2003;44:469–473.

Book Review Compte rendu de livre

Diagnostic Techniques in Veterinary advanced imaging. There is an abundance of high quality Dermatology photos depicting various procedures, organisms, and derma- tological lesions as well as charts, diagrams, and graphs that Neuber A, Nuttall T. Wiley-Blackwell, Hoboken, New Jersey, are scattered throughout the book. I anticipate the parasite USA. 2017. 312 pp. ISBN: 9781-1192-3304-6. identification guide on pages 39–40 will be visited frequently and I would encourage everyone to read the section on basic or those of us who may have, at one time or another, histopathological terminology as it is very helpful. The discus- F approached their dermatology patient with a little bit of sion surrounding the interpretation of bacterial culture and apprehension, this book is a step in the right direction in alle- sensitivity results in chapter 6 is highly relevant and practical. viating those fears. The authors have compiled a step-by-step The schematic representations of tests (e.g., PCR, ELISA, guide as to how to perform and interpret tests that are essential fluorescent antibodies) in the infectious disease chapter were to every dermatology case workup, as well as detailing other also very useful. The chapter which I think will attract the diagnostics which may be required in more complex cases. I most attention, however, is chapter 14, “Which Test to Choose believe this book will benefit students, technicians, and practic- When,” of which the figures regarding lesion distribution for ing veterinarians. pruritic skin conditions in dogs (there is also one for cats) is The book is comprised of 15 chapters, the first of which invaluable and highly needed. The references provided at the introduces us to the equipment needed for performing a der- end of the book are very useful if more in-depth information matological examination. Included in this chapter are point- is required. ers on the use of the microscope and maximizing success in Patients with skin and ear problems are a daily occur- cytology slide preparation and staining. The reader is then rence in practice. This book gives you the tools and confi- guided through a systematic dermatology workup whereby dence in working up these cases as well as knowing when to the first half of the book revolves around fundamentals such recommend referral. as looking for parasites, performing hair plucks, trichograms and cytology, while the second half introduces the reader to Reviewed by Cheryl Vargo, DVM, MVetSc, Dip ACVIM, Western histopathology, allergy, endocrine, and infectious testing and College of Veterinary Medicine, Saskatoon, Saskatchewan.

1120 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY Commentary Commentaire

Access to veterinary care for low-income Canadians

Martha J. Harding

read with great interest Dr. Carlton Gyles’ editorial in the those living without (5) and seniors with dementia become I April 2018 issue of the Canadian Veterinary Journal, titled less anxious and confused when sitting with and stroking a pet “Challenges for the veterinary profession” (1). Dr. Gyles dis- (6). Pets have been found to influence the course and optimal cusses 4 of 7 challenges that are common in both the US and functioning of persons with mental health disorders includ- Canada. These areas for concern were originally identified by ing schizophrenia, depression, anxiety, and attention deficit Dr. Patty Khuly in Veterinary Practice News in her article, “The hyperactivity disorder (ADHD) (7,8). Mental health patients 7 top challenges facing veterinary medicine in 2017” (2). become more involved in their environment in nonthreatening I am especially interested in Dr. Khuly’s and Gyles’ comments ways with a companion animal (4). Therefore, aiming to support regarding the challenges of providing veterinary care for low- pets, both medically and behaviorally, provides great benefits for income pet owners, the so-called “Money Gulf.” society, including citizens of all socioeconomic groups. Dr. Khuly writes: Across Canada, many veterinary practices and veterinarians offer reduced rate services and payment plans to impoverished “The yawning divide between rich and poor pet owners shows Canadians in times of emergency, especially for their long-term no signs of abating. Those with the finances and education clients. Furthermore, many non-profit animal rescue organiza- will manage to redirect their disposable dollars toward their tions, community foundations, and veterinary outreach efforts pets. Those with few to speak of will continue to show me regularly fund veterinary care at hospitals of their choice for pets their $40 and ask me how much that’ll buy. Heartbreaking. owned by low-income clients and by women seeking refuge from Moreover, as we build this castle ever higher, we’ll continue to domestic abuse situations. In Ontario, the Ontario Veterinary face the harsh reality that this glorious standard of care we’re Medical Association’s Farley Foundation (9) and Community so proud of is leaving the majority of pet owners behind. And, Veterinary Outreach (10) are notable examples. However, all of as history shows, an uncomfortable uprising often accompanies the generous goodwill efforts nationally are unable to provide economic disparities like this one. Could an antiveterinary widespread, consistent, and comprehensive assistance to low- backlash be too far behind? This is the biggest issue veterinary income pet owners because of the overwhelming need, notably medicine faces as it enters 2017. What’s more, it’s not as if for working age adults, persons with disabilities, children in we can’t do something about it. Increased compassion toward single-parent families, seniors, and indigenous people (11). price sensitivity at the micro level may not be profitable in An exceptional veterinary hospital structure model that aims the short term, but it’s worth millions in goodwill over the to ensure access to veterinary care for pets of low-income citizens long haul.” (2). is the United Kingdom’s Registered Charity “Peoples Dispensary As a Canadian veterinary profession, we should ensure that for Sick Animals (PDSA)” (12). Per their website: “Founded systems are in place to support access to veterinary care for all in 1917 by animal welfare pioneer, Maria Dickin CBE, PDSA domesticated animals regardless of owners’ income and geo- is the UK’s leading veterinary charity. Operating through a graphic circumstance. Dr. Froma Walsh, when Co-Director of UK-wide network of 48 Pet Hospitals and additional mobile ser- the Center for Family Health, University of Chicago, detailed vices, PDSA provides low cost and free veterinary care to the sick the literature supporting broad evidence that interactions with and injured pets of people in need and promotes responsible pet companion animals contribute to good health, psychosocial ownership.” Animals are also cared for with the same accessible well-being, and recovery from serious conditions (3,4). As rates in one of nearly 400 collaborating clinics during weekends, examples, children living with pets are more empathetic than holidays, and after-hour periods. The PSDA network is one of the largest corporate veterinary employers in the UK, with nearly 500 full- and part-time veterinarians. The organization offers Address all correspondence to Dr. Martha J. Harding; e-mail: free emergency veterinary service for 1 pet per household and [email protected] low-cost preventative services for all additional pets for eligible Owner/Veterinarian, East Village Animal Hospitals, London/ pet owners on social assistance. Their outreach programs run Kitchener, Ontario. active fundraising campaigns and volunteer programs, as well as Use of this article is limited to a single copy for personal study. provision of Pet Insurance and educational resources. Anyone interested in obtaining reprints should contact the Our East Village Animal Hospitals (EVAH) (13) in London CVMA office ([email protected]) for additional and Kitchener, Ontario, are “beta-testing” the PDSA type of copies or permission to use this material elsewhere. charitable veterinary clinic model in Canada. Both hospitals

CVJ / VOL 59 / OCTOBER 2018 1121 FOR PERSONAL USE ONLY

are College of Veterinarians of Ontario “Companion Animal ensure the legacy of current non-profit veterinary hospital Hospital” facilities devoted exclusively to providing veterinary initiatives, and their associated funding support systems, while services of pets cared for by low-income citizens and animal addressing “The Money Gulf” issue identified by Dr. Khuly (2). rescue organizations. The hospitals house ASPCA/Humane We welcome the opportunity to continue to work with pro- Alliance-partnered High Volume Spay/Neuter clinics (14), with vincial colleges, veterinarians, veterinary technicians and other grant support from Pet Smart Charities of Canada (15) and interested staff members, animal rescue organizations, volunteers funding from the Registered Charity Animal Outreach (16), and donors to assist in the creation of additional non-profit as well as many other charitable organizations and individuals. veterinary clinics, such as the EVAHs, and collaborating after- EVAH-London opened in January 2014 and EVAH-Kitchener hour clinics across the country that would mirror the network became operational in July 2017. Both hospitals also offer com- of PDSA clinics in the UK. As such, the veterinary profession

COMMENTAIRE prehensive general medical and surgical care. Since opening, we will become truly invested in the Canadian Veterinary Medical have worked to derive price-points for all products and services Association’s Canadian Veterinary Oath (18), which in part as low as possible to ensure sustainability in the long-term, declares that “I will strive to promote animal health and welfare, assuming the hospital is situated amongst a human population prevent and relieve animal suffering, protect the health of the public of at least 1 million persons within a 100-km radius. EVAH and the environment…”, for all Canadians, regardless of the pet employs approximately 15 full- and part-time staff in each owner’s socio-economic status. clinic and as well are fortunate to welcome dozens of volunteers, including student veterinary externs, pre-veterinary/technician References students, high school co-op seniors, and disadvantaged youth. . 1 Gyles C. Challenges for the veterinary profession. Can Vet J 2018;59: 339–342. To help ensure widespread access to veterinary care, notably 2. Khully P. The 7 top challenges facing veterinary medicine in 2017. Vet in more remote regions, EVAH runs mobile clinics on First Pract News February 26, 2017. Nations communities throughout the province. In collaboration 3. Walsh F. Human-animal bonds I: The relational significance of companion animals. Fam Process 2009;48:462–480. with the London-Middlesex Housing Corporation, our staff and 4. Walsh F. Human-animal bonds II: The role of pets in family systems volunteers provide veterinary visits in pet owners’ homes in local and family therapy. Fam Process 2009;48:481–499. geared-to-income housing units. EVAH is officially partnered 5. Melson GF. Child development and the human-companion animal bond. Am Behav Sci 2003;47:31–39. with a Registered Charity [Animal Outreach (16)], which is a 6. Baun M, McCabe B. Companion animals and persons with dementia mandate for an ASPCA/Humane Alliance Spay/Neuter clinic of the Alzheimer’s type: Therapeutic possibilities. Am Behav Sci 2003; (14) and unofficially partnered with many animal rescue and 47:42–51. 7. Barker S, Dawson K. The effects of animal-assisted therapy on anxiety community service organizations, including local women’s ratings of psychiatric patients. Psychiatr Serv 1998;49:797–801. shelters. Through donations and volunteer efforts of our staff 8. Beck AM. Review of pets and our mental health: The why, the what, and partner non-profit organization, Progressive Animal Welfare and the how. Anthrozoos 2005;18:441–443. 9. Farley Foundation. [Website on Internet]. Available from: https://www. Services (PAWS) (17), a “micro-loan” program is often avail- farleyfoundation.org Last accessed July 30, 2018. able, which supports a loan of up to $200 to $300 per client, 10. Veterinary Community Outreach. [Page on Internet]. Available from: to cover the costs of emergency veterinary care performed at https://vetoutreach.org Last accessed July 30, 2018. our EVAH clinics. 11. Citizens for Public Justice, Poverty Trends 2017. [Page on Internet]. Available from: https://www.cpj.ca/poverty-trends-2017 Last accessed A network of charity clinics across Canada, similar to the July 30, 2018. PDSA or EVAH structure, would help provide comprehen- 12. People’s Dispensary for Sick Animals (PDSA). [Page on Internet]. sive assistance for low-income pet owners on a national scale. Available from: https://www.pdsa.org.uk Last accessed July 30, 2018. 13. East Village Animal Hospital Professional Corporation — London, East Currently, Registered Charities are not allowed to own and oper- Village Animal Hospital Professional Corporation — Kitchener. [Page ate veterinary clinics in most Canadian provinces. EVAHs are on Internet]. Available from: www.evah.ca Last accessed July 30, 2018. each their separate Professional Corporations; however, they are 14. American Society for the Prevention of Cruelty of Animals/Humane Alliance Program. [Website on Internet]. Available from: https://www. unofficially designated and operated as non-profit corporations aspca.org/humane-alliance Last accessed July 30, 2018. (Matthew Veterinary Consulting Inc, personal communication, 15. PetSmart Charities of Canada. [Page on Internet]. Available from: 2016). Concerted efforts to work alongside provincial colleges https://www.petsmartcharities.ca Last accessed July 30, 2018. 16. Animal Outreach. [Page on Internet]. Available from: www.animalout to update veterinary regulations and with provincial legislatures reach.ca Last accessed July 30, 2018. to expand business corporations acts, which would allow both 17. Progressive Animal Welfare Services (PAWS). Available from: www. professional AND non-profit corporations to own and operate pawslondon.ca Last accessed July 30, 2018. 18. The Canadian Veterinary Oath, Canadian Veterinary Medical Asso veterinary practices accessible to the low-income community ciation. Available from: https://www.canadianveterinarians.net/about/ would be a giant leap forward. These latter endeavors would veterinary-oath Last accessed July 30, 2018.

1122 CVJ / VOL 59 / OCTOBER 2018 FOR PERSONAL USE ONLY The Art of Private Veterinary Practice L’art de la pratique vétérinaire privée

Communication: Too compliant client communication

Myrna Milani

eterinary education often comes across as uncompromis- After clipping and thoroughly cleaning the injured areas, V ing. Problems receive specific names; their symptoms are the veterinarian ascertained that the lacerations were superficial described, diagnostic protocols defined, and treatments dis- and that no deeper structures were involved. She then sutured cussed. Students commit this to memory and subsequent quizzes those that required it and medicated and bandaged the affected and tests more deeply implant this information. Rarely during area to keep it clean and control the waning bleeding from the this process do the effects of different kinds of client compliance puncture wounds. When Dr. Snyder discharged the dog later on this process receive much, if any, attention. When it does, that day, she gave the client verbal and written instructions to lack of compliance, or rather the wrong kind invariably receives medicate the dog as directed, keep the bandages clean and dry, all the attention. and monitor the dog’s activities. The client sincerely thanked Consequently, when Dr. Snyder discovers during her clinical the practitioner for giving his dog such good care and prom- rotations throughout her veterinary education and even more ised to follow her instructions to the letter. so in private practice that noncompliance is not an alien client When Dr. Wertlieb returned with his dog for suture response, she begins to dream about how perfect the practice removal, Dr. Snyder could not believe what she saw. The of veterinary medicine would be if only all clients were compli- bandages were clean and dry, but only what little remained ant. When she shared this observation with her employer, Dr. of them. Mistaking her look of befuddlement as a request for Sagendorf, he smiled and replied, “Be careful what you wish for.” more information, the client then referred to his copious notes At the time, she could not imagine anything that would make describing all the dog activities since the client picked him up client compliance problematic. at the clinic. He told Dr. Snyder exactly when and where the Several months later, Dr. Snyder thought the veterinary dog chewed at the bandages and how he — the client — care- compliance gods had answered her prayers when she met with fully trimmed any damp edges to ensure the remnants would Dr. Wertlieb — a faculty member at a nearby university — and remain clean and dry as directed. The client also observed his dog for the first time. The dog had attempted to enlarge a carefully as his dog played with his toys in the yard as usual small opening in an old wire fence surrounding an abandoned and rough-housed with the neighbor’s dog, also as usual. This chicken coop by digging through it. The client suspected that resulted in a small amount of blood oozing from one of the the presence of some wild animal inside the coop had triggered puncture wounds on the left foot, but it soon stopped. The the frenzied digging that resulted in several lacerations to the dog displayed no signs of discomfort during the recovery dog’s front legs and puncture wounds in both front feet. Because period. Nor was there any evidence of bleeding in the house of the nature of the injuries and the young dog’s high-spirited that the client could see. temperament, Dr. Snyder recommended that she anesthetize “His idea of ‘monitoring’ went on and on,” Dr. Snyder later the dog so she could evaluate his injuries and treat them prop- explained to Dr. Sagendorf. “It was maddening because, in a erly. The client readily agreed and told the veterinarian to do way, he did do everything I told him to do. Literally. But he whatever was necessary. missed the whole point of it. I just don’t get it. He’s an edu- cated man and this wasn’t rocket science!” Dr. Milani is a behavior and bond practitioner, teacher, and “That was the problem,” replied Dr. Sagendorf with a smile. author of several books on the interaction of animal behavior, When his associate gave him a puzzled look, he elaborated. health, and the human-animal relationship. “Dr. Wertlieb is a rocket scientist. He’s a highly regarded Use of this article is limited to a single copy for personal study. aeronautical and space researcher. I’m sure he did his best, Anyone interested in obtaining reprints should contact the but he knows as little about veterinary medicine as you and I CVMA office ([email protected]) for additional combined probably know about rocket science. Consequently, copies or permission to use this material elsewhere. he had no choice but to take everything literally.”

CVJ / VOL 59 / OCTOBER 2018 1123 FOR PERSONAL USE ONLY

“If he didn’t know, why didn’t he just tell me?” asked his client tells herself she got the gist of it in spite of Dr. Snyder’s still frustrated associate. “I would have been happy to clarify speedy delivery and her own age-related hearing loss. Similarly, anything he didn’t understand.” when doubts arise about her animal’s condition several days “But he thought he did understand,” replied her employer. later, Ms. Patel recalls how exhausted and frazzled “that poor “He interpreted the instructions you gave him the same way Dr. Snyder” looked and decides not to bother the veterinarian. he would those related to comparable situations in his area In this situation, perceiving client compliance where it does of expertise. Because you didn’t give him specific instructions not exist may be another side effect of clinician work-related or regarding how to keep the bandages clean and dry or how to other sources of exhaustion or stress. When frazzled Dr. Snyder replace them if they became wet or dirty, he simply removed any discusses the animal’s problem and how to address it, the veteri- wet and dirty parts. When you told him to monitor the dog, narian could miss the fleeting expressions of confusion on her he did the same kind of monitoring he does when he runs an client’s face as she breezes through her instructions. This doesn’t experiment: he observed and made notes.” occur because she does not care about Ms. Patel or her animal; Dr. Snyder’s initial thought was to tell Dr. Sagendorf that, the veterinarian does care. But her compromised mental state if Dr. Wertlieb truly cared about his dog, he would not have blinds her to the existence of these subtler forms of client com- behaved in such a ridiculous way. Fortunately, she suppressed munication. Similarly, Dr. Snyder may miss telltale signs that

L’ART DE LA PRATIQUE VÉTÉRINAIREPRATIQUE LA DE PRIVÉE L’ART the retort when she sensed what her more experienced employer indicate clients with invisible disabilities such as mild hearing would say. loss or vision impairment, may struggle to comprehend her soft- “I shouldn’t have assumed that, just because Dr. Wertlieb spoken instructions or read the small print on her written ones. was a professor, he had a lot of knowledge about animal care or Comparing faux-compliant client responses to those of even what I consider plain old common sense about dogs,” she clients she expects to understand her instructions because of admitted instead. “I’ll never make that mistake again.” their education or expertise in other areas, she may not see any Feeling confident that his associate was sincere, Dr. Sagendorf signs of confusion in either group because she does not expect then used the incident as a catalyst for a discussion of other them. Same result — diminished animal care — but quite kinds of compliant client communication dilemmas. Like different causes. most veterinary practices, theirs also serves several clients with “But with all these possibilities, how can I prevent mak- autism spectrum disorder whose limitations are not discernable. ing these mistakes again without hurting their feelings or However, when confronted by situations outside their experi- violating their rights?” asks Dr. Snyder who now is feeling ence, these people also may interpret any information — includ- somewhat beleaguered. ing any veterinary instructions — quite literally. In this regard, Asking, “Do you have any questions about these instruc- though, these clients are no different from Dr. Wertlieb. And, tions?” as part of her routine examination or discharge summary in fact, they are no different from anyone hearing or reading for all clients eliminates the possibility of making these mistakes. instructions that are outside their areas of expertise. Reiterating key elements of the treatment process for all clients Other times clients, who do not fully understand any veteri- also facilitates client communication. For example, Dr. Snyder nary instructions, may feign compliance because they hesitate could tell Dr. Wertlieb that, if his dog’s bandage gets wet or to ask the practitioner for clarification for some reason. For soiled, he can change it himself or bring the dog to the clinic example, when Dr. Snyder rushes into the examination room, for this service. When she feels frazzled and rushed, she could she immediately apologizes profusely to Ms. Patel for keeping remind her clients that they can contact her or the practice the client waiting. The veterinarian then explains that an emer- should any questions arise later. gency case plus on-going viral outbreak at a local shelter has Client compliance may take different forms and, relative to wreaked havoc with her schedule. This causes the ever-gracious ensuring animal health, some succeed better than others. But and compliant Ms. Patel to decide not to further complicate by acknowledging this possibility and incorporating preventive the busy veterinarian’s life by asking Dr. Snyder to repeat the communication into their routine, practitioners can avoid the instructions regarding the proper treatment of her animal. The negative fallout that otherwise may occur.

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COLOURS: CLIENT: Nestlé Purina PetCare DATE: June 28, 2018 SPECIAL INSTRUCTIONS: Press Quality Pdf provided as Cyan final artwork. CONTACT: EK, VPN TRIM: 8.5” x 11” Magenta PROJECT ID: PRINTS: English only CONTACT: Walter Castaldi at (905) 741-9221 Yellow [email protected] FONTS: Antenna, Berling, Gotham Condensed Black FILE NAME: PPPVD NF Feline Sheet for CVJ July-October MAC SOFTWARE: ID CC18, IL CC18, PS CC18 Full Page Ad - English FILE ORGIN: wac