Partners In Care Fall 2020 | Volume 14:3 | angell.org | facebook.com/AngellReferringVeterinarians

VETERINARY REFERRAL NEWS FROM ANGELL ANIMAL MEDICAL CENTER

ANESTHESIA ANESTHESIA

PAGE 1 Anesthesia and Anesthesia and Analgesia for the Cesarean Section Analgesia for the

CARDIOLOGY Cesarean Section PAGE 1 Kate Cummings, DVM, DACVAA | angell.org/anesthesia | [email protected] | 617-541-5048 Oral Antiarrhythmic Therapy n considering an anesthetic protocol for both emergent barrier also cross the blood-placental barrier. Enzymes and elective cesarean sections (C-sections), it’s responsible for hepatic metabolism are ineffective until 3-5 INTERNAL MEDICINE important to first understand maternal physiologic weeks of age. Finally, the fetal oxyhemoglobin dissociation PAGE 6 changes associated with pregnancy and fetal physiology curve is shifted to the left, meaning that there is less unloading Diagnosis and Treatment Iconsiderations. Major body systems affected by pregnancy of oxygen to tissues.1,2,3 of Chronic Hepatitis in include the cardiovascular (CV), respiratory, gastrointestinal, An ideal protocol for C-section patients provides adequate Dogs: Summary of the and renal systems — all of which are equally important to consider during any anesthetic event. A brief summary of how analgesia to the mother, optimal operating conditions, rapid 2019 ACVIM Consensus these systems are impacted during pregnancy and anesthesia recovery, and minimal fetal depression (Table 2). It is important is outlined in Table 1 on page 2. In regard to fetal physiology, to note that maternal and puppy or kitten mortality increases SURGERY it is imperative to know that drugs that cross the blood-brain (CONTINUED ON PAGE 2)

PAGE 8 Idiopathic Chylothorax in the Dog

EMERGENCY

PAGE 11 Addison’s Disease CARDIOLOGY DENTISTRY Oral Antiarrhythmic Therapy PAGE 12 Canine and Feline Rebecca L. Malakoff, DVM, DACVIM (Cardiology) Extractions and angell.org/cardiology | [email protected] | 617-541-5038 Dealing with Common hen your patient’s heart beats too are most likely to prescribe or encounter. (Dosages for the Complications fast or irregularly, it’s enough to make a medications can be found in Plumb’s Veterinary Drugs). veterinarian’s heart speed in response. My SURGERY hope is that this review of the most commonly QUICK REVIEW OF Wused oral antiarrhythmic medications in veterinary medicine ANTIARRHYTHMIC CLASSIFICATIONS PAGE 14 will help to reduce the heart rate of patient and doctor alike. Patellar Groove On page 4 you will find a quick reference of the actions, side You may not have spent much time thinking about the Replacement effects, and considerations for selection of the four drugs you Vaughan-Williams classification scheme for antiarrhythmic (CONTINUED ON PAGE 4)

INSIDE: REFERRAL CONTACT INFO AND ADDITIONAL RESOURCES ON A REMOVABLE POSTCARD ANESTHESIA Anesthesia and Analgesia for the Cesarean Section CONTINUED FROM PAGE 1 ANESTHESIA

TABLE 1 — MATERNAL PHYSIOLOGIC CHANGES AND THEIR ANESTHETIC IMPACT.1,2,3

Body System Changes During Pregnancy Anesthetic Impact

Cardiovascular • Blood volume increases ~40% with larger increase in plasma • Common to battle hypotension with patients in dorsal recumbency volume); thus, relative anemia develops as venous return is compromised by pressure of large uterus on • Increased cardiac output (CO) due to increased heart rate and vena cava stroke volume • Following removal of the uterus, abdominal vessels may vasodilate, • Right shift of oxyhemoglobin dissociation curves facilitates oxygen leading to systemic hypotension delivery to fetus • Judicious use of IV fluids recommended unless patient is at risk for • Increased myocardial work and reduced cardiac reserve — susceptible developing CHF +/- use of vasopressors animals incapable of mounting a significant response to CV stressors • Animals with preexisting myocardial dysfunction may decompensate and develop heart failure

Respiratory • Oxygen consumption increases by ~20% (due to developing fetus, • Patients predisposed to hypoxemia — pre-oxygenation IMPERATIVE placenta, uterine muscle, and mammary tissue) • Increase in alveolar ventilation and reduced FRC result in reduced • Functional residual capacity (FRC) and total lung capacity reduced MAC requirements

• Increased tidal volume and respiratory rate result in increased • Reduced PaCO2, generally in the range of 30-33 mmHg minute ventilation

Gastrointestinal • Positioning of uterus and increased progesterone result in reduced • Increased risk of regurgitation and aspiration gastric emptying and reduced gastric motility • Higher percentage of brachycephalic breeds requiring C-section adds to this risk • Rapid sequence induction and intubation to quickly protect the airway • Consider use of metoclopramide and/or an H2-receptor antagonist

Renal • Renal blood flow and GFR increased • Elevated renal values may indicate dehydration or underlying • Patients often have low or low normal BUN and creatinine kidney disease • Pre-surgical fluid resuscitation and adjusted fluid therapy/use of vasopressors during anesthesia necessary to maintain kidney perfusion

TABLE 2 — ELECTIVE AND EMERGENT C-SECTION PROTOCOL SUGGESTIONS IN DOGS AND CATS.3

Species Anesthetic Protocol Analgesia

Dog 1. Pre-oxygenate, clip, and prep 1. Line block with bupivacaine (1 mg/kg) or lidocaine (2 mg/kg) 2. Propofol (4-6 mg/kg) or alfaxalone (2-3 mg/kg) titrated to effect IV 2. Buprenorphine (0.01 mg/kg) or hydromorphone (0.05-0.1 mg/kg) IV 3. Maintenance on isoflurane or sevoflurane after removal of puppies 4. Balanced crystalloid IVF at 5-10 mL/kg/hr (adjust if preexisting 3. Single dose of carprofen (4.4 mg/kg) or meloxicam (0.1 mg/kg) SC heart disease)

Cat 1. Same as above 1. Same as above aside from these changes 2. Buprenorphine (0.02 mg/kg) IV after removal of kittens 3. Single dose of meloxicam (0.1 mg/kg) or robenacoxib (2 mg/kg) SC

with emergent versus planned C-section.4,5 Fetal initial abdominal clipping and prepping before effects. Both drugs cross the placenta, but there is and neonatal mortality can be minimized by administration of anesthetic agents. Pre-anesthetic rapid clearance and minimal fetal depression. avoiding placental hypoperfusion and hypoxemia medications can and should be avoided unless the Newer studies have shown improved APGAR and providing proper neonatal care upon patient is overly fractious or unmanageable. scores within the first 60 minutes following delivery.6,7,8 Prior to anesthesia, the mother should If dealing with an aggressive patient, consider delivery in neonates with an alfaxalone induction have a full physical exam, thorough history short-acting and reversible drugs such as fentanyl compared to propofol.9,10 Survival out to 3 months taking, and a minimum database of blood work and midazolam. Alpha-two adrenergic agonists, was similar between groups, however, indicating (e.g., PCV/TP/Azo/iCa/Glu). In debilitated particularly xylazine, should be avoided as they that either induction agent is appropriate.9 patients or those with comorbidities, a complete have been linked to decreased survival in the database of lab work should be performed prior to neonate.4 All patients should be pre-oxygenated for Following induction, maintenance can be anesthesia. Correction of electrolyte and/or at least five minutes and induced in the or when achieved with isoflurane or sevoflurane, keeping hydration/volume deficits should occur before possible. The primary determinant of fetal viability in mind that maternal anesthetic requirements are induction. is the time from anesthetic induction to delivery, often reduced due to pregnancy-induced changes. with a target of < 15 minutes.4,5,6,7,8 Propofol or Occasional small boluses of propofol or alfaxalone Most dystocia patients are easy to handle and alfaxalone are induction agents of choice, both can be used if patient depth suddenly lightens. calm, allowing for IV catheter placement and short-acting and with similar CV and respiratory Multimodal analgesia is important and possible

2. Partners In Care  Fall 2020  Volume 14:3 ANESTHESIA Anesthesia and Analgesia for the Cesarean Section

CONTINUED FROM PAGE 2 INTERNAL MEDICINE INTERNAL ANESTHESIA in the mother. Prior to surgery, a line block can be FIGURE 1 performed quickly with either bupivacaine or lidocaine. After delivery (Figure 1), an opioid and 4 Successful delivery and survival following emergency C-section. chosen intra-operatively antibiotic can be administered. Inhalants should be adjusted following removal of the puppies/kittens since the opioid effectively reduces anesthetic requirements. Buprenorphine, a partial mu agonist, is recommended as it results in minimal sedation and adequate analgesia. A full mu agonist (e.g., hydromorphone or methadone) can be used as an alternative, but lower doses are recommended to minimize CV and respiratory depression as well as limit the degree of sedation. An epidural can be considered postoperatively with morphine alone or morphine and lidocaine. If an epidural is performed, owners should be made aware of possible urinary retention and hind end weakness (short duration) if lidocaine is used.1,2,3 Finally, a single postoperative dose of an NSAID can be considered in patients with normal blood work and adequate intraoperative blood pressures (MAP > 65 mmHg).

Neonatal management and resuscitation begins by having one person dedicated to each neonate when possible. Early and frequent rubbing to dry helps stimulate respiration and keep the neonates warm. A bulb syringe can be used to suction oral and airway secretions. Swinging the neonate is not recommended as this has been shown to result in cerebral hemorrhage.1,2,3,6,7,8 Neonates that are thriving can be placed in an incubator for heat support until the mother recovers. In neonates that Robertson SA. Wiley Blackwell; 2015. 7 Neonatal critical care. Moon PF, Massat may be struggling, ventilation is key as it 1) allows BJ, Pascoe PJ. Vet Clin North Am Small 2 Small Animal Anesthesia and Analgesia. for elimination of gas anesthetics and 2) aids in Anim Pract 2001, 31:343-367. increasing HR as bradycardia is caused by Carroll GA. Ames: Blackwell; 2008. 6,7,8 8 Small Animal Neonatal Health. Wilborn hypoxia. Attempts can be made to stimulate 3 Canine and Feline Anesthesia and RR. Vet Clin: Small Anim Pract 2018, ventilation by activating the acupuncture point, Co-Existing Disease. Snyder LBC, 48(4):683-699. GV26, with a small gauge needle inserted into the Johnson RA. Wiley Blackwell; 2015. nasal philtrum. Oxygen supplementation can be 9 Apgar scores after induction of 4 Perioperative risk factors for puppies provided via mask or intubation. The most anesthesia for canine cesarean section delivered by cesarean section in the common arrest rhythm for neonates is asystole with alfaxalone versus propofol. United States and Canada. Moon PF, and should be treated with basic life support Doebeli A, Michel E, Bettschart R, et al. Erb HN, Ludders JW et al. JAAHA 2000, measures, including epinephrine +/- atropine. Theriogenology 2013, 80(8):850-854. Consider sublingual use of reversal agents 36:359-368. 10 Alfaxalone for total intravenous (e.g., flumazenil, naloxone) if benzodiazepines or 5 Perioperative management and mortality anaesthesia in bitches undergoing opioids were used prior to fetal delivery. rates of dogs undergoing cesarean section elective caesarean section and its effects in the United States and Canada. Moon on puppies: a randomized clinical trial. PF, Erb HN, Ludders JW, et al. JAVMA REFERENCES: Conde Ruiz C, Del Carro AP, Rosset E, 1998, 213(3):365-369. et al. Vet Anaesth Analg 2016, 1 Lumb and Jones’ Veterinary Anesthesia 6 Resuscitation of canine and feline 43:281-290. and Analgesia, 5th Edition. Grimm KA, neonates. Traas AM. Theriogenology Lamont LA, Tranquilli WJ, Greene SA, 2008, 70(3):343-348.

Partners In Care  Fall 2020  Volume 14:3 3. CARDIOLOGY Oral Antiarrhythmic Therapy

CONTINUED FROM PAGE 1 CARDIOLOGY drugs since veterinary school, but it can be receptors increases with long-term administration, MEXILETINE useful for a reminder of both the intended effects stopping suddenly could lead to hyper-reaction to and side effects of various medications. For physiologic adrenergic stimulation. Mexiletine is a class I agent (sodium channel example, any drug with beta blocking or calcium blocker) with similar properties to lidocaine. Mexiletine is most commonly used along with a channel blocking action will be both negatively Atenolol Highlights chronotropic (lowering the heart rate) but also beta blocker such as atenolol or sotalol, which negatively inotropic (reducing contractility). The • Inexpensive further enhances arrhythmic suppression through cooperative drug action.4 When used as scheme divides antiarrhythmic drugs into • Does not work well alone for ventricular a solo agent, higher doses are often required, classes according to the ion channels they block: tachycardia in dogs (but may in cats) which increases risk of adverse effects. CLASS I: Sodium channel blockers • Caution with systolic dysfunction, CHF, Mexiletine does have disadvantages compared (e.g., lidocaine, procainamide, AV block to sotalol monotherapy, including increased cost, and typically three times daily dosing (some mexiletine) • Caution in poorly controlled patients may respond adequately to twice-daily asthmatics, diabetics dosing when given with sotalol5). Given routine CLASS II: Beta blockers (e.g., • Reduce dose with severe renal dysfunction atenolol, metroprolol) availability in only three different doses of • Avoid stopping suddenly after chronic use capsules (150 mg, 200 mg, 250 mg), mexiletine can be challenging to dose, especially in smaller CLASS III: Potassium channel blockers patients. Mexiletine does have the advantage of (sotalol and amiodarone SOTALOL not possessing negative inotropic actions, both have class III activity making it a safer choice in patients with in addition to other channel Sotalol is one of the most commonly used oral significant systolic dysfunction (even if it blockade(s), making them antiarrhythmic agents for ventricular tachycardia, requires concurrent beta blocker use, it may mixed agents) for good reason. Sotalol has the benefits of being allow reduced doses of those agents to be used). relatively inexpensive, fast-acting, tends to be well tolerated, and only requires twice-daily CLASS IV: Calcium channel blockers Mexiletine has higher potential to cause adverse administration. A mixed agent, with both beta (e.g., Diltiazem, verapamil) side effects compared to sotalol, most commonly blocking (class II) and potassium channel GI upset (reduced appetite, vomiting and/or blocking (class III) properties, sotalol tends to diarrhea). Giving the drug with food reduces have more potent effect against ventricular ATENOLOL this risk. Potential CNS effects (trembling, arrhythmias than a solo beta blocker such as In addition to being used for heart rate unsteadiness, dizziness, depression) in people atenolol in dogs.2 What many veterinarians may reduction in cases of outflow tract obstructions taking the drug have been reported. Similar not realize is that sotalol can also be effective in (e.g., hypertrophic obstructive cardiomyopathy, signs have been seen in dogs, with a subset of treating supraventricular tachycardia. pulmonic or aortic stenosis), atenolol is a patients exhibiting mildly dull or disoriented commonly used medication either alone or in behavior. In my experience, this reaction does Due to negative inotropic effects, caution must combination with other drugs to treat not appear to be dose-dependent and does be taken when the patient has concurrent supraventricular or ventricular arrhythmias. resolve if the drug is stopped. congestive heart failure, especially with reduced Although it is not particularly efficacious as a solo systolic function such as with dilated drug for ventricular tachycardia in dogs, it Due to liver metabolism, the half-life of cardiomyopathy. As sotalol is a nonselective beta can be more useful in treating ventricular mexiletine may be significantly increased in blocker (albeit a relatively weak one; most of its premature complexes or tachycardia in cats. patients with moderate to severe hepatic disease. pharmacologic actions are related to its class III Atenolol is a beta blocker (class II agent), and one It is recommended to test dogs of breeds potassium channel blockade), it may also cause that is relatively specific for the beta 1 receptors susceptible to the MDR1 gene mutation prior to bronchoconstriction and should be used with (found in the heart muscle). However, it does using the drug, as those homozygous for the caution in patients with lower airway disease. have some beta 2 activity (affecting bronchial MDR1 gene defect may be susceptible to Elimination of sotalol is almost entirely via the and smooth muscle), and, as such, caution mexiletine toxicity.6 kidney, and dosage intervals may need to be should be taken when using the drug in poorly extended in patients with renal dysfunction. controlled asthmatic patients due to potential Sotalol has a quick onset of action, reaching peak Mexiletine Highlights bronchoconstriction. It could mask physiologic plasma levels two to four hours after dose response to hypoglycemia, so caution in poorly • More effective with concurrent atenolol administration, providing enhanced usefulness controlled diabetics is also warranted. Because or sotalol in the ER setting.3 atenolol will also have negative inotropic effects, • Typically requires TID dosing caution should be used with reduced systolic • No negative inotropic effects function, and it is best to avoid starting the drug Sotalol Highlights 1 during active congestive heart failure. • Inexpensive • Higher risk of side effects (GI upset, CNS signs) Atenolol has the advantage of being inexpensive, • Twice-daily dosing • Caution in dogs with MDR1 gene mutation and generally well-tolerated. Due to renal • Well-tolerated metabolism, doses should be adjusted when • Quick onset of action significantly reduced renal function is present. DILTIAZEM Avoid stopping the drug suddenly or missing • Caution with systolic dysfunction, Calcium channel blockers are very useful agents doses with chronic use. Since the number of beta congestive heart failure, AV block for treatment of supraventricular arrhythmias

4. Partners In Care  Fall 2020  Volume 14:3 CARDIOLOGY Oral Antiarrhythmic Therapy

CONTINUED FROM PAGE 4 CARDIOLOGY such as atrial fibrillation or atrial tachycardia, the drug would not be started during active 3 Sotalol. Reviewed and updated by and diltiazem is the most commonly used oral congestive heart failure. It also should not be Eichstadt Forsythe, Lauren and Barletta, calcium channel blocker in veterinary medicine. started with severe hypotension, sick sinus Michele. Plumb’s Veterinary Drugs. Studies have shown it is most effective for heart syndrome, or significant AV block. Caution is Online version (last update August 2017). rate control with atrial fibrillation when used in warranted with use in geriatric patients, or those 4 Combined mexiletine and propranolol conjunction with digoxin,7 but it may be with serious hepatic or renal impairment.8 treatment of refractory ventricular adequately effective on its own. It is important tachycardia. Leahey Edward B. Br Med J. to be aware that oral diltiazem comes in Diltiazem Highlights Volume 281 (6236), 357-358. numerous human dosage forms, including standard release tablets (e.g., Cardizem®) and • Comes in standard (TID) and sustained 5 Mexiletine serum levels with twice-daily various sustained release products (e.g., Dilacor release (BID) forms; dosing is not equivalent dosing in combination with sotalol in healthy XR®, Cardizem CD® and LA®). Standard release • GI side effects common in cats dogs. Scollan, Katherine. Proceedings: forms are typically used three times daily for 23rd ECVIM-CA Congress 2013. • Some negative inotropic effects arrhythmia control in dogs, whereas the 6 Mexiletine. Reviewed and updated by sustained release products are typically used • Better heart rate reduction in atrial Eichstadt Forsythe, L. Plumb’s Veterinary twice daily (although there is limited fibrillation when used in conjunction Drugs. Online version (last update pharmacokinetic data for use of the sustained with digoxin August 2017). release products in veterinary patients). The most critical thing to note is that the 7 Combination therapy with digoxin and recommended or utilized mg/kg dose for the two diltiazem controls ventricular rate in chronic forms is not equivalent (sustained release REFERENCES: atrial fibrillation in dogs better than digoxin or diltiazem monotherapy: a randomized products are typically used at a higher dose BID), 1 Atenolol. Reviewed and updated by crossover study in 18 dogs. Gelzer, Anna and they are not simply interchangeable. Scansen, Brian A and Eischstadt Forsythe, et al. JVIM. Volume 23, 499-508. Lauren. Plumb’s Veterinary Drugs. Standard forms of diltiazem are relatively Online version (last update August 2017). 8 Diltiazem. Reviewed and updated by inexpensive, whereas the sustained release forms Barletta, Michele and Eichstadt Forsythe, 2 Comparison of the effects of four can be more costly. Both forms have been Lauren. Plumb’s Veterinary Drugs. antiarrhythmic treatments for familial associated with decreased appetite and weight Online version (last update July 2017). loss, especially in cats. Diltiazem possesses ventricular arrhythmias in boxers. Meurs, negative inotropic properties, and so caution Kathyrn M et al. JAVMA. Volume 221, must be used with systolic dysfunction. Ideally, No.4, 522-527.

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Partners In Care  Fall 2020  Volume 14:3 5. T hepatitis in dogs (CH). dogs in chronic hepatitis primary discuss will We addressed. and investigated be to needs disease primary the because biopsies liver interpreting when consideration important very a is This fibrosis. and necrosis without liver the in causes that inflammation (GIT), tract gastrointestinal the in often body, the in elsewhere process primary disease a to due or occur hepatopathies Secondary “reactive” regeneration. and fibrosis of degrees variable with along seen is death cell hepatocyte of evidence in hepatopathies, that primary is difference key The inflammation. granulomatous or plasmacytic, lymphocytic, including present, are cases, infiltrates both inflammatory In hepatopathy. secondary primary and between differentiate to careful be must we inflammation, reveals biopsy hepatic When hepatology. canine in training and experience 6. Strong sequelae. potential are cirrhosis or CH instances some in but hepatopathy, acute cause they often Most cycasin. and aflatoxin, amiodarone, oxibendazole, carprofen, including injury, liver in implicated been have toxins and drugs Several Toxins and Drugs disorder. of amultisystemic part and necrotizing and acute typically are lesions but involvement, have can hepatic diseases systemic spp with infection experimentally and canis Ehrlichia response. pyogranulomatous chronic a induce CH. canine also but can hepatitis acute causes in Leptospirosis etiology viral a of evidence is no strong there medicine, to human contrast In Causes Infectious (Table 1.). idiopathic are cases most CH, of causes infectious, immune and of toxic, metabolic, evidence is there Although ETIOLOGY INTERNAL MEDICINE . can cause subacute hepatitis. Multiple other other Multiple hepatitis. subacute . cause can of seven specialists with extensive extensive with specialists seven of panel a by summarized studies human selected and from veterinary published generated was consensus his has been associated with CH, CH, with associated been has angell.org/internalmedicine | [email protected] | 781-902-8400 | MSPCA-Angell West |MSPCA-Angell |781-902-8400 |[email protected] angell.org/internalmedicine DACVIM Ackley, DVM, Vrabelova Daniela Consensus ACVIM 2019 Hepatitis in Dogs: Summary of the Diagnosis and Treatment of Chronic Anaplasmosis proteins causing CH in American and English English and American in CH folded causing proteins abnormally of retention hepatocyte in AAT,ofresults processing hepatic abnormal by (AAT) caused deficiency, antitrypsin Alpha-1 conditions Metabolic studies. multiple in noted as dogs in accumulation Cu hepatic are increased to 1990s, linked the in premixes Cu bioavailable to more a change with along copper), for dietary limit maximum (no guidelines that dietary believes current panel The suspected. are both or intake, dietary excessive bile, in excretion copper hepatic Altered content. copper hepatic abnormal for evaluated be should biopsy liver every therefore, CH; copper-associated is dogs in CH causing injury toxic common most The vital. —is supplements including — history drug complete a but medicine, veterinary in prove to difficult usually is toxicity Supplement injury! liver to drug-induced and of up 18% for herbal responsible are that supplements estimated dietary is CH. it in humans, result In can lomustine and phenytoin, primidone, phenobarbital, that indicates evidence Infectious Metabolic Toxic Immune ETIOLOGY 1— TABLE OF EVIDENCE BASED ON LITERATURE. STRENGTH RELATIVE AND CH IN IMPLICATED FACTORS ETIOLOGIC SUBCATEGORY Viral Toxoplasma) Sarcocystis, (Neospora, Protozoal Bartonella Histoplasmosis Mycobacteria Rickettsial Leishmaniasis Leptospirosis Alpha-1-anti-trypsin Protoporphyria Copper

Partners In Care Care In Partners accumulation of hepatic AAT causes liver liver injury. liver reflects merely or disease causes whether AAT hepatic unknown of is accumulation It spaniels. cocker immunosuppressive treatment. treatment. immunosuppressive to response afavorable of and etiologies other elimination requires CH immune-mediated of diagnosis clinical Presumptive predisposition). female and history, familial serum autoantibodies, positive II, class MHC abnormal of expression infiltrate, (lymphocytic criteria several by suggested an is CH for studies, basis immune veterinary available on Based changes). or GI microbiome toxins, vaccinations, drugs, (pathogens, triggers certain to exposed individuals predisposed genetically in occur to thought to is It treatment. response immunosuppressive and histology, typical other causes, of exclusion kidney antibodies), microsomal and anti-liver antinuclear, and anti-mitochondrial, IgG, serum (enzymes, including markers criteria, several on relies hepatitis of autoimmune diagnosis the humans, In CH Immune-mediated EVIDENCE Negligible Moderate Weak Moderate Moderate Weak Moderate-strong Moderate Weak (rare) Moderate Strong Moderate-strong  Fall 2020 2020 Fall  Volume 14:3 Volume

INTERNAL MEDICINE INTERNAL MEDICINE Diagnosis and Treatment of Chronic Hepatitis in Dogs; Summary of the 2019 ACVIM Consensus

CONTINUED FROM PAGE 6 INTERNAL MEDICINE INTERNAL

SIGNALMENT minor compared to surgery and hemostasis can not proven in human studies; therefore, it is not be more tightly controlled compared to recommended. There is limited evidence of the There is strong evidence for an increased ultrasound-guided needle biopsy. Patients should efficacy of vitamin E in CH in dogs. prevalence of CH in Bedlington terriers, Doberman be hospitalized overnight after a liver biopsy to pinschers, Labrador retrievers, dalmatians, monitor for hemorrhage or other complications. Any increase in hepatic copper should be treated American and English cocker spaniels, English There is not enough evidence to recommend with D-penicillamine (the chelator of choice) and springer spaniels, West Highland white terriers, routine prophylaxis with fresh frozen plasma, a copper-restricted diet, likely for months to years. and standard poodles. The overall mean age of other blood products, or vitamin K, and their use onset of clinical signs is 7.2 years. should be considered on a case-by-case basis. Studies support the existence of a subset of dogs with CH that respond to immunosuppressive Fine needle aspirates have no role in the treatments. However, not enough evidence is CLINICAL PATHOLOGY definitive diagnosis of CH, because they often available to recommend an optimal Persistent (> 2 months) unexplained increases in miss inflammatory infiltrates, extent of fibrosis, immunosuppressive protocol. Corticosteroids ALT with or without other laboratory changes is or abnormal copper accumulation. are efficacious as a first-line treatment, but carry the best screening test currently available for many side effects problematic in dogs with early detection of CH. Laparotomy is indicated if there is a concern advanced liver injury (sodium and water for extra-hepatic biliary duct obstruction retention that provoke ascites, catabolism, risk If both ALT and ALP are increased, the (EHBDO), severe gallbladder pathology, or a for enteric ulceration precipitating hepatic magnitude of ALT increase often exceeds that of vascular anomaly. encephalopathy, hypercoagulability). Some ALP. There is a long subclinical phase when panel members combine corticosteroids with diagnosis should be pursued with the best chance Laparoscopy is the method of choice for liver azathioprine or cyclosporine to enable more for intervention. Once overt signs develop, they biopsy in dogs with suspected CH, as this rapid tapering of steroids to every other day often represent complications of late-stage minimally invasive method enables gross anti-inflammatory doses. For most experts, disease with poor prognosis (portal hypertension, evaluation of the liver, extra-hepatic biliary maintenance on the second drug alone was the ascites, HE, coagulation disorders, infection, and system, and safe acquisition of large targeted goal. Some experts use single agent cyclosporine gastroduodenal ulceration). biopsies from multiple liver lobes (Figure 1.). twice daily as first-line treatment to avoid the A minimum of five biopsies from at least two liver adverse effects of corticosteroids. My personal Hyperbilirubinemia is reported in 50% of dogs lobes should be obtained for histopathology experience with cyclosporine (Atopica) for with CH and is a negative prognostic indicator. (3), aerobic/anaerobic culture (1), and quantitative treatment of CH has been excellent. Hypoalbuminemia is a late marker of hepatic copper analysis (1). Ultrasound-guided hepatic Mycophenolate also has been used by panel synthetic failure. Decreased BUN and cholesterol biopsy is least invasive, but small sample size members as a first- or second-line treatment and develop in approximately 40% of dogs with CH, frequently compromises diagnosis. in combination with steroids. The length of time usually once cirrhosis develops. Hypoglycemia is to remission and whether or not lifelong more often associated with acute liver failure. maintenance therapy is necessary are undefined. Serum bile acids are the most sensitive hepatic FIGURE 1 function test. However, they are not sensitive for 4 Laparoscopic liver biopsy in a early stages of CH and should not be used as the 2-year-old male castrated Havanese PROGNOSIS basis for deciding to pursue liver biopsy. (McDevitt: Short-term clinical outcome Dogs with CH do not typically go into of laparoscopic liver biopsy in dogs: 106 cases; JAVMA 248, No. I, January 2016). spontaneous remission, and there is a large IMAGING amount of evidence that once diagnosed, histological lesions of CH progress and many Abdominal ultrasound is the most useful and dogs die from causes related to their hepatic informative imaging modality for dogs with disease. In multiple studies, mean survival time suspected chronic hepatitis (CH), but is highly was 561 ± 268 days. In dogs with cirrhosis, operator dependent, its sensitivity is low, and survival is considerably shorter (23 ± 23 days). no changes are pathognomonic or diagnostic Factors associated with poor prognosis include for CH. hyperbilirubinemia, prolonged PT and aPTT, hypoalbuminemia, the presence of ascites, and BIOPSY the degree of fibrosis on biopsy. The primary concern for any hepatic sampling is hemorrhage. Published studies, including a TAKE-HOME POINTS heterogeneous group of hepatic disorders, Many dogs have an increase in ALT. When should indicate a relatively low incidence of bleeding I be worried? complications of 1.2-3.3%. Tests used to assess risk of hemorrhage include PCV, platelet • Predisposed breeds TREATMENT count, PT, aPTT, fibrinogen, BMBT, and • Progressive increase during vWF in predisposed breeds. High-risk dogs If thorough diagnostic investigation fails to find serial evaluations (PCV < 30%, Platelets < 50,000, either PT or an etiology, then treatment with nonspecific aPTT > 1.5 x upper limit, fibrinogen < 100 mg/dl, hepatoprotective agents such as ursodeoxycholic • ALT greater than three times the BMBT > 5 min, vWF < 50%) should have acid and S-adenosylmethionine may be upper limit of normal laparoscopic liver biopsy where tissue injury is indicated. Beneficial effects of Silymarin were • Any increase in bilirubin

Partners In Care  Fall 2020  Volume 14:3 7. C runs from the fourth to the first lumbar vertebrae, aorta. the to vertebrae, dorsal lumbar first the to fourth the from runs that sac elongated an is chyli cisterna The cisterna chyli. the into drain trunk, intestinal the viscera, via abdominal and trunks, lymph via lumbar the limbs, pelvic The vein. precaval or jugular the into empty that ducts via to system circulatory returned the be to particles foreign and fluid, tissue protein, extravascular allows which capillaries is a of network system permeable lymphatic The 8. 10 100x to often serum, than higher is level that triglyceride a has which fluid milky is Chyle leakage of chyle. leakage the transmural allow within to thought is system lymphatic a pressure in Altered resulting cavity chylothorax. thoracic the in of chyle accumulation an be can there lymphatic occurs, of drainage disruption When venous the circulation. into released be to chylomicrons within system lymphatic this through transported lobe torsion, and neoplasia. and torsion, lobe failure, heartworm disease, vena caval heart obstruction, lung right-sided including reported, considered have been of chylothorax causes Other is idiopathic. it and etiology, underlying no is some variation to its termination. its to variation some is there although cava, vena cranial and vein jugular left the at terminates and vertebra, thoracic fifth the around side left the to over crossing before aorta, the to dorsal side, right the on courses duct thoracic the dogs, In duct. thoracic the as the thorax into continues and diaphragm the at cranially shown to resolve in fivein to resolve toshown days. 10 been has chylothorax resulting the transected, or lacerated experimentally is duct thoracic the when chylothorax, cause can duct thoracic the to Shiba Inus and Oriental breeds of cats are are cats of chylothorax. developing to breeds predisposed Oriental and Inus Shiba aa ass hltoa i mr ta hl of dogs. the half than more in chylothorax causes cava vena cranial the of ligation while chylothorax, in results rarely duct thoracic the of obstruction mid thorax. mid and caudal the both in present be may collaterals multiple as structure single a always not is duct SURGERY 7 dogs and cats. In most cases, there is is there cases, most In cats. and dogs both in seen is that disorder a rare is cavity, thoracic of the in fluid chylous accumulation the hylothorax, 3 During digestion, triglycerides are 4,5 Although traumatic disruption disruption traumatic Although 3 The cisterna chyli narrows 1 Afghan hounds, hounds, Afghan angell.org/surgery | [email protected] |617-541-5048 |[email protected] angell.org/surgery DACVS DVM, Casale, Sue Idiopathic Chylothorax Dog the in 6 Experimental Experimental 3 The thoracic thoracic The 1,2

leaking in the cranial thorax. cranial in the leaking 4 4 FIGURE 2 FIGURE 1 FIGURE

Lymphangiogram showing the thoracic duct running just below the spine and and spine the below just running duct thoracic the showing Lymphangiogram achylothorax. with in adog effusion pleural showing radiographs Thoracic Partners In Care Care In Partners  Fall 2020 2020 Fall  Volume 14:3 Volume

SURGERY Partners In Care Care In Partners K. as as such vitamin vitamins fat-soluble well as including imbalance, electrolyte and dehydration protein. result and can lipid of Hypoproteinemia loss the of because malnutrition to result. lead can fluid can this of Drainage pneumothorax and laceration accidental of tolerant less become lungs The serum. than less is level that a cholesterol and greater, or may appear serosanguinous. appear may or not bemilky aswill fluid the is anorexic, patient although it may have a milky top layer. top milky a have may it although appearance, milky its retains chyle Upon standing, lymphocytes. large and small mostly becomes pocketed and harder to fully drain. fully to harder and pocketed becomes often effusion the and adhesions, and restrictive pleuritis in result can development solution. Fibrin long-term a not is but chylothorax for treatment initial the is thoracocentesis repeated with management Medical chyle. reveals and thoracocentesis effusion pleural reveal radiographs and dyspnea, with present often Patients results. devastating have can thorax the within chyle of chyle but will not decrease the volume. the the decrease of not will but chyle content triglyceride the disease, decrease can diets restrictive of Low-fat continued. be can therapy conservative amount large a be to appear not does there and thoracocentesis, months) few (every infrequent the requires If patient resolves. or diminishes fluid the if see for to 10 therapy is reasonable days conservative reported benefit is slight. is benefit reported the but recommended, been has benzopyrone, a shows the thoracic duct above the aorta. The second photo shows multiple surgical clips occluding the thoracic duct. duct. thoracic the occluding clips surgical multiple shows photo second The aorta. the above duct thoracic the shows 4 FIGURES 3+4 FIGURES PAGE FROM 8 CONTINUED Idiopathic Chylothorax in the Dog SURGERY

Intraoperative injection of a mesenteric LN with methylene blue will highlight the TD and branches can be seen. The photo on the left left the on photo The seen. be can branches and TD the highlight will blue methylene with LN amesenteric of injection Intraoperative 8 It is a modified transudate that contains contains that transudate It a is modified  Fall 2020 2020 Fall 13 If frequent taps are 9 Accumulation Accumulation  Volume 14:3 Volume 9,12 9,12 10 8 Rutin, If the Initial 9,10,11

duct within two to 13 minutes. 13 to two within thoracic duct the in appear will Contrast node. lymph popliteal a into iohexol injecting by achieved novs iaig h toai dc truh a through duct thoracic the ligating involves surgery Traditional to injection. prior be diluted blue can Methylene for up to 60 minutes. persist urudn structures. surrounding making minutes to compared when simpler 10 identification within duct thoracic the highlight will blue methylene of volume in or a small with at surgery help nodes lymph popliteal mesenteric the can of Injection which identification. white, appear duct thoracic the make will and chyle the of content fat the increases surgery to prior cream Feeding clear. astypically itis to identify may be difficult branches its and duct thoracic the surgery, At planned. be can and surgery identified be can branches and aorta, the of surface dorsal the along as it is duct seen runs itra hl alto (CCA). ablation chyli cisterna and pericardectomy subtotal a with often combined is which (TDL) ligation duct is thoracic treatment successful most and performed commonly but most the shunts, and pleuroperitoneal omentalization including chylothorax, for described been have procedures Multiple effusion. to the resolve chance best but the gives successful always not is chylothorax for Surgery recommended. be should surgery produced, of fluid amount the in no decrease with required for branches of the thoracic duct. thoracic the of branches for to look is helpful a CT lymphangiogram surgery, 21 The blue color will 20 20 The thoracic thoracic The 14-19 This can be be can This Prior to success rate in dogs. in rate success 50% a about have to reported was ligation TD ports are placed in the caudal thorax for the instruments. the and for camera thorax caudal the in placed are three ports and recumbency, sternal in patient the with reported success rate of 60-85% in dogs. in of 60-85% rate success reported a has pericardectomy and ligation duct thoracic ugcl lp, r ih eie lk the like devices or Ligasure shears activated with ultrasonically or clips, surgical with suture, en bloc with be ligated can duct The space. at 10th the intercostal thoracotomy lateral steroids and placement of a pleural port can can considered. be port pleural a of placement of and doses steroids anti-inflammatory effusion, with continued treatment is there If recurrence. for regularly monitored is patient the present, is effusion no If effusion. for pleural of assess recurrence to surgery after weeks two to one taken are radiographs thoracic Recheck diet. fat alow- on discharged patient the and removed is tube chest the that, After monitored. production fluid and hours 48 to 24 for place in left is tube chest A procedures. thoracic other to similar is chylothorax with dogs of care Postoperative popularity. gained has TDL thoracoscopic recently, More n diin o h T lgto and ligation TD the CCA performed. often is CCA to pericardectomy, addition In minimally invasive techniques. invasive with minimally performed be also can Pericardectomy device. is asealing or clips endoscopic which with ligated duct, thoracic the reveals aorta the 24,25 Thoracoscopic TDL is achieved achieved is TDL Thoracoscopic 27,28

(CONTINUED ON PAGE ON 10) (CONTINUED 1,9,11,26 24 The combination of Dissection dorsal to to dorsal Dissection 17,25 2,5,14,17-19 ™ . 22,23 9.

SURGERY 10. dogs. in rate success abetter and morbidity less in resulted have surgery invasive minimally of condition, use the and devastating techniques surgical in improvement a is Although chylothorax dogs. in reported been yet not has simultaneously performed procedures three all with rate Success chylothorax. with dogs for pericardectomy and CCA, TDL, perform currently we Center, Medical Animal Angell chylothorax. their of resolution dogs having of 83% with pericardectomy and to TDL success similar shown has CCA and TDL opened. or formed being ducts lead collateral to may which ligation, after duct thoracic the in buildup pressure the prevents into and abdomen fluid lymphatic of drainage allows REFERENCES: 8  7  6  5  4  3  2  1  PAGE FROM 9 CONTINUED Idiopathic Chylothorax in the Dog SURGERY there any hope? WSSAVA hope? any there 2015 Congress. is of chylothorax: Management E. Monnet JVet 1986,Am 47(4):967-71. Res. dogs. in cava vena cranial of the ligation after chylothorax induced experimentally of evaluation Lymphangiographic SJ. TW, Birchard Fossum Vet 1993, 22(6):431-435. Surg transection. and laceration experimental after healing duct of thoracic Evaluation W. TW, Evering Fossum CC, Hodges 18:307-310. 2004, Med JVet Intern chylothorax. idiopathic of treatment for pericardectomy and ligation duct MW, Thoracic al. et Miller MM, TW, Mertens Fossum 1982, 18:769-777. Assoc Hosp Anim Am J chylothorax. with dogs three and dogs normal in astudy duct: thoracic canine of the ligation and Lymphangiography RM. Bright HD, SJ, Cantwell Birchard 2013. Louis, St. Elsevier, edn. 4th dog the of Millerʼs anatomy HE. Evans Vet 2011, Surg 926-934. 40: dog. the in chylothorax idiopathic occurring of spontaneously treatment for pericardectomy to ablation chyli cisterna of comparison JF. Prospective McAnulty 188:1315-1317. JAVMA dogs. 34 1986, in Chylothorax RM. SJ, Jacobs TW, Birchard Fossum 2 At At . 29

19 18 17 16 15 14 13 12 11 10 9  review. Lymphology 1995, 28:64-72. review. Lymphology a cat: and dog the in DD. Chylothorax Smeak MA, SJ, McLoughlin Birchard 212:652-657. JAVMA cats. 1998, and dogs in chylothorax of idiopathic Treatment MA. DD, McLoughlin SJ, Smeak Birchard 39:21-27. Vet 2010, dogs. Surg in chylothorax of treatment for pericardectomy thoracoscopic and ligation duct thoracic CA. Thoracoscopic AG, Rawlings Ralph MG, DA, Radlinsky Allman 2001, 219 (11): 1590-1597. (1985-1999). 14 dogs: in cases JAVMA shunts pleuroperitoneal with effusion pleural of chronic Treatment al. et MA, SJ, McLoughlin DD, Birchard Smeak 107-113. (1995-2009). JAVMA, 2011; 239(1): 11 cases chylothorax: idiopathic for surgically treated of dogs outcome term Long- E. Monnet C, Sulva da Adrega dogs. Vet Surg 2005, 34:519- Vet 2005, dogs. Surg 523. eight in results chylothorax: for ligation duct thoracic with ablation chyli Cisterna al. et K, Gellasch G, Sicard K, Hayashi dogs. J Vet Intern Med 1993, Med 7:119. JVetdogs. Intern in composition and volume lymph duct thoracic on fat of dietary Effect al. SJ, et Birchart MA, DA, McLoughlin Sikkema 61-65. Vet 1999, adog. in 28 Surg chylothorax of treatment for drain aphysiologic as of Use omentum JD. JA, Niles Williams for treatment of idiopathic chylothorax chylothorax of idiopathic treatment for ablation chyli cisterna without or with pericardiectomy subphrenic plus ligation duct of thoracic Comparison al. et JB, Strouse KM, Gazzola SL, Stockdale JAVMA 1999, 215(3):345-8, 339. cats. four in chylothorax of idiopathic management medical for ofUse rutin RC. Jordan LA, Cohn MS, Thompson in four dogs. JAVMA dogs. 1991, four in 199:353-358. chylothorax induced experimentally or idiopathic with associated hyperkalemia and Hyponatremia A. Lippert A, TW, Torrance Fossum MD, Willard

Partners In Care Care In Partners 21  20 29  28 27  26  25  24  23  22 in dogs. Vet Surg 2003, 32:359-364. Vet 2003, dogs. Surg in duct thoracic of the coloration for blue methylene with injection node lymph mesenteric and Popliteal al. et DE, Mason MG, Radlinsky TM, Enwiller in cats. JAVMA, 2018, cats. in 252:976-981. cats. Vet 2011, Surg cats. 40:935-941. four and dogs six in effusion pleural of management for device pleuralport of Use the RJ. AC, Hardie Brooks 2005, 34:64-70.2005, Vet Surg drainage. lymphatic abdominal on ligation duct thoracic with combined ablation chyli of cisterna effect The JF. McAnulty KR, Waller GK, Sicard 193:68-71. JAVMA 1988, chylothorax. with dogs in ligation duct of thoracic Results TW. DD, Fossum, SJ, Smeak Birchard 241(7):904-909. (2007-2010).6 cases JAVMA 2012, pericardectomy: subphrenic and ligation duct thoracic thoracoscopic by dogs in chylothorax of idiopathic treatment invasive Minimally ODE. Morgan KN, Mayhew WTN, PD, Culp Mayhew dogs. Vet 2011,dogs. Surg 40:802-804. six in shears activated ultrasonically using duct thoracic of the Occlusion al. JF, et GW, Ellison Roberts CS, Leasure dogs. JAVMAdogs. 2007, 230(4): 527-531. three in effusion of pleural treatment for drains intrathoracic with ports access of Use vascular KM. Rassnick MA, JA, Steffey Flanders AK, Cahalane dogs. Vet Surg 2008, 37:696-701. Vet 2008, dogs. Surg 14 in study descriptive duct: thoracic the of ligation en bloc of Efficacy RD. NJ, Burrow Noble PJM, MacDonald application. Vet Surg, 2006, 35:377-381. 2006, Vet Surg, application. clinical and study experimental dogs: of node lymph popliteal the iohexol into of injection percutaneous by duct thoracic of the T, Lymphography eal. Y, Akiyoshi Ohigashi K, Naganobu Vet Surg 2002, 31:138-146.Vet 2002, Surg dogs. in duct thoracic of the ligation and visualization D. Thoracoscopic Olsen DS, Biller DE, Mason MG, Radlinsky  Fall 2020 2020 Fall  Volume 14:3 Volume

SURGERY I hypoadrenocorticism are attributable to the the to attributable are hypoadrenocorticism with dogs in abnormalities Clinicopathological patients. these in database minimum a of part a as bloodwork point-of-care obtain to important it is so signs, these cause can that ailments other many are There shock. of signs and hypovolemic diarrhea, bloody vomiting, with distress gastrointestinal severe includes often This crisis.” “Addisonian of an because it is typically hospital, emergency to the present Addison’s dogs with disease When cats. in occur rarely also It can breeding. of mixed are disease Addison’s by affected Rottweilers. dogs many and However, terriers, white West Danes, Highland Great dogs, water terriers, Portuguese Wheaten include predisposed are that breeds other poodles, Besides females. as well as dogs male in and age any at appear can it although dog, female is middle-aged to young a disease this for signalment common most The glands. adrenal of their portions destroy where cases to medications given in been have dogs Cushingoid veterinarian) a by (caused be iatrogenic also can disease This cortices. adrenal the of destruction immune-mediated by is caused hypoadrenocorticism of type The common glands. most adrenal the by produced are of substances lack These a glucocorticoids. and from mineralocorticoids results disease Addison’s disease, Addison’s of hypoadrenocorticism. or markers classic contains history patient’s this and differential, a sometimes-overlooked is disease endocrine However, a to ofbrew case pancreatitis. starting is she and leftovers, the cooking ate and into trash got she that be could It obstruction. intestinal an is causing that decoration or holiday stocking a running ate she Maybe are mind? your through differentials what her, to triage front up go you As herself. like acting not is and weak seems she that worried also is owner Her appetite. decreased and vomiting Partners In Care Care In Partners EMERGENCY emergency room for a one-day history of history one-day a for your room emergency to presents female, Labradoodle spayed 4-year-old, before a week and a Christmas night Saturday a t’s  Fall 2020 2020 Fall angell.org/emergency | [email protected] | 781-902-8400 | Angell West, Waltham |Angell |781-902-8400 |[email protected] angell.org/emergency DVM Mueller, Kate Addison’s Disease  Volume 14:3 Volume

or even a reverse stress leukogram, with with leukogram, lymphocytosis. and stress neutropenia reverse a even or leukogram normal a have may dog Addisonian an lymphopenia, and neutrophilia exhibiting than Rather animals. ill in seen typically is that leukogram” “stress a lack will many face the illness, of in response stress appropriate to an mount inability body’s the to Due anemic. often are patients ways. Addisonian several in disease Addison’s of supportive be also can CBC The retention. sodium inadequate to due urine concentrate to inability body’s the of result a as azotemia, and dehydration of light in noteworthy especially gravity, urine-specific low a reveals frequently Urinalysis hypoglycemia. often and dehydration) to secondary (pre-renal azotemia include These ratio. potassium to sodium low a of light in especially diagnosis, the can confirm help findings panel chemistry Other 28:1. than less of ratio potassium to sodium a with potassium, high and sodium low include sufficient findings common produce most The mineralocorticoids. and to glucocorticoids inability body’s therapeutic regimen, typically do very well and and well very do typically regimen, therapeutic and monitoring long-term an appropriate on placed an are who and in crisis, treated Addisonian aggressively and diagnosed promptly are who Dogs of prednisone. form the in daily given typically glucocorticoids, as well as injection) of aonce-a-month form the takes this (usually aimed is mineralocorticoids both at replacing treatment confirmed, is diagnosis Once cortisol. unable is produce to body the because administration ACTH Addison’s after with increase not level will cortisol dog the disease, a In cortisol. blood in increase significant a cause will compound this of administration exogenous dog, normal a In body. the in of cortisol release the regulates that substance the is ACTH test; stimulation ACTH the via made is diagnosis Definitive possible. as soon as hormone begin should therapy because replacement however, important, and is hypovolemia diagnosis Prompt abnormalities. electrolyte address to therapy fluid intravenous aggressive involves initially setting emergency the in disease Addison’s of Treatment 11.

AVIANEMERGENCY AND EXOTIC T 80-85% in dogs and cats over 2 years of age. of years 2 over cats and dogs in 80-85% of aprevalence has disease periodontal that shown have studies Multiple disease. periodontal ay f hs fatrs r cue by bones. caused marrow and antlers, Nylabones, as are such items chew fractures inappropriate these of many should erupt by the age of 5-7 age months. the by erupt should ofas dentition most adult the surgery spay/neuter 12. months. 5-7 by erupting of process dentition the in or adult erupted be should the as spay/neuter a is during investigate to time great A cats. and dogs in investigated be should teeth “missing” Any periodontium. ahealthy for room teeth remaining the gives This extraction. selective with treated be also can teeth Crowding/supernumary occlusion. functional goal a is to provide pain-free The successful. be also can extraction issue, selective the resolve can appliances orthodontic While dogs. purebred some and breed toy/small our in finding frequent another is Malocclusion of patients. 25% canine nearly our in incidence an with seen are teeth Fractured treatment. for extraction requires often disease periodontal end-stage or advanced but not does teeth, of affected disease the extraction necessitate always periodontal mild or Early hl etatos r otn eurd for fractures. crown complicated required often or long-standing fractures root crown complicated are extractions while fractures, crown complicated for option an is can be treated with an operculectomy to allow allow to operculectomy an with treated be can impaction tissue soft while extraction, require will impaction Bony time. that at treated be can removed. be should they present, still are they if erupted; fully has tooth successive permanent the once exfoliate should teeth Deciduous tooth. permanent adjacent of the disease periodontal irreversible cause can teeth deciduous of presence continued the place, in Left young. still are dogs the when addressed be should and in dogs toy/small-breed frequently found are teeth deciduous Persistent DENTISTRY 1 Often timing of removal coincides with with coincides of removal timing Often perform extractions is advanced advanced is extractions perform to reasons common most of the One patients. feline and of canine our in number reasons a for extracted are eeth 1 Any unerupted or impacted teeth teeth impacted or unerupted Any 4 Root canal treatment treatment canal Root 4,5 angell.org/dentistry | [email protected] |617-522-7282 |[email protected] angell.org/dentistry Surgery Oral and Dentistry to Limited Practice DVM, Ekerdt, Alice Complications Common Dealing with and Canine Feline and Extractions 2 Unfortunately, Unfortunately, 1,3 1,3 1,3

1,2 1

type and extent (or stage) of tooth resorption. tooth of stage) (or extent and type the determine to treatment to prior obtained be must radiographs Intraoral tooth. the of regions different to approaches different necessitating is tooth resorption, tooth 2 and one 1 Types both by affected when occurs resorption tooth 3 Type amputation. crown with treated be can tooth cats in resorption tooth remaining 2 Type while all structures, of extraction requires This type does not always require treatment treatment require always not does type cats. This in resorption tooth 2 Type resembles which resorption, replacement external is dogs in seen resorption tooth of type common most The 3. and 2, 1, Type as classified not is theirs but resorption, tooth with present also can Dogs as 3. or classified 2, 1, Type be can cats in resorption Tooth process. resorption to tooth the reverse or way stop no is there Unfortunately, resorption. tooth with present dogs) (and often some Cats fractures. jaw potential and structures, nearby to damage loss, bone significant cause can which cysts, dentigerous of development can the prevent age younger a at teeth these Addressing h toh o otne t nra eruption. normal its continue to tooth the premolar tooth, commonly called a “slab” fracture. a“slab” called commonly tooth, premolar 4 FIGURE 1 FIGURE

This is an example of a complicated crown root fracture of the right maxillary 4th 4th maxillary right the of fracture root crown acomplicated of example an is This 6 Type 1 tooth resorption in cats 7,8,9 6 1 1

Partners In Care Care In Partners hne o a cure. a best for the chance as recommended are they but cure, extraction immediate an provide do not always mouth procedures caudal or Total feline patients. our affecting disease debilitating but is an uncommon gingivostomatitis Feline chronic abscesses due to endodontic disease and/or and/or disease. periodontal disease advanced endodontic to due abscesses root tooth to relation in seen often resorption, inflammatory external is dogs in found resorption be treated with crown amputation when when amputation crown indicated. with treated be may resorption tooth of type this cats, in 2 Type aae te nert o te tooth. the of integrity severely the has damaged or crown the involves it unless mouth extractions are performed. are extractions mouth caudal/partial/total after treatment adjunct good time. of for a period medication refractory requiring and disease having 30% about with improve indicative of endodontic disease. of endodontic indicative lucencies periapical the to due extraction require permission from the client. Estimates should be be should Estimates client. the from get permission to sure be extractions, performing to Prior 10,11 Studies have found cyclosporine to be a cyclosporine have found Studies 7,8,9 The second most common type of  10 Fall 2020 2020 Fall h mjrt o ct do cats of majority The 7,8,9 7,8  10

Volume 14:3 Volume These teeth teeth These

7,8,9 Like Like

DENTISTRY (see charts in the slides that follow). that slides the in (see charts cats and dogs larger in site per given be (mental), and caudal mandibular (inferior (inferior mandibular alveolar). caudal and (mental), mandibular rostral maxillary, caudal infraoribital, the include blocks anesthetic local performed Gel-foam of Vetspon for hemostasis. for of Vetspon Gel-foam and needles), 5-0 or to tapered cutting reverse 3-0 with sizes, in (Monocryl suture (mandatory), lighting, excellent radiographs dental picks, tip tooth, 7X7 root (Dean), scissors holders, needle Olsen-Hegar Brown-Adson forceps: tissue curette, alveolar small forceps, extraction various sizes, in elevators elevators luxators #1-4), dental elevators freer), (winged periosteal #4, molt #2, #15C), (molt #15, (#11, blades stone), scalpel white conical handpiece high-speed diamond, 701,701L, 700, 4, 1,(1/2,2, for cylindrical burs coolant, water integrated with unit delivery include: high-speed supplies Recommended for success. imperative is instruments proper and with equipment operatory dental the Equipping presentation. the during discussed be will Partners In Care Care In Partners consideration. into taken be to needs also anesthetic local of volume The opioids. formulations with as mixed be can they or purchased vasoconstrictors with be can These patients. feline and canine our in used anesthetics local common are Bupivacaine and Lidocaine control. pain requirements, postoperative provide and anesthetic decrease prevent help windup, they surgery; oral and dentistry of part important an are blocks anesthetic Local estimate? of your end high the go over will work disease required the if the happens What about cost. process…or understanding of lack a due to is often This are permission. without extractions? teeth extracted if upset for very become day owners Some another return and prophylaxis dental complete a perform teeth just or necessary the all extract to you prefer owner the Would reached? be can’t owner the findings? if What unexpected only or findings the all of informed and to be called need owner the Does information. pertinent the all obtaining after place in plan a Have anesthesia. general under performed are radiographs examination, intraoral and charting, an until appreciated be cannot needed treatment of extent the Often extractions. multiple for allows that range a with provided or 2 mg/kg of Bupivacaine for dogs and cats. and dogs for Bupivacaine of mg/kg 2 or CONTINUED FROM PAGE FROM 12 CONTINUED Complications Common with and Dealing Canine and Feline Extractions DENTISTRY 1,3 1,3 Do not exceed 4 mg/kg of Lidocaine Lidocaine of mg/kg 4 exceed not Do Specific landmarks and guidelines  Fall 2020 2020 Fall 12,13 Larger volumes can  12,13 Volume 14:3 Volume 1,3 Commonly Commonly 1,3 3

and occasional intraoperative radiographs. radiographs, postoperative magnification, +/- lighting, good intraoral technique, proper radiographs, preoperative include measures extractions. “surgical” versus “simple/closed” categories: major two into be divided can extractions Dental hemorrhage, and dehiscence. and hemorrhage, penetration, orbital canal, cavity/mandibular nasal the into roots tooth t pushing roots, ooth retained include complications Common the training. appropriate with improves using technique and intended as includes instruments correct technique Proper of reasons; the best approach for handling handling for prevention. is complications approach best the reasons; of for a number occur can complications Extraction and learn from your mistakes. your from learn and honest, be help, for ask to Remember treatment. and today’s prevention their to addition in in presentation discussed be will complications for extraction site closure, using a simple simple a using interrupted suture pattern. closure, site extraction for tension. without closed be should they and extractions, surgical for created are flaps Mucoperiosteal do. extractions surgical while teeth, multirooted of sectioning or bone of alveolar removal REFERENCES: REFERENCES: 6  5 4  3  2  1  (2004-2012). Visits Patient 660 in 959 Injuries Cats: and Dogs in Injuries Dentoalveolar Traumatic of Epidemiology and Classification A. Paul S, JW, Hetzel Soukup www.avdc.org Tooth Resorption. AVDC Nomenclature. www.avdc.org Classification. Tooth Fracture AVDC Nomenclature. 2012. Ltd; Elsevier Cats and Dogs in Surgery Maxillofacial and Oral AJ. Bezuidenhout MJ, Lommer FJM, Verstraete Assoc Hosp Anim J Am hospital. aveterinary at anesthetized dogs in diseases dental and of oral A survey CE. Harvey M, Stoller AL, Golden 1997. Lippincott-Raven; Philadelphia: Practice and Principles Dentistry Veterinary HB. Lobprise RB, Wiggs 1,3 Absorbable sutures are recommended recommended are sutures Absorbable 1,3 Simple do extractions not require J Vet Dent 1,3 . 2015; 32(1): 6-14. . 1982; 18: 891-899. 14,15 . Edinburgh: . Edinburgh: 1,3 Each of these of these Each Preventive Preventive . 14,15,16 14,15

13 12 11 16 15 14 10 9  8  7  veterinary-patients. tooth-resorption-name-it-tame-it-your- veterinarymedicine.dvm360.com/ DVM360 patients. veterinary your itin tame it to Name SJ.Wooten Tooth resorption: 71(7):794-798. JVet Am Res dogs. in resorption tooth of extent the of classification of the evaluation PH. Radiographic Kass FJM, Verstraete S, Peralta 71(7): 784-793. AJVR dogs. in resorption of tooth types of the evaluation Radiographic PH. Kass FJM, Verstraete S, Peralta Transl Med Transl Cells Stem Cats. in Gingivostomatitis Refractory Severe for Cells Stem Mesenchymal Autologous of Fresh, Efficacy Therapeutic al. et B, Arzi Blackwell Publishing; 2006. Publishing; Blackwell Techniques of A Manual Dentistry: Animal Tutt Small C. AZ. 2018; Phoenix, November Forum; Dental Veterinary the from Proceedings In: Extractions. of Complications Handling K. Bannon, Study. JVetStudy. Dent Clinic Double-Blinded Controlled, Placebo- ARandomized, Cats: in Stomatitis Refractory Chronic, for Cyclosporine of Efficacy MJ. Lommer Jan 2018:Jan 14-20. Extractions. of Tooth TopTaney K. 5Complications Surgery in Dogs. Dogs. in Surgery Oral for Blocks B. Nerve Beckman Jan 2014:Jan 21-23. Feb 2014: 41-43. NAVC Cats. in Clinician’s Brief Surgery Oral for Blocks B. Nerve Beckman . 2016; 5(1):75-86. NAVC Clinician’s Brief . May 2018.. May http:// . 2013; 30(1): 8-17. NAVC Clinician’s Brief . Oxford: . Oxford: . 2010; . 2010; . 13. . .

DENTISTRY C lateral or medial patellar luxation. Careful Careful luxation. patellar medial or lateral to either secondary be addressed can deformities trochlear and age, of months six than greater be should Dogs osteoarthritis. femoro-patellar severe of cases in sulcoplasty to alternative an surgeon the offers KYON) (PGR, replacement groove patellar prosthesis, low-friction shaped, anatomically sized, appropriately An area. fibro- surface alarger over of cartilage development suboptimal ensures trochleoplasty, to compared and, function, to a in slower return results is painful, Sulcoplasty patella. the “capture” to groove faux a create to order in bone subchondral bleeding expose to exists cartilage away what or rasping burring sulcoplasty, a perform to forced is surgeon the that damaged or deformed severely so is groove trochleoplasty; patella the which in occasions are however, block there or recession wedge a either with addressed be can abnormalities groove part, most the For quality. cartilage and shape, depth, alignment, to respect with groove 14. FIGURES 1&2 FIGURES plate application. bone for required surface bone flat asmooth of appearance the representing position, A/P mode, Bone (Right) groove. trochlear margin the of proximal to the tendon extensor digital long the of origin the from osteotomy arequired of axis the 4 SURGERY

(Left) Bone model, lateral position, red-inked line delineating delineating line red-inked position, lateral model, Bone (Left) the time of corrective surgery, surgery, of patellar the evaluation necessitates corrective of time the at that, condition orthopedic common extremely an is luxation patellar anine angell.org/surgery | [email protected] |617-541-5048 |[email protected] angell.org/surgery DACVS, MB, ECVS VET MA, Trout, Nick Patellar Replacement Groove imbrication, imbrication, tibial tuberosity distal transposition, release/ capsule joint — treatments concurrent standard other the All luxation. patella for cure a PGR the is itself, in not, to that note It is important glides. patella the as hitch or of aclick absence and tracking, between smooth implant, and patella relationship “snug” a size, the correct ensure to vital is flexion/extension, stifle and reduction patella with together implants, trial of use placement, and choice prosthesis final to Prior 5). & 4 (Figures position locked the into hammered gently and carefully being before plate the engage that prongs three has prosthesis The position. appropriate the in plate an secure the 3). secure Screws (Figure plate to base implant which on 2) (Figure bed bony smooth, flat, a leave will This 1). (Figure groove trochlear the of margin extensor proximal the to digital tendon long the of origin the from line a along saw oscillating an using is performed groove diseased the remove to An osteotomy exposed. groove the and the luxated, routinely, patella approached is joint stifle The of prosthesis. size correct the choose to order in essential is planning radiographic preoperative FIGURE 2 FIGURE FIGURES 3, 4, &5 4, 3, FIGURES PGR (patella reduced) (patella PGR demonstrating position, lateral model, Bone (Right) luxated). (patella PGR demonstrating position, A/P model, Bone (Middle) 4

(Left) Base plate screwed into the appropriate position. position. appropriate into the screwed plate Base (Left) Partners In Care Care In Partners take nine months. nine take bone however, to reported been time; has plate base the into ingrowth this at useful be ten. can to eight weeks implants stable follow-up to ensure by Radiographic normal to return and three, week at walks leash five-minute of introduction restriction, of postoperative period two-week a KYONsuggests function. to return earlier and comfort increased noting owners with a prosthesis, to of innervation lack the is sulcoplasty over PGR to advantages the of One outcome. apositive to essential still — are osteotomies corrective tibial or proximal femoral REFERENCE: (www.kyon.ch). KYONof courtesy are figures All 2/2015;Traumatol 124-130. Weigel, Vet Orthop AVezzoni. Comp JP D. Lorinson, Dokic, Z. osteoarthritis. femoro-patellar severe with luxation patellar in replacement groove Patellar  Fall 2020 2020 Fall FIGURE 2 FIGURE  Volume 14:3 Volume

SURGERY 4 Angell Offers Two Low-Cost Clinic Locations

Angell at Essex (Danvers, MA) and Angell at To Financially Qualify for Discounted Services Nashoba (Westford, MA) clinics are dedicated Angell clinics welcome all pet owners and reserve a sizable portion of appointment times to providing quality care to the general public for discounted services. For those interested in discounted services, clients must as well as offering deeply discounted services financially qualify by presenting a photo ID and one of the following: for qualified low-income families. The clinics provide primary veterinary care, spay and • Women, Infants, and Children (WIC) Program card neuter services, vaccinations, and surgery and dental services. • Supplemental Nutrition Assistance Program (SNAP) card (formerly known as Food Stamps/EBT) Angell at Essex and Angell at Nashoba are open weekdays from 7:45am – 4:00pm throughout the • Spay and Neuter Assistance Program certificate year. The clinics do not provide overnight care, specialty service care, or 24/7 emergency care. • Letter/lease from the owner’s local housing authority showing that the owner is Appropriate cases will be referred to Angell’s a participant in public housing Boston or Waltham facilities or a surrounding specialty veterinary referral hospital. • Veterans card

To schedule an appointment with the Angell To schedule an appointment with the Angell at Nashoba clinic, please call 978-577-5992. at Essex clinic, please call 978-304-4648.

Left to Right: Dr. Laurence Sawyer. Angell at Nashoba on campus at Left to Right: Dr. Erin Turowski. Angell at Essex on campus at Essex Nashoba Valley Technical High School (Westford, MA). North Shore Agricultural and Technical School (Danvers, MA).

Partners In Care  Fall 2020  Volume 14:3 15. CHIEF STAFF OF 617-522-5011 Referrals: 617-522-7282 Phone: 978-577-5992Main Nashoba: at |Veterinary (Waltham) |781-902-8400 |Angell (Boston) „ 16. [email protected] Waltham Officer, Medical Chief DACVECC Sumner, DVM, Catherine [email protected] Jessica Seid, DVM [email protected] DACVECC DVM, Peck, Courtney [email protected] DVM Lohin, Amanda [email protected] DVM Gergis, Mina [email protected] DVM Fetto, Jordana WALTHAM MEDICINE, CARE 24-HOUR EMERGENCY & CRITICAL [email protected] Officer Medical Chief DACVECC, CVA DVM, Whelan, Megan [email protected] Turley,Kelsey DVM [email protected] DVM, DACVECC Sinnott-Stutzman Virginia [email protected] DVM Koid, Audrey [email protected] DVM Kelley, Morgan [email protected] DVM Doyle, Sara [email protected] DVM Dorsey, Kate [email protected] DVM Cazlan, Callie [email protected] DVM Brandifino, Maria [email protected] Co-Director Service DACVECC Bracker, DVM, Kiko [email protected] Becker, DVM Jami [email protected] DVM Bartling, Justina [email protected] Alison Allukian, DVM BOSTON MEDICINE, CARE 24-HOUR EMERGENCY & CRITICAL [email protected] DACVECC DVM, Greenleaf, Marie Ann

We encourage you to contact Angell’s specialists with questions. with Angell’s specialists contact you to We encourage STAFF DOCTORS ANDSTAFF RESIDENTS DOCTORS

[email protected] &Waltham) (Boston Trained) (Residency DVM Simon, Brooke [email protected] DACVD DVM, Painter, Rock Meagan [email protected] DVM Loft, Klaus (W/B) DERMATOLOGY [email protected] DAVDC DVM, Riehl, Jessica [email protected] DVM McCarthy, Colleen [email protected] DVM Ekerdt, Alice DENTISTRY [email protected] DVM Zarin, Joseph [email protected] Wiley,Elizabeth DVM [email protected] DVM Oranges, Michelle [email protected] (Waltham) (Cardiology) DACVIM DVM, Malakoff, Rebecca [email protected] (Boston) (Cardiology) DACVIM DVM, Hogan, Katie (W/B) CARDIOLOGY [email protected] CAAB BCBA-D, PhD, Terri Bright, BEHAVIOR (W/B) [email protected] (Waltham) (Avian Practice) DABVP DVM, Sullivan, Patrick [email protected] (Avian DABVP Practice) DVM, Simone-Freilicher Elisabeth [email protected] &Waltham) (Boston (Avian Practice) DABVP DVM, Noonan, Brendan (W/B) MEDICINE &EXOTIC AVIAN [email protected] DACVAA DVM, Krein, Stephanie [email protected] DACVAA DVM, Cummings, Kate ANESTHESIOLOGY

Partners In Care Care In Partners [email protected] (Waltham) DVM, DACVIM Vrabelova Ackley Daniela [email protected] Spear, DVM Daisy [email protected] DVM Sheu-Lee, Annie [email protected] Director Service DACVIM DVM, O’Bell, Susan [email protected] DACVIM DVM, Mariotti, Evan [email protected] DACVIM DVM, Kearns, Shawn [email protected] (Waltham) DACVIM DVM, Gorman, Lisa [email protected] Duddy, DVM Jean [email protected] DACVIM DVM, Crouse, Zach [email protected] DACVIM DVM, Carroll, Maureen [email protected] DVM Brum, Douglas [email protected] Beehler,Michelle DVM (W/B) MEDICINE INTERNAL [email protected] DACVR DVM, VanRuth Hatten, [email protected] DACVR Tsai, DVM, Steven [email protected] DACVR DVM, Ford, Naomi (W/B) IMAGING DIAGNOSTIC [email protected] &Waltham) (Boston (Neurology) DACVIM DVM, Michaels, Jennifer [email protected] &Waltham) (Boston (Neurology) DACVIM DVM, James, Michele [email protected] &Waltham) (Boston DACVIM (Neurology) DVM, Daniel, Rob NEUROLOGY (W/B)

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Fall 2020 2020 Fall

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Volume 14:3 Volume

STAFF DOCTORS AND RESIDENTS

STAFF DOCTORS AND RESIDENTS CONTINUED FROM PAGE 14

ONCOLOGY PATHOLOGY Nicholas Trout STAFF DOCTORS DOCTORS STAFF RESIDENTS AND Megan Duckett, DVM, DACVIM (CLINICAL & ANATOMIC)* MA, VET MB, MRCVS, (Medical Oncology) Patty Ewing, DVM, MS, DACVP DACVS, DECVS [email protected] [email protected] [email protected] Lyndsay Kubicek, DVM, DACVR Pamela Mouser, DVM, MS, DACVP Emily Ulfelder, BVetMed (Radiation Oncology) [email protected] (Boston and Waltham) [email protected] [email protected] Ji-In (Jean) Lee, DVM PHYSICAL REHABILITATION Mallory Watson, DVM (Board Eligible for Medical Oncology) Jennifer Palmer, DVM, CCRT [email protected] [email protected] [email protected] ANGELL AT ESSEX J. Lee Talbott, DVM, DACVIM Amy Straut, DVM, CCRT Erin Turowski, DVM (Medical Oncology) [email protected] [email protected] [email protected] SURGERY (W/B) Jillian Walz, DVM, DACVIM ANGELL AT NASHOBA (Medical Oncology) Sue Casale, DVM, DACVS Laurence Sawyer, DVM (Board Eligible for Radiation Oncology) [email protected] [email protected] [email protected] Megan Cray, VMD [email protected] OPHTHALMOLOGY Andrew Goodman, DVM, DACVS Daniel Biros, DVM, DACVO [email protected] [email protected] Michael Pavletic, DVM, DACVS Martin Coster, DVM, MS, DACVO [email protected] [email protected]

(W/B) Services also available at our Waltham location 4 Our Service Locations

BOSTON & WALTHAM BOSTON ONLY

Avian & Exotic Medicine Anesthesiology 617-989-1561 617-541-5048 Behavior Dentistry 617-989-1520 617-522-7282 Cardiology Diagnostic Imaging* 617-541-5038 617-541-5139 Dermatology Oncology 617-524-5733 617-541-5136 Internal Medicine Ophthalmology 617-541-5186 617-541-5095 Neurology Pathology* 617-541-5140 614-541-5014 Physical Rehabilitation** 781-902-8400 Surgery 617-541-5048

24/7 Emergency & Critical Care  Boston: 617-522-5011  Waltham: 781-902-8400

*Boston-based pathologists and radiologists serve both Boston and Waltham locations **Available only in Waltham

Partners In Care  Fall 2020  Volume 14:3 17. 4 Courtesy Shuttle for Patients Needing Further Specialized Care

Angell Animal Medical Center offers the convenience of our MSPCA-Angell West facility in Waltham, MA. With 24/7 Emergency and Critical Care service and two board-certified criticalists on staff, the Waltham facility also offers specialized service appointments Monday through Saturday. If needed, an oxygen-equipped courtesy shuttle can transport animals to Boston for further specialized care and then take them back to Waltham. Whether in Boston or in Waltham, our specialists regularly collaborate and plan treatments tailored to our patients’ emergency, surgical, and specialty needs.

WE OFFER A BROAD RANGE OF EXPERTISE AND DELIVER THIS CARE WITH THE ONE-ON-ONE COMPASSION THAT OUR CLIENTS AND PATIENTS DESERVE.

4 Physical Rehabilitation at MSPCA-Angell West

Canine and feline physical rehabilitation is used to treat a wide variety Currently physical rehabilitation services include: of orthopedic and neurological conditions. Whether recovering from an injury, or cross training, or facing a mobility issue, dogs and cats can • Hydrotherapy • Land-based exercise substantially benefit from physical rehabilitation. • Manual therapy • Therapeutic laser treatment MSPCA-Angell West Physical Rehabilitation offers services seven days • Massage • Consultation and fitting of a week. Jennifer Palmer, DVM, Certified Canine Rehabilitation Therapist assistive devices (CCRT), and Amy Straut, DVM, CCRT, lead our Physical Rehab team. • Chiropractic Visit angell.org/rehab for details and video footage of the impact their work on our patients. 4 COVID-19/Hospital Updates

18. Partners In Care  Fall 2020  Volume 14:3 4 The Angell Critical Care Unit: A Transformation in Critical Care Increased Comfort, Enhanced Functionality and Amenities

This summer we broke ground on Within the unit, families will have access construction of Angell's new Critical Care to two private visiting rooms. The space Unit (CCU). There has been a dramatic will also incorporate bays designed increase in nationwide veterinary specifically for a mechanical ventilator and emergency cases since the COVID-19 dialysis, two key life-saving technologies. outbreak, perhaps due to more adoptions, An isolation area will be part of the layout, 4and closer oversight of pets as people stay and a doctor work space will be built into home COVID-19/Hospital during the pandemic, so the CCU the CCU. Updates Around the corner from the CCU, renovation couldn't be more timely. Our an innovative two-story treatment area CCU treatments and training are ever- equipped with an elevator will serve evolving, and it is only fitting to transform boarders and others. the physical space to the next level as well. The move will streamline care and Angell’s ECC team has the expertise and significantly improve patient comfort. technology to treat the most fragile patients including those recovering from complex The new CCU will have direct access to the surgeries, or suffering from acute illness, outdoors to ease the walking of patients. chronic disease or injuries. Our donors have Skylights will provide natural lighting to generously provided this new space to patients and staff, and there will be increased further help the Angell team to bring the capacity for all species with large cage space best care possible to the patients whose to maximize comfort. In addition, there will lives depend on it. be separate areas for dogs and cats with built-in noise control to lessen patient anxiety.

Starting Top Right: CCU patients like Skipper (top) and Simba (bottom with Dr. Jinni Sinnott-Stutzman) will benefit tremendously from renovations to the Angell Emergency and Critical Care Unit. (Above) Rendition of the new double-story CCU from the outside.

New Features in the CCU • Visiting rooms in the unit • Bays designed specifically for ventilator and dialysis Besides the addition of more space, • Separate areas for dogs and cats with Angell offers increased comfort and noise control • Natural lighting (skylights) quality of care for patients, including: • Separate emergency room with easy • Access from CCU to outdoors (no long access/transition to critical care hallway for patients to traverse)

• Doctor work space built in to the CCU • Increased capacity for all species with large cage space • Isolation built into CCU • 2nd floor for boarders with elevator

Partners In Care  Fall 2020  Volume 14:3 19. Nonprofit Org. US Postage PAID Permit No. 1141 Boston, MA

We mail one complimentary copy of our newsletter to each of our referring partners. Please circulate this copy within your practice. Fall 2020 | Volume 14:3 | angell.org | facebook.com/AngellReferringVeterinarians

MSPCA-ANGELL 350 South Huntington Avenue Boston, MA 02130 617-522-5011 angell.org

MSPCA-ANGELL WEST 293 Second Avenue Waltham, MA 02451 781-902-8400 angell.org/waltham

ANGELL AT NASHOBA 100 Littleton Road Westford, MA 01886 978-577-5992 angell.org/nashoba

ANGELL AT ESSEX 565 Maple Street Danvers, MA 01923 978-304-4648 angell.org/essex

ANGELL.ORG/DIRECTIONS (FREE PARKING) | ANGELL.ORG/HOURS | ANGELL.ORG/CE Please consider adding Angell’s main numbers to your after-hours phone message.

4 Angell Fall Continuing Education — Registration is Open!

Management of Ear Disease and Food Allergies — Everything You’re Itching to Know

Wednesday, October 14, 2020 6:15pm – 8:45pm 2 Interactive CE Credits (pending RACE approval)

TOPICS INCLUDE: • Management of Ear Disease: Acute vs Chronic Klaus Loft, DVM • When, Why, and How — Making the Most of the Diet Trial as a Diagnostic Test Meagan Rock Painter, DVM, DACVD

JOIN US FOR AN ONLINE LIVE INTERACTIVE WEBINAR! To register for this online webinar, please visit angell.org/ce