Sunday, November 16, 2014

Home , Veterinary surgery

SUNDAY, NOVEMBER 16, 2014 Wet Lab and Hands-on Learning Event! Continuing education in a small group clinical setting on the campus of the specialty practices in Tustin

ADVANCED CARE FOR PETS

Advancing th gy e Art of Veterinary Dermatolo SUNDAY, NOVEMBER 16, 2014 Wet Lab and Hands-on Learning Event! PRESENTATION NOTES

Groups Speakers Topics ECFA Julius Brinkis, DVM, DACVO Eyelid Mass Wedge Resection VSS Tony Cambridge, BVMS, DACVS Wound Closure Techniques and Surgical Reconstruction Options AVMI Mike Broome, DVM Advanced Imaging Case Studies - Answering the Clinical Question. AVIM Cindy Duesberg, DVM, ACVIM Catheterizing the Female Dog Can be a Bitch Michelle Cieplucha, DVM AVCC Sarah Zimmerman,DVM, DACVIM (Cardiology) The Echocardiogram: When and Why (Notes available on-site) ADC Melissa Hall, DVM, DACVD My Five Favorite Products in Dermatology Patients and Why! VCG Mona Rosenberg, DVM, DACVIM (Oncology) Cytology and Slide Preparation for Everyday Lumps and Bumps Sara Fiocchi, DVM, DACVIM (Oncology) Julie Bulman-Fleming, DVM, DACVIM (Oncology) David Bommarito, DVM, MS, ACVR, DACVIM (Oncology) VNC Stephen Hanson, DVM, DACVIM (Neurology) Strange “Neuro” Cases Stacy Dillard, DVM, DACVIM (Neurology) AVSG Sarah Beaman, DVM Taps and Tubes After Hours Diane Craig, DVM, DACVS OCVS Andrea McDooling, BVSc, MS, DACVIM (SAIM) Immune Mediated Polyarthritis (Notes available on-site) Ashley Cruse, DVM, DACVIM (SAIM) Leyla Fatourechi, DVM, DACVECC

CE CERTIFICATES WILL BE AVAILABLE FOR PICK-UP FOLLOWING YOUR LAST SESSION AND COMPLETION OF YOUR EVALUATIONS OF TODAY’S PROGRAM www.AVSG.net

ADVANCED CARE FOR PETS

Advancing th gy e Art of Veterinary Dermatolo EYELID MASS WEDGE RESECTION Julius Brinkis, DVM, DACVO and Douglas Esson, BVSc, MRCVS, DVM, DACVO

Eyelid lacerations as well as tumors affecting the lid margins are relatively commonly encountered. As a consequence eyelid re-apposition is a frequently performed procedure.

Referral to an ophthalmologist is sometimes not possible; however the anatomy of this region dictates a high risk for post-surgical complication and failure.

As a consequence we will aim to provide a brief anatomical and surgical review of simple eyelid repair following wedge resection.

This review will take the form of a short video presentation followed by an instructional wet lab (using pig eyes), guided by Drs. Esson DACVO & Brinkis DACVO, who will also be available (time-permitting) to discuss interesting or challenging cases.

Eye Care for Animals acknowledges Cara Animal Care Products for providing wet lab instrumentation & suture material.

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Wound Closure and Surgical Reconstruction Techniques

Tony Cambridge BVMS MRCVS Dip ACVS www.vssoc.com Email: [email protected] (949) 936-0055

The majority of wounds in our patients, be it from trauma or tumour resection, are simply closed. Having a variety of available practical techniques can allow the surgeon to avoid significant complications associated with large wound dehiscence or the compromise of distal tissue associated with a closure that is too tight, on a limb for example.

KISS- "Keep It Simple, Stupid" Apply the least complex method that has a high probability of success. Use of towel clamps/skin hooks and/or temporary sutures to map or test a closure.

If you don't think it will stay closed, it probably won't. Augment the closure with Button Stents!

Be aware of distal extremity closures that are too tight. If any doubt, re-exam day 1 and day 2 post-op. Be prepared to open the wound if a compromise occurs.

Don't be scared to admit this is a wound you can't close and convert to partially closing with a plan for secondary intension healing augmented by stents, tie over dressing, skin stretching or a second "planned" surgery.

Always have a plan B available whenever you think it could be less than a simple closure. Shave much more hair than you expect to remove. Consider the use of simple flaps or if you are feeling brave, complex flaps. Axial pedicle flaps are based on precise anatomic vascular pedicles giving advantage of much longer flaps without a wide base.

When using Flaps the K.I.S.S. principle is out, GO BIG OR GO HOME, small flaps add little to a closure defect. Big flaps close wounds but require LARGE areas to be shaved ahead of time.

Dead space and seroma are your enemy, plan accordingly. Use wound drains prior to closure if you think you might need them. They can always be removed. Penrose drain is a 2 way street- exposed drains ideally should be covered.

Buy Suction drains and have them in your clinic. If you don't have them, you won't use them.

Wound stents can be made from tubing buttons. They are simple and easiest to use; Buy 3 sizes of Buttons have them ready in your clinic steam or cold sterilize. Use them to; 1. Assist in abolishing/compressing dead space. 2. As stents to support a wound closure. 3. As anchor points for skin stretching/traction with umbilical or suture to partially close wounds.

K.I.S.S. meets GO BIG OR GO HOME !!

Flank Fold and Elbow fold Flaps- Simple practical flaps. Greta in cats and majority of dogs Caution in Pit Bull/Bull terrier type breeds which have little surplus skin in these locations. base is ideally 2:1 base to length of free flap, cat’s skin is elastic and more tolerant of narrow base, can often make flaps 1:1 and then stretch to carpus/tarsus from Axilla/Flank

Flank fold flap used to cover lateral and medial Or cover entire lateral thigh, note cranial stifle defect and 360 degree proximal tibia wound closure from donor site

Elbow Flap used to cover an axillary medial elbow defect

Elbow flap used to cover antebrachium down to the carpus

Flank folds can also be used to close large central abdomen or groin defects.

References

Hunt, G. B. (1995). Skin fold advancement flaps for closing large sternal and inguinal wounds in cats and dogs. Veterinary Surgery : vs, 24(2), 172–175.

Hunt, G. B., Tisdall, P. L. C., Liptak, J. M., Beck, J. A., Swinney, G. R., & Malik, R. (2001). Skin-fold advancement flaps for closing large proximal limb and trunk defects in dogs and cats. Veterinary Surgery : vs, 30(5), 440–448.

Drains available form Victor Medical.

Trochar Drain- 10Fr Jackson Pratt Flat Drain SU130-1309 10mm Jackson Pratt Flat Drain SU130- 0321 100ml Jackson Pratt Reservoir (grenade) SU130-1305

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PASS THE LASER POINTER, INTERACTIVE SESSION OF READING DENTAL X-RAYS

Eric Van Nice DVM, DAVDC

The group will view dental x-rays from clinical cases. Participants will take turns reading the x- rays. We will practice an orderly approach:

Is the image of diagnostic quality? If not, what problems need to be improved: exposure, contrast, elongation, foreshortening, superimposition of structures, failure to get the entire area of interest on the image, “cone cutting” etc?

Is the image mounted correctly for viewing? Maxillary teeth roots should point upward and crowns downward, mandibular teeth roots should point downward and crowns upward, patient’s left is to viewer’s right and vice versa. If you think about it, it’s just like looking at a VD chest film, just imagine moving the x-ray view up to the mouth.

What is the species of the patient?

What teeth or region are in the image? Identify which maxillary or mandibular teeth, left or right, incisors, canines, premolars, molars. 1st, 2nd, 3rd, 4th, deciduous, permanent teeth? Sinuses, bullae, TMJ’s?

Describe any abnormalities:

 Developmental abnormalities  Bony lesions. May include fractures, neoplasia, osteomyelitis, osteopathies.  Missing or supernumerary teeth  Periodontal disease  Endodontic disease  Tooth resorption, true carious lesions (cavities)

Further reading:

Mulligan T, Aller MS, Williams CA. Atlas of Canine and Feline Dental Radiography. Trenton NJ: Veterinary Learning Systems, 1998.

DuPont G, DeBowes L. Atlas of Radiography in Dogs and Cats. Saunders, 2008.

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April 27th, 2014

Advanced Veterinary Internal Medicine

Michelle Cieplucha, DVM

Victoria Vorathavorn, DVM, DACVIM

Catheterizing the Female Dog Can be a Bitch

 Indications o Relieving an anatomic or functional obstruction o Monitor ins/outs (e.g. Renal failure) o Obtain a urine sample (less likely to perform in a female vs male dog) o Recumbent patient o Radiographic contrast procedure  Anatomy o Review of normal anatomy o Examine external genitalia for any anatomic abnormalities or discharge o Palpation of distal urethra during a rectal digital exam (identify urethral mass vs urethral stone)  Tips on urinary catheter placement o Digital palpation of urethral orifice o Direct visualization using speculum or otoscope  Equipment o Type of urinary catheter (with or without a stylet)  Cystoscopy clinical applications o Recurrent urinary tract infections, mass lesions seen on ultrasound or radiographs, incontinence, urethral obstruction, abnormalities of micturition, abnormal urine composition o - images/cases  Practical time o Placing urinary catheter using the digital palpation method o Placing urinary catheter using the direct visualization method

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The Echocardiogram: When and Why Mike Lesser, DVM, DACVIM (Cardiology)

NOTES AVAILABLE ON-SITE

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My Five Favorite Products…..and Why!

AVSG WetLab-Dermatology

Animal Dermatology Clinic

Rusty Muse DVM, ACVD

Colleen Mendelsohn DVM, ACVD

It isn’t an accident that the tagline for Animal Dermatology Clinic is “Advancing the art of veterinary dermatology” because as much as science plays a role in management of dermatology patients, there is an equal part “art” that enters the equation. Tremendous advancements have been made in the past decade with innovative technologies, delivery systems and products from companies dedicated to the support of veterinary dermatology. However the presence of these products themselves if not used correctly or in the right situation provide little benefit to our patients. Product advancement and utilization is not a substitute for thorough history taking, physical examinations and diagnostic workup in assessing and correctly managing dermatology cases. Using these products without a thorough knowledge of the science behind them will result in little progress and limited management that is manifested as relapsing patients and frustrated clients. In the hands of experienced dermatologists or clinicians the following products are ones that can bring significant benefit and are utilized frequently in our case management schemes. Learning when to use these products will help you become an integral component in the team concept of managing dermatology cases with the dermatologist.

Convenia

Cefovecin (Convenia®, Pfizer) is a third-generation cephalosporin developed to treat aerobic and anaerobic gram-negative and gram-positive infections. Cefovecin is bactericidal against Staphylococcus and Streptococcus species, Escherichia coli, Pasteurella multocida, and Klebsiella and Proteus species, but is not active against Pseudomonas or Enterococcus species. Cefovecin has a long half-life and demonstrates prolonged concentrations in extracellular fluid, allowing for dosing every 14 days. If required, the dose of 8 mg/kg subcutaneously can be repeated every 14 days for a total of three doses. Cefovecin is eliminated primarily by the kidneys but has up to 25% biliary excretion. It should not be given to animals that are allergic to penicillins or cephalosporins, less than 8 weeks old, pregnant or lactating, or that have severe renal dysfunction. Controlled studies in both cats and dogs show good clinical efficacy. Treatment with cefovecin of naturally occurring bacterial infections of skin and soft tissues in dogs has shown to be as effective as amoxicillin/clavulanic acid administered orally. The author finds that this drug offers the additional benefits of enhancing owner

compliance and the injectable form in pyoderma cases is helpful when issues of oral absorption are a concern. It is particularly beneficial in cats because of the usual difficulties of oral administration. Recently in vitro cefovecin disk-diffusion test results were found helpful in predicting the presence of the mecA gene in Staphylococcus pseudintermedius, as well as the in vivo efficacy of cefovecin therapy in dogs with superficial pyoderma.

Douxo Chlorhexidine Shampoo/Spray

The most commonly used antibacterial agent found in shampoos is chlorhexidine. It is generally well tolerated and is not drying or irritating and at 2-3% concentrations in shampoo formulations has generally been found to be clinically effective. However, newer formulations with 3% or higher have been quite impressive in clinical cases and are available commercially. Recently multiple in vivo and in vitro studies have demonstrated the efficacy of chlorhexidine and chlorhexidine containing shampoo formulations on both methicillin sensitive and methicillin resistant Staphylococcus pseudintermedius strains. Douxo Chlohexidine Shamoo and Spray (Sogeval) is a 3.2% Chlorhexidine product that has become the product of choice at our practice. These products have the added benefit of including phytospingosine which is a ceramide that is present in the cutaneous barrier of the skin and helps to provide improved barrier function of the skin to protect against secondary bacterial infection.

A simulated in vivo study looked at the residual effects of chlorhexidine on the hair shafts of dogs bathed with various concentrations; 0.8%, 2%,3% and 4% chlorhexidine containing shampoos. Dogs were bathed and hairs were removed immediately and then again at 2, 4 and 7 days after bathing. These hairs were inoculated onto a culture agar plate streaked with Staphylococcus pseudintermedius organisms. Zones of inhibition around the hair shafts were then measured to assess antimicrobial activity that was present around the hair. There was inhibition noted even at 7 days in some cases. Efficacy was noted to be greater in 2% and 3% containing shampoos however other factors including shampoo formulation are likely to have played a role in the final results. In addition, factors such as the ability to penetrate into the hair follicle and deeper layers of the epidermis may affect the efficacy of various formulations of chlorhexidine-containing shampoos. However given the increasing prevalence of more resistant strains of Staphylococcus noted in clinical dermatology, these studies suggest that the role of topical therapy is a critically important factor in managing bacterial infections in the canine.

Atopica

Cyclosporine has low cytotoxicity relative to its immunosuppressive potency. It blocks IL-2 transcription and T-cell responsiveness to IL-2, leading to impaired T-helper and T-cytotoxic lymphocytes. It also inhibits IFN-α transcription, thus diminishing amplification signals for macrophage and monocyte activation. The production of other cytokines, including IL-3, IL-4, IL- 5, TNF-α, and IFN-α may be impaired. In these ways, cyclosporine inhibits mononuclear cell function, antigen presentation, mast cell and eosinophil production, histamine and prostaglandin release from mast cells, neutrophil adherence, NK cell activity, and growth and differentiation of B cells. It has also been suggested that a mechanism of action in the treatment of AD involves the inhibition of mast cell degranulation by affecting the interaction between mast cells and nerves. Cyclosporine also directly inhibits histamine release from dog mast cells.

Cyclosporine has been extensively evaluated for the treatment of canine AD and found to be highly effective and comparable in efficacy to prednisolone and methylprednisolone, making it a practical alternative to glucocorticoids. Another advantage of using cyclosporine in canine AD patients is the benefit of controlling pruritus while still allowing intradermal skin testing to be performed. A recent double-blinded placebo study evaluated two groups of intradermal positive dogs before and 30 days after therapy. Group A contained 8 dogs treated with Atopica (Novartis Animal Health) at 5 mg/kg every 24 hours, and group B contained 8 dogs treated with a placebo. At the end of 30 days, there was no effect on immediate intradermal test reactivity in the Atopica-treated dogs.

Different cyclosporine formulations are available, both human brand-name products and generic formulations. Two formulations are available, an emulsion and a microemulsified preparation; the microemulsified form is better absorbed. Atopica is a microemulsion concentrate that is absorbed quickly and more effectively through the gastrointestinal tract of dogs than non- microemulsified formulations. Although absorption is better with Atopica, it is still poorly and erratically absorbed, and bioavailability varies from 23% to 45%. Presence of food in the gastrointestinal tract increases the range of bioavailability and can reduce it by 20%, although some dogs will have increased absorption, especially when the food is high in fat. The only product approved by the FDA for veterinary use is Atopica, which is available in a variety of different sizes (10 mg, 25 mg, 50 mg, and 100 mg). Recently, Atopica for cats has been released as a cyclosporine oral solution (USP Modified), making it easier to prescribe for cats and small dogs. Some generic formulations carry a warning on the label that states they are not bioequivalent, and it is anecdotally stated by many specialists that some dogs will not respond as well to generic formulations. For this reason and because this is the only FDA-approved veterinary product, it is recommended to start with the brand-name cyclosporine, Atopica.

Comfortis

Spinosad (Comfortis [Elanco]) is a novel insecticide produced from a family of natural products derived from fermentation of the actinomycete, Saccharopolyspora spinosa, that has been

marketed for oral use in dogs. Separate randomized blinded studies were undertaken to determine the minimum effective dose of spinosad given orally for the treatment of experimentally induced flea infestations on dogs, and to assess any potential impacts of feeding canned or dry food at the time of dosing. It was found that only the 30 and 40 mg/kg doses maintained high efficacy (97.2%-100%) until 30 days after treatment, and since there was no significant difference between the higher spinosad rates, 30 mg/kg was selected as the optimal minimum effective dose in the United States. The authors concluded that repeated monthly oral treatments with spinosad at 30 mg/kg provide sustained control of C. felis on dogs independently from events in either study, indicating that spinosad has potential to be used monthly as a safe and effective flea adulticide, providing sustained activity that matched that of currently used topical products

The major benefits of spinosad especially for dermatology cases is the fact that topical therapy will not have any adverse affects on the level of flea control. Many of our allergic skin disease cases will require routine bathing and this will have adverse effects on all topical therapy used for flea control. In addition, in Southern California, swimming in the ocean can also have adverse affects of the longevity of topical flea control so this variable is avoided with the use of the oral spinosad.

Dermoscent Spot on Therapy

Dermoscent Essential 6 Spot-on (Laboratoire de Dermo-Cosmétique Animale) contains a combination of fatty acids and emollients that restores hydrolipidic film on the skin, maintains hydration, controls transepidermal water loss (TEWL) and maintains epidermal barrier function. It also helps diminish inflammation by having antioxidant and anti–free radical effects. This product contains natural plant ingredients including hempseed and neemseed oils for a high concentration of EFAs with an omega-6/omega-3 ratio of 4:1. In addition, other essential oils (rosemary, lavender, melaleuca, cedar, oregano, clove, camphor, wintergreen, peppermint, curcuma), along with vitamin E, are included to replenish the hydrolipidic film, hydrate the skin, and control odor. Anecdotal reports of this product helping with coat quality and controlling pruritus in dogs with AD exist. One open trial looked at seven dogs with atopic dermatitis and five normal dogs that were treated with a spot-on containing essential oils and unsaturated fatty acids once weekly for 8 weeks. Seven more atopic dogs received a daily spray containing similar ingredients. In all dogs, TEWL was measured with a closed-chamber device before and after treatment. The mean Canine Atopic Dermatitis Extent and Severity Index (CADESI) scores in atopic dogs decreased with the spot-on from 25.1 to 15.3, and with the spray from 29 to 6. Similarly, the pruritus scores decreased from 3.1 to 2.1 with the spot-on and from 2.3 to 1.3 with the spray. There was a significant difference between healthy and atopic dogs’ TEWL values on the abdomen and back. TEWL decreased significantly on the back after treatment with the spray on the abdomen, the decrease was not quite statistically significant. Adverse effects were not observed. These preliminary results indicate that topical fatty acids and essential oils may be a useful treatment option for canine AD.

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CYTOLOGY AND SLIDE PREPARATION FOR EVERYDAY LUMPS AND BUMPS Mona Rosenberg, DVM DipACVIM (Oncology) Julie Bulman-Fleming, DVM, DipACVIM (Oncology) Sara Fiocchi, DVM DipACVIM (Oncology) David Bommarito, DVM, MS, DipACVR (Radiation Oncology), DipACVIM (Oncology)

Cytology is an attractive diagnostic technique since it is minimally invasive, does not require anesthesia or sedation in most cases, has low morbidity, low cost and typically yields results within 24-48 hours. Agreement between cytologic and histologic samples has been reported as greater than 90%. Cytology has high specificity and positive predictive values (98 and 99% respectively), which indicates that when a cytological diagnosis is obtained, these results are correct. The sensitivity is slightly lower at 89%, meaning that some samples do not yield a diagnosis. The negative predictive value is 69%. An online survey asked 870 clinical veterinarians how they use cytology. More than 70% said they use cytology as a screening test, as a rule-out for specific disease or to obtain a definitive diagnosis. 34% reported using cytology to stage disease, a practice usually left for referral clinicians as reported in the March 2008 issue of JAVMA.1

Notable pathologist John M. Bjorneby, DVM, PhD Diplomate ACVP states that “cytopathology is a useful and accurate tool to evaluate cutaneous and internal lesions in conjunction with the clinical signs and history, laboratory results, and sonographic findings.” However, there can be limitations to this usefulness if the sample quality is not adequate. Sample quality is the most common reason cited by pathologists for a non- diagnostic sample. Good Sample Quality + Clear Communication = Definitive Diagnosis, per Dr. Bjorneby.

Is there an easy and cost effective way to ensure sample quality? Good news, yes there is.

The following are tried and true methods for avoiding poor sample quality.

To avoid drying artifact:

 Do not allow slides to dry on their own. Rapid air drying is the key to good sample quality.  A blow drier on low to medium heat is very useful.  Slides can be dried by waving through the air, although many a slide has been broken this way.  If a blow dryer is not handy, a small fan can be used. The tiny, hand held personal fans work well.  Fluids submitted via a lavender top tube can be prepared at the lab and will avoid all of the above.

To ensure cell integrity:

 Formalin fumes can damage the cell by fixing the cell membrane and thus reducing the ability of the stain to penetrate causing loss of detail.2 Submit cytology and histopathology samples separately.  Ultrasound gel should be cleaned off prior to aspirating as it can cause cell lysis and/or swelling.  Apply sample to only one side of the slide, preferably the frosted side.  When smearing, do not apply too much pressure as this can cause nuclear streaming.  Heat fixation should not be used for this type of cytology.

Other useful tips:

 Submitting unstained, properly dried slides is helpful, especially in the event that a special stain is requested or will be at a later date.  Submitting only one slide is not recommended. The slide may be broken or may not yield enough of a sample for a definitive diagnosis.  Peripheral blood contamination on the slide or hemodilution may inhibit the pathologist’s ability to accurately read the slide.  Spreading the sample thinly and evenly across the surface of the slide is essential to a definitive diagnosis. This allows the pathologist to accurately assess each cell individually.

From a practical standpoint, in-clinic cytology may be used to ensure that a representative sample was obtained. Evaluating the slide prior to submission limits frustration for both the doctor and the client, shortens time to appropriate treatment and is both time and cost effective. View the sample under 10x powers to ensure the sample

is cellular, contains a lymphoid population if sampling a lymph node, and that cells are intact. Hemodilution, accidental salivary gland aspiration, crush artifact/DNA streaming and aspiration of perinodal fat are the most common causes for non-diagnostic samples.

While the majority of cytological diagnoses can wait to be made by a pathologist, recognizing mast cell tumors, skin abscesses, lipomas, cysts, suppurative lymphadenitis and large cell (lymphoblastic) lymphoma on cytology may expedite or negate the need for treatment. If cytology is equivocal or does not match your clinical suspicions, histopathology is recommended. Biopsies can be excisional (intending to remove completely), wedge (if needed, a wider surgical margin can be obtained) or needle core samples. Many pets tolerate these procedures with local anesthetic with or without a sedative.

References: Portions of this information were provided courtesy of John M. Bjorneby, DVM, PhD Diplomate ACVP (Clinical Pathology) 1 Use of cytology as a diagnostic method in veterinary practice and assessment of communication between veterinary practitioners and veterinary clinical pathologists. M. M. Christopher, et al, JAVMA, Vol 232, No. 5, March 2008

2 http://www.cytopath.co.uk/advicecytology.html

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Strange “Neuro” Cases

Stephen Hanson, DVM, MS, Dip. ACVIM (Neurology) Stacy Dillard, DVM, Dip. ACVIM (Neurology) Veterinary Neurology Center Tustin, CA

In this presentation, we will share some cases we find particularly interesting. Some of these are examples of unusual neurological conditions and some are only masquerading as neurological disease.

Idiopathic Head Bobbing

Idiopathic head bobbing is a condition of dogs that involves episodes of rhythmic up-and-down (“yes”), side-to-side (“no”) or bobble type movements. The episodes occur at rest, and do not involve loss of consciousness. In fact, a dog with head bobbing can oftentimes be “distracted” out of the episode by showing them something exciting, like a treat or toy. Idiopathic head bobbing can occur in any breed of dog, but English bulldogs, Doberman pinchers and boxers are over-represented. Dogs with idiopathic head bobbing usually start the abnormal motor activity at a young age. The frequency of episodes tends to wax and wane, but the episodes tend to stop occurring as a dog ages.

Idiopathic head bobbing is not a rare condition – You Tube videos of this abound. But, it has received very little attention in the literature, probably because the condition is poorly understood. It is thought to be similar to a condition in people called “essential tremor,” which likely involves malfunction of the stretch reflex mechanism. Idiopathic head bobbing is benign and does not require treatment. Since it occurs at rest, it does not interfere with normal activities. Furthermore, it does not progress to more serious problems, such as seizures.

Conditions that can appear similar to idiopathic head bobbing are focal seizures and cerebellar- associated tremors. Focal seizures often involve some impairment of consciousness, and the animal generally cannot be distracted out of them. They frequently progress to generalized seizures. Cerebellar tremors are typically exacerbated by movement, so they worsen with activity.

Feline Hyperesthesia Syndrome

Feline Hyperesthesia Syndrome (FHS) manifests as episodes of agitated behavior, often associated with pupil dilation, crawling movements of the skin, aggressive licking or biting at the flank, back and hind limbs and abnormal vocalization. Typically these cats have normal brain MRIs, normal CSF and do not respond consistently to anticonvulsant therapy. Some reports suggest the signs may be caused by a type of myopathy called inclusion body myositis, although histopathological evidence of this is not

evident in every case. Additionally, it is unclear why a cat with myositis would have such severe episodic signs.

Other sources of pain and agitation should be ruled out in cats with signs of FHS. Also, since a post-ictal state can involve agitation resembling what is seen with FHS, owners should watch for generalized seizure activity, which would indicate a different pathological process. Amitripylene and clomipramine are helpful in controlling the episodes FHS, although they may still occur in a less frequent and severe form.

Fibrotic Myopathy

Fibrotic Myopathy is an idiopathic condition that causes a very characteristic lameness. It affects most commonly the gracillis muscle, but has been reported in semitendinosus, supraspinatous, quadriceps, infraspinatous, iliopsoas and tensor fascia lata muscle. Dense collagenous connective tissue, as seen on muscle biopsy, creates a fibrous band that can often be palpated. This fibrous band in the gracilis/semitendinosus muscle produces a tethering effect, preventing full extension of the limb, resulting in internal rotation of the stifle and external rotation of the hock with limb advancement and the characteristic flipping or jerking of the foot. This disorder is seen overwhelmingly in German Shepherds. The age onset is from 8 months to 9 years and typically is a progressive over weeks. Medical management has been ineffective and surgery initially dramatically improves the gait; however, the results are transient and signs recur within months, making long-term success poor. Most dogs appear unaffected by the lameness and continue to be active. Historically, this disorder was not considered painful, however one study found pain with hip abduction and palpation of the fibrotic area in affected dogs, so pain control may be indicated in some dogs.

Aortic Thromboembolism

Aortic thromoboembolic (AT) disease is vastly different in the dog than the cat and therefore may be under diagnosed in dogs. Though dogs can present acutely paraplegic just like in the cat, a chronic progressive history (weeks to months) is more common. Unlike in cats, a high percentage of dogs with AT do not have structural heart disease. AT can be associated hypercoagulable diseases such as protein losing nephropathy/enteropathy, hyperadrenocortism, hypothyroidism, as well as diseases that affect the endothelial lining (neoplasia, trauma, hypertension, infection, etc.) Some dogs have no identifiable concurrent illness at the time of diagnosis of AT. Clinical signs in dogs with AT can vary, including exercise intolerance, monoparesis, paraparesis and paraplegia. The more severely affected dogs tend to be those with an acute onset whereas the clinical signs are milder in chronic disease. Because of this variable presentation both in history and clinical features, a through physical and neurological examination is important. Common clinical features include: dysfunction in ambulation

(varying degrees), pain with palpation of the pelvic limbs, decreased segmental spinal reflexes (patellar reflex is reduced or absent) and flaccid paresis. There should be normal tone and function to the tail and perineum. Femoral pulses can be present or absent, though if present the quality is typically reduced. Definitive diagnosis is most commonly made by ultrasound however MRI features have been described. Treatment consists of administration of warfarin (or other anticoagulant) and treating the underlying cause. Dogs have better long-term survival rates than in the cat, and depending on severity of signs and underlying cause of AT, aggressive treatment may be beneficial.

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Sarah Beaman, DVM AVSG After Hours

Chest Tube Placement

In general, an animal presenting with pleural space disease should have radiographs to confirm pleural space disease. Radiographs allow one to determine which side, if not both, the disease is present in and if the problem is air, fluid or a mass.

Thoracocentesis should be performed: 1. For stabilization. 2. To help determine if a chest tube is indicated. 3. If there is fluid - to determine the type of fluid and its composition.

The general indications for a chest tube are: 1. Air or fluid that accumulates quickly after a productive thoracocentesis.  If greater than three taps in a 24 hour period are needed, a chest tube should be considered.  If the patient is not able to be stabilized with a thoracocentesis, a chest tube is needed.  Nota bene: if the volumes of air or fluid are considerably decreasing with each tap, a chest tube may not be needed. 2. Pyothorax 3. Post-operative thoracotomy

Types of tubes Chest tube diameter should be the size of the diameter of the mainstem bronchus. 1. Argyle chest tube 8fr (cats/small dogs) to 32fr (large dogs) 2. Red rubber chest tubes: may need to make more holes 3. Mila over-the-wire: early reports are good for removing smaller volumes of air and they may be placed with sedation. They are unlikely to be helpful with thick fluid.

Placement Typically done under general anesthesia. May use a local with a heavily sedated, debilitated patient.

Materials Have materials out before placing: Small surgical pack (blade, blade handle, thumb forceps, needle driver, hemostats, suture scissors) Sterile chest tube

C clamp Christmas tree adaptor 3-way stopcock Procedure  Sterile technique – clip, prep, drape, sterile gloves  Clip a wide margin  Chest tube should enter at the 8th ICS space  Tunnel under the skin from the 10th ICS space (a) May pull skin cranially to aid in tunneling after incising at the 10th ICS space (b) Incise halfway between spine and sternum. (c) Before inserting tube into the 8th ICS space:  Measure the tube cranially before placement (from skin incision to the area caudal to the thoracic limb).  Hemostat method (Kelly, Carmalt) (a) Remove the trocar. Grasp the end of the tube and bluntly dissect through the chest wall. (b) Dissect through into the chest cavity, leave the hemostats and guide the tube through with the trocar. Remove the trocar after advancing the tube into the chest.  Trocar method (a) Partially incise the intercostal muscles. (b) Use firm steady pressure to advance the trocar into the chest cavity.  Once the chest is open, breathing will need to be controlled.  Clamp the tube after entering the chest cavity. (a) Clamping with hemostats may damage the chest tube-use a C clamp.  Feed cranially and ventrally to the point previously measured.  Secure the tube to the skin with a Roman Sandal or Chinese Finger Trap.  Suction the tube, clamp, place the Christmas tree adapter and 3 way stop cock.

Post placement radiographs Confirm the tube placement, position and effectiveness.

Tube care E collar and light wrap with gauze at the stoma Stockinette wrap with gauze at the stoma

Removal Continuous suction- when negative change to intermittent suction. Intermittent suction – q 1-2 hours until negative 2-3 times, then q 2-4 hours, etc. When negative q 24 hours, okay to pull.

With pleural fluid, the body produces 2ml/kg/24 hours, so the tube can be pulled if the amount suctioned is comparable. If infectious fluid – check fluid before removing and follow fluid guidelines. Close the skin incision with sutures or staples.

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Immune Mediated Polyarthritis Andrea McDooling, BVSc, DACVIM (SAIM) Ashley Cruse, DVM, DACVIM (SAIM)

NOTES AVAILABLE ON-SITE

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