January / Janvier 2020 / Volume 61 / No. 01

THE CANADIAN VETERINARY JOURNAL

Published by the Canadian Veterinary Medical Association Publiée par l’Association canadienne des médecins vétérinaires FOR PERSONAL USE ONLY

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JANUARY/JANVIER 2020 Contents Table des matières

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

CASE REPORTS RAPPORTS DE CAS 30 Diabetic remission in a cat treated with an implantable pump to deliver insulin Chiara Crinò, Francesca Iavazzo, Filippo Ferri, Luigi M. Coppola, Elena Salesov, Thomas A. Lutz, Claudia E. Reusch, Eric Zini 35 Spontaneous mural gallbladder hematoma in a dog Olivia Jerrems, Carlos H. de Mello Souza, Vincent Wavreille, Benjamin I. Davids 39 Mycobacterium porcinum causing panniculitis in the cat Allison Cox, Tyler J. Udenberg 44 Diagnostic imaging of a basihyoid bone 69 The comparative efficacy of disinfectant fracture and partial avulsion of the medial wipes on common-use computer keyboards pterygoid muscle in a horse in a veterinary teaching hospital Brittany Veerasammy, Massimo Delli-Rocili, Eileen K. Wong, Brandy A. Burgess, Monica Jensen, Nicola Cribb, Alex zur Linden Ben M. Brainard, Craig E. Greene, David J. Hurley, Amie Koenig 49 Intravenous lipid emulsion to treat suspected cocaine toxicosis in a dog BRIEF COMMUNICATION Kirsty Royle, Carsten Bandt COMMUNICATION BRÈVE 75 Update on demographics of the Canadian ARTICLES Dairy Industry for the period 2011 to 2016 53 Comparison of single, fixed-time artificial Christopher D. Luby, Cheryl Waldner, insemination in weaned sows using Murray D. Jelinski 2 different protocols to synchronize ovulation STUDENT PAPER Lima Rodrigues, Rocio Amezcua, Glen Cassar, COMMUNICATION ÉTUDIANTE Terri O’Sullivan, Robert Friendship 79 A peculiar case of soft tissue sarcoma 57 Concentrations and deficiencies of in a cat minerals in cattle submitted to a Werdah Iqbal diagnostic laboratory in Saskatchewan from 2003–2012: A retrospective study 11 QUIZ CORNER Ursula Perdrizet, Barry Blakley, Ahmad Al Dissi TEST ÉCLAIR 63 Pilot study of the effectiveness of a xylitol-based drinking water additive to reduce plaque and calculus accumulation in dogs Candace Lowe, James Anthony

CVJ / VOL 61 / JANUARY 2020 3 FOR PERSONAL USE ONLY

What’s your vision for the future of your business?

Questions to ask as you enter discussions with potential partners.

– Dr. Louis Kwantes, Park Veterinary Centre. Sherwood Park, AB. NVA partner since 2016. 3

NO. 01 NO. 02 NO. 03 Is it the right culture Are there flexible How comprehensive fit for your team? deal structures? are the support services?

As you begin considering your options Because selling your pet hospital is As you contemplate transitioning for selling your pet hospital business, such a personal decision, you’ll want your business, you’ll want to know it’s important to find a partner aligned to understand what types of options every aspect is covered. Seek out with your values, respectful of the are available, and to what level they a partner with a dedicated individuality of what you’ve built, and can tailor the terms to meet your team seasoned in marketing equipped to grow your business, while needs. (including digital advertising your team and culture remain intact. and social media strategy), ASK IF THE BUYER CAN: web development and hosting, Ask around to find out which buyers client satisfaction surveys, IT, HR, • Make all cash offers with no have the best reputation for caring for accounting, taxes, legal and more. finance contingency pets and the people who love them. • Offer Joint Venture partnerships for growth and flexibility • Buy the real estate outright or lease from you

NVA has over 700 partnerships in the US, Canada, Australia and New Zealand. Our passionate, visionary local pet resort and hospital leaders embody NVA’s unique entrepreneurial spirit. We’d be more than happy to talk through your questions and concerns. You can reach us at 888.767.7755 or [email protected]. FOR PERSONAL USE ONLY

JANUARY/JANVIER 2020 Contents Table des matières

FEATURES RUBRIQUES

PRESIDENT’S MESSAGE NOTICES ANNONCES LE MOT DE LA PRÉSIDENTE 7 Stay challenged and continue growing 88 Index of Advertisers Garder la motivation et continuer Index des annonceurs à s’épanouir 92 Classifieds Melanie Hicks Petites annonces

9 VETERINARY MEDICAL ETHICS DÉONTOLOGIE VÉTÉRINAIRE NEWS | NOUVELLES

13 HAPPY 60TH BIRTHDAY CVJ! LA RVC FÊTE SES 60 ANS! 23 NEWS Carlton Gyles, Ron Lewis, Greg Harasen, NOUVELLES John Prescott Heather Broughton, Sophie Perreault

VETERINARY DERMATOLOGY DERMATOLOGIE VÉTÉRINAIRE 82 Atopic dermatitis in humans and dogs Martín A. Arcique, Jangi Bajwa

VETERINARY PRACTICE MANAGEMENT GESTION D’UNE CLINIQUE VÉTÉRINAIRE 85 The demand for associate veterinarians: Surveying the “shortage”/Analyse de la « pénurie » de médecins vétérinaires Chris Doherty

89 DIAGNOSTIC OPHTHALMOLOGY OPHTALMOLOGIE DIAGNOSTIQUE Lynne S. Sandmeyer, Marina Leis, Stephanie Osinchuk

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net). Les «Directives à l’intention des auteurs» sont disponibles en ligne (www.veterinairesaucanada.net).

CVJ / VOL 61 / JANUARY 2020 5 FOR PERSONAL USE ONLY

The Canadian Veterinary Journal Editorial policy: All published articles including editorials and letters reflect the La Revue vétérinaire canadienne opinions of the authors and do not necessarily reflect the opinion of the publisher. Publication of an advertisement does not necessarily imply that the publisher agrees 339 rue Booth Street with or supports the claims therein. Ottawa, Ontario K1R 7K1 The Canadian Veterinary Medical Association holds complete copyright of all articles Telephone: (613) 236-1162 within this issue. Fax: (613) 236-9681 Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les E-mail: [email protected] lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de Website/Site Web: www.canadianveterinarians.net l’éditeur. www.veterinairesaucanada.net La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord avec son contenu ou qu’il l’appuie. © C anadian Veterinary Medical Association 2020 L’Association canadienne des médecins vétérinaires détient le droit d’auteur complet L’Association canadienne des médecins vétérinaires 2020 sur tous les articles contenus dans le présent numéro.

The Canadian Veterinary Journal is indexed or abstracted in: Editor-in-Chief/Rédacteur en chef La Revue vétérinaire canadienne est indexée ou ses articles sont Carlton Gyles, Guelph, Ontario résumés dans : AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Associate Editors/Rédacteurs associés Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Bruce Grahn, Saskatoon, Saskatchewan Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Wayne McDonell, Guelph, Ontario Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update. Feature Editors/Rédacteurs des chroniques Jangi Bajwa, Burnaby, British Columbia Bruce Grahn, Saskatoon, Saskatchewan Photo by/Photo de : AN Design Communications Myrna Milani, Charlestown, New Hampshire Debbie Stoewen, Ayr, Ontario Typesetting/Typographie Tim Blackwell, Fergus, Ontario AN Design Communications Assistant Editors/Rédacteurs adjoints Printed by/Imprimé par Dr. Aylin Atilla, Calgary, Alberta Dollco Print Solutions Group Dr. Marcio Costa, Saint-Hyacinthe, Quebec Ottawa, Ontario Dr. Robert Friendship, Guelph, Ontario ISSN 0008-5286 Dr. Luis Gaitero, Guelph, Ontario Dr. Greg Harasen, Regina, Saskatchewan Dr. Emily John, Charlottetown, Prince Edward Island Report undeliverable Canadian addresses to: Dr. Ron Johnson, Guelph, Ontario e-mail: [email protected] Dr. Shawn McKenna, Charlottetown, Prince Edward Island Dr. Shannon Martinson, Charlottetown, Prince Edward Island Subscriptions (2020). Annual: Canada $220 + applicable GST or HST; foreign Dr. Javier Sanchez, Charlottetown, Prince Edwad Island $235 US; institutional $290. Express subscriptions available. Single issue/back issue: Dr. Richard Kennedy, Pincher Creek, Alberta $25 each, institutional single issue = $50.00 + GST or HST, if applic­able. (All prices Managing Editor/Directrice de la rédaction subject to change.) Missing issues will be replaced if the Subscriptions Office is Heather Broughton, Ottawa, Ontario notified within 6 months (for requests within Canada) and 1 year (for requests from Assistant Managing Editor/Directrice adjointe de la rédaction abroad) of the issue date. The pub­lisher expects to supply missing issues only when Stella Wheatley, Ottawa, Ontario losses have been sustained in transit and when the reserve stock will permit. Telephone Editorial Coordinator/Coordonnatrice de la rédaction (613-236-1162) or (1-800-567-2862) and fax (613-236-9681) orders accepted with Kelly Gray-Sabourin, Ottawa, Ontario a valid Visa or MasterCard number. Please advise the publisher of address changes promptly. Advertising and Sponsorship Consultant/Consultante, publicité et commandites Laima Laffitte, Wendover, Ontario Abonnements (2020). Annuel : Canada 220 $ + TPS ou TVH en vigueur; pays étranger 235 $ É-U; prix d’une institution 290 $. Abonnement express disponible. Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + TPS ou TVH Published monthly by/ en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas Publication mensuelle de reçus seront remplacés si l’éditeur en est informée dans les 6 mois (pour les demandes Canadian Veterinary Medical Association venant du Canada) et 1 an (pour les demandes venant de l’étranger) suivant la date de parution. L’éditeur s’engage à remplacer les numéros manquants seule­ment lorsque les pertes ont été subies en transit et lorsque ses réserves le permettent. On peut payer son abonnement par téléphone (613-236-1162) ou (1-800-567-2862), par télé­copieur (613-236-9681) ou par carte de crédit (Visa ou MasterCard). Veuillez aviser le bureau de l’éditeur de tout ­changement d’adresse.

STUDENT SUBSCRIPTIONS/ABONNEMENTS DES ÉTUDIANTS

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

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

6 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY President’s Message Le mot de la présidente

Stay challenged and continue growing Garder la motivation et continuer à s’épanouir

hree years ago, while I was attending a conference network- l y a trois ans, alors que j’assistais à une activité de réseautage, T ing event, a newly introduced colleague turned to me and I une collègue qui venait de m’être présentée s’est tournée bluntly asked, “So, what do you want to be when you grow vers moi et m’a demandé : « Alors, que voulez-vous faire quand up?” I was a little baffled, since I’m not exactly a spring chicken vous serez grande? » J’étais un peu déroutée, car je ne suis plus and I had 13 years of experience as a veterinarian at the time. toute jeune et j’avais déjà 13 ans d’expérience à titre de médecin I asked her what she meant. She explained, “Everybody evolves vétérinaire à ce moment-là. Je lui ai demandé ce qu’elle voulait and changes what they are doing, even veterinarians. What do dire. Elle a précisé : « Tout le monde évolue et on finit tous par you want to do next?” changer ce qu’on fait, même les médecins vétérinaires. Quel sera This certainly made me think about the career paths that votre prochain projet? » can be taken. As veterinarians in general practice, we are gen- Cette question m’a fait réfléchir aux différents cheminements erally driven yet compassionate people. There may be a time, de carrière qui s’offrent à nous. Les médecins vétérinaires en or multiple times in your career where you begin to look for a pratique générale sont généralement des personnes à la fois com- different kind of challenge. With a current workforce shortage patissantes et motivées. Cela dit, il pourrait y avoir des moments in general practice, I certainly don’t want you to think that I am au cours de votre carrière où vous songez à chercher un nouveau encouraging veterinarians to leave practice. There are so many type de défi à relever. Avec la pénurie actuelle de main-d’œuvre tremendous opportunities within practice with our Doctor of dans la pratique générale, je ne voudrais pas qu’on pense que Veterinary Medicine degree. It may mean a decision to obtain j’encourage les médecins vétérinaires à quitter la pratique. Au additional training in a specific area such as dentistry or imag- contraire! Notre diplôme de médecine vétérinaire nous offre un ing. Some consider management. Others begin to work with vaste éventail de possibilités dans la pratique. Par exemple, on a species they hadn’t in the past. And never forget about vol- peut décider de suivre une formation complémentaire dans un unteering for your local association, an animal shelter or other domaine particulier, comme la dentisterie ou l’imagerie. Certains valuable organization. s’intéressent à la gestion. D’autres commencent à travailler avec Others may develop or expand upon their entrepreneur- une nouvelle espèce qu’ils ne traitaient pas auparavant. De plus, ial skills while remaining in practice. I was able to meet il est toujours possible de faire du bénévolat au sein de votre Dr. Leheurteux, creator of the Euthabag, at the L’Ordre des association locale, un refuge pour animaux ou un autre orga- médecins vétérinaires du Québec (OMVQ) Convention. In nisme dont la mission vous tient à cœur. her companion animal practice, she recognized the need for a D’autres médecins vétérinaires peuvent choisir de développer product that was a functional yet respectful alternative to using leurs compétences entrepreneuriales sans quitter la pratique. plastic bags for euthanasia, and designed a creation that is now C’est le cas de la Dre Leheurteux, créatrice d’Euthabag, que available in 15 countries. With the evolution of our profession, j’ai eu la chance de rencontrer lors du Congrès de l’Ordre des there will be many more occasions where veterinarians can make médecins vétérinaires du Québec (OMVQ). Dans sa pratique improvements in how we practice, which will impact not only des animaux de compagnie, elle a constaté un besoin pour un our patients and clients, but also veterinary teams. produit qui soit une alternative à la fois fonctionnelle et respec- There will be some veterinarians who decide to explore alter- tueuse aux sacs de plastique utilisés lors des euthanasies, et la native careers within veterinary medicine outside of practice, housse mortuaire qu’elle a conçue est désormais commercialisée wanting to remain connected to the profession yet challenged dans 15 pays. Avec l’évolution de notre profession, les médecins in a different manner. This was the position I was in after a vétérinaires auront de nombreuses occasions d’améliorer nos Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

CVJ / VOL 61 / JANUARY 2020 7 FOR PERSONAL USE ONLY

decade in companion animal practice. Our degree and the skills and development, commercial operations, pharmacovigilance, that have been cultivated are certainly translatable, and if you or regulatory affairs are just a few other examples. We are highly decide to make a change, sometimes you need to think outside valued for our wealth of knowledge on a broad range of topics, the box. Is there a specific area of your current role that you making us unique additions to any kind of cross-functional really like and want to focus on? Do you have other interests team. In the company division in which I work, I’m proud that you can combine with your veterinary degree? Are you to say that veterinarians lead the medical, customer care, and interested in going back to school to specialize, or to consider marketing teams. another diploma/degree such as in business, law or information Research is another area to consider, particularly if you technology? already have another advanced degree. We’ve been fortunate If returning to school isn’t appealing after the 6 to 8 years to read the tremendous work of veterinarians published in of post-secondary education that you have already invested The CVJ for the past 60 years. Government agencies, practice in, explore other choices available. Many veterinarians work consulting, biotech companies — the list continues. Whether in educational institutions, whether that be general science, you’re a seasoned veterinarian, a new graduate, or an aspiring LE MOT DE LA PRÉSIDENTELA DE MOT LE veterinary or veterinary technician based. It does require a high veterinarian, you will find a wide array of career pathways avail- level of comfort in public speaking, and for those who didn’t able to you. A veterinary degree provides choice and versatility. go through years of 4-H public speaking events when they were If you decide a change is needed and are exploring ideas and kids, it may be a bit daunting. If you’ve never done any public opportunities within practice or outside of practice, don’t be speaking, trying Toastmasters or a similar group can help with afraid to reach out to veterinarians who are in a role in which the development of this skill. you are interested. A mentor can make the world of difference Companies that support the veterinary industry, such as in helping you navigate the complexities of a new path. nutrition or pharmaceutical companies, are also another consid- So, what do you want to be when you grow up? ■ eration. Professional services tend to be the area we think about, but there are so many more opportunities available — research Melanie Hicks

pratiques, et ainsi avoir un impact non seulement nos patients entreprises offrent beaucoup d’autres possibilités, comme la et nos clients, mais aussi sur les équipes vétérinaires. recherche et le développement, les opérations commerciales, la Ainsi, il y aura des médecins vétérinaires qui décideront d’ex- pharmacovigilance ou les affaires réglementaires. Nous sommes plorer d’autres carrières vétérinaires à l’extérieur de la pratique, très valorisés dans l’industrie pour notre richesse de connais- pour rester dans le domaine tout en relevant un nouveau défi. sances sur un large éventail de sujets, ce qui fait de nous des C’est la position dans laquelle je me trouvais après une décennie ajouts uniques à tout type d’équipe multidisciplinaire. Je suis en pratique des animaux de compagnie. Notre formation et fière de dire que dans l’entreprise pour laquelle je travaille, ce les compétences acquises peuvent certainement être utilisées sont des médecins vétérinaires qui dirigent les équipes de la autrement, et si vous décidez d’emprunter une voie différente, division médicale, du service à la clientèle et du marketing. vous devrez parfois sortir des sentiers battus. Y a-t-il un aspect La recherche est un autre domaine à envisager, en particulier particulier de votre rôle actuel que vous aimez vraiment et sur si vous possédez déjà un autre diplôme d’études supérieures. lequel vous souhaitez vous concentrer? Avez-vous d’autres inté- Nous avons eu la chance de lire dans La RVC au cours des rêts que vous pouvez combiner avec votre diplôme en médecine 60 dernières années les résultats de l’immense travail effectué vétérinaire? Souhaitez-vous retourner aux études pour vous dans ce domaine par des médecins vétérinaires. Il ne faut spécialiser, ou encore pour obtenir un nouveau diplôme en pas oublier les organismes gouvernementaux, les cabinets de commerce, en droit ou en informatique? consultation, les sociétés de biotechnologie – la liste des options Si le retour aux études n’est pas attrayant après les 6 à 8 années continue! Que vous soyez un médecin vétérinaire chevronné, un d’études postsecondaires dans lesquelles vous avez déjà investi, nouveau diplômé ou même un futur vétérinaire, un large éven- explorez les autres options possibles. De nombreux médecins tail de cheminements de carrière et de parcours professionnels vétérinaires enseignent dans le domaine des sciences générales, s’offrent à vous. Un diplôme de médecine vétérinaire vous donne de la médecine vétérinaire ou des techniques de santé animale. le choix et la polyvalence. Si vous envisagez un changement et Évidemment, l’enseignement exige une certaine aisance pour souhaitez explorer une nouvelle direction dans la pratique ou parler en public, et pour ceux qui n’en ont pas l’habitude, cela en dehors de la pratique, n’hésitez pas à communiquer avec des peut être un peu intimidant. Si vous n’avez jamais parlé en médecins vétérinaires qui occupent un poste qui vous intéresse. public, joindre un club Toastmasters ou un groupe similaire Un mentor peut faire toute la différence en vous aidant à vous peut vous aider à développer cette compétence. orienter dans les complexités d’une nouvelle voie. Les entreprises qui soutiennent l’industrie vétérinaire, telles C’est donc à mon tour de vous poser la question : que voulez- que les sociétés pharmaceutiques ou d’aliments pour animaux, vous faire quand vous serez grands? ■ sont également des employeurs potentiels. Les services profes- sionnels sont ceux qui nous viennent d’abord en tête, mais ces Melanie Hicks

8 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — Question de déontologie du mois – October 2019 Octobre 2019 Six horses died during the chuckwagon races at the 2019 Six chevaux sont morts lors des courses de chariots durant Calgary Stampede. Injuries and occasional deaths will never be le Stampede de Calgary de 2019. Les blessures et les morts eliminated from equine competitive events. Should a threshold occasionnelle­ s ne seront jamais complètement éliminées des for injuries and mortalities be established to distinguish concours hippiques. Devrait-on établir un seuil pour les between competitive events with reasonable and unreasonable blessures et la mortalité afin de faire la distinction entre les risks for the safety of the horses competing? Should the fact compétitions comportant des risques raisonnables et dérai- that chuckwagon races do not represent an authentic historic sonnables pour la sécurité des chevaux qui y participent? Le component of western Canadian cattle culture be considered fait que les courses de chariots ne représentent pas un élé- in such a decision? ment historique authentique de la culture de l’élevage bovin de l’Ouest canadien devrait-il être pris en considération dans la prise d’une telle décision?

An ethicist’s commentary on hurtful rodeo events There are a variety of events involving the use of animals within “machismo,” we find a similar phenomenon in those who hunt the panoply of things that have humanly historically counted grizzly bears with high powered rifles fitted with long-range as entertainment. While some of these are benign, or may be telescopic sights. But whatever causes it, it is reprehensible and structured as benign, such as children riding horses, many essentially a form of bullying. involve significant pain, stress, and fear to the animals. Too “Chuck wagon races” are one of the most mindless of such many of such events allegedly celebrate western heritage. These events, often leading to serious horse injury. Anyone who works include steer roping, calf roping, steer wrestling, and numerous with horses knows they are prone to serious, often life-ending variations upon these themes. skeletal injury. Whipping them into a frenzy in competition By the end of the 20th century, society had become aware with other horse-drawn chuck wagons, (i.e., food-bearing that while many of these events were entertaining to people, they vehicles), is almost guaranteed to cause injury. One of the most are often hurtful physically or cause pain and fear to the animals. interesting paradoxes in this area is that cattle people remain Among such events are calf roping, steer wrestling, taken for among the last strong advocates of good animal husbandry left granted as comprising an essential part of “western heritage.” in agriculture, yet that seems to vanish in the frenzy of entertain- In fact, many of these events are an outright perversion of what ment. Some of the worst wrecks I have ever witnessed in rodeo does count as an integral part of “western heritage.” As one come as a result of chuck wagon races. of my close friends has pointed out (he runs one of the most There are thus prudential reasons for not engaging in that prominent United States rodeos), hurting animals, frightening sort of activity. That is, of course, in addition to the ethical them, or stressing them are all wisely avoided by good cattlemen. reasons. Ethical and prudential reasons combine synergistically In the case of calf roping on the range, the best cattle people I when the general public grows ever increasingly concerned about know will counsel treating the livestock gently, and people who animal abuse. If rodeo wishes to retain public (and legislative) violate that rule will often find themselves summarily fired. Not support, one consideration that must loom large is lack of only does such an approach exemplify humaneness, it represents animal abuse! good common sense. It is not wise to develop an antagonistic For all of these reasons, it would be extremely wise for rodeo relationship with an animal, which can weigh close to a ton, to clean up its own house. Here is a partial list of jurisdictions that you will work with throughout your life. Watch what hap- that have totally banned rodeo or traditional rodeo devices: pens at a serious rodeo like the National Western Stockshow, • San Francisco when an animal is jerked off its feet and the audience emits a • St. Petersburg horrified gasp. • Pasadena, California We have neither time nor space to do a psychological analy- • Baltimore, Maryland prohibits calf roping sis of what leads people to abuse animals in the name of • Fort Wayne, Indiana

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

CVJ / VOL 61 / JANUARY 2020 9 FOR PERSONAL USE ONLY

• Pittsburgh, Pennsylvania prohibits the use of electric shock- • Various jurisdictions in Brazil ban rodeos, electric prods, ing devices, fixed flank and bucking straps, wire tie downs, flank straps, and spurs. sharpened or fixed spurs. • The Netherlands banned US rodeo. Outside the United States: For these reasons, it would be preemptively wise for Canadian • United Kingdom rodeo to stay ahead of societal forces, particularly concerned • Australia’s capital territories with animal cruelty, that militate against the perpetuation of • Auckland, New Zealand rodeo or at least those events perceived by the majority of society • Germany prohibits calf roping as cruel and abusive. • Vancouver, Canada prohibits calf roping • Cloverdale rodeo in British Columbia, Canada prohibits calf Bernard E. Rollin, PhD roping, team roping, cowboy cow milking, and steer wrestling. • South Australia and Victoria have eliminated roping of small animals. DÉONTOLOGIEVÉTÉRINAIRE

Ethical question of the month — Question de déontologie du mois – January 2020 Janvier 2020 You are presented with a healthy 1-year-old crossbred farm dog Vous recevez en consultation un chien de ferme croisé âgé with a moderate lameness in the right front leg. The dog runs d’un an en bonne santé, qui présente une boiterie modérée du loose around the farm. The dog is mildly weight-bearing on the membre antérieur droit. Ce chien vit en liberté à la ferme. Il leg but is sore on palpation. Radiographs reveal a non-displaced met un peu de poids sur sa patte, mais celle-ci est douloureuse à fracture of the radius just above the carpus. The owner is unin- la palpation. Les radiographies révèlent une fracture non dépla- terested in surgical stabilization, so you cast the leg and send the cée du radius juste au-dessus du carpe. Comme le propriétaire dog home on pain medication. Two days later the owner returns, écarte l’option de la stabilisation chirurgicale, vous plâtrez la as the dog has chewed off the cast. You re-cast the leg and put an patte et vous renvoyez le chien à la maison avec un analgésique. Elizabethan collar on the dog. Two days later the owner returns Deux jours plus tard, le propriétaire revient parce que le chien as the dog has somehow removed the collar and again chewed a mâchouillé son plâtre et a réussi à l’enlever. Vous refaites un off the cast. The owner is frustrated over the mounting costs nouveau plâtre et mettez un collier élisabéthain au chien. Deux and repeated trips to your clinic. The owner suggests keeping jours plus tard, le propriétaire revient encore, car le chien a the dog in a small pen in the barn without casting the leg and trouvé le moyen d’enlever le collier et le plâtre. Le propriétaire seeing if the leg can heal provided the dog has limited mobility. est frustré par les frais qui s’additionnent et les visites répétées à You believe this is a reasonable approach and decide to stop the votre clinique. Il propose de garder le chien dans un petit enclos pain medication to further reduce activity. You believe in situa- dans la grange sans remettre de plâtre et de voir si la patte peut tions such as this that pain serves as a natural signal to encourage guérir en restreignant la mobilité du chien. Vous estimez que resting an injury so it can properly heal. Your younger associ- cette approche est raisonnable et décidez d’interrompre le trai- ate completely disagrees with this approach and feels denying tement analgésique afin de réduire davantage le niveau d’activité pain medication to an animal with a fracture is inhumane and du chien. Vous croyez que, dans de telles situations, la douleur unprofessional. How should you respond? sert de signal naturel pour encourager le repos afin de permettre à une blessure de guérir correctement. Votre jeune collègue vétérinaire est totalement en désaccord avec ce plan et pense que ne pas administrer un analgésique à un animal souffrant d’une fracture est une décision inhumaine qui dénote un manque de professionnalisme. Comment devriez-vous réagir?

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

10 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY

Quiz Corner Test éclair

1. Portosystemic shunts (PSSs) in cats have been linked to 1. Chez le chat, le shunt portosystémique a été associé auquel which of the following phenotypical findings? des phénotypes suivants? A. Lack of a tail. A. Absence de queue B. Rosette ears. B. Oreilles en rosette C. Lack of whiskers. C. Absence de vibrisses D. Copper-colored irises. D. Iris de couleur cuivre E. Cranial abdominal hernia. E. Hernie abdominale crâniale 2. An animal has two bladder stones, and the owner does not 2. Un animal a deux pierres dans la vessie et le propriétaire ne want surgical treatment. Given this scenario, which of the veut pas de traitement chirurgical. Lequel des traitements following treatments is the best match for the stone type suivants est le meilleur compromis en fonction des scénarios given? donnés? A. Antibiotics for struvite stones in a cat. A. Antibiotiques dans le cas de calculs de struvite chez un B. Allopurinol for urate stones in a Dalmatian. chat C. Allopurinol for cystine stones in a dog. B. Allopurinol dans le cas de calculs d’urate chez un D. 2-MPG [N-(2-mercaptopropionyl)glycine] for calcium dalmatien oxalate stones in a dog or cat. C. Allopurinol dans le cas de calculs de cystine chez un chien D. 2-MPG [N-(2-mercaptopropionyl)-glycine] dans le cas de 3. Which of the following groups of congenital heart defects calculs d’oxalate de calcium chez un chien ou un chat is most common in dogs? A. Tricuspid valve dysplasia, pulmonic stenosis, ventricular 3. Lequel des groupes de cardiopathies congénitales suivants septal defect. est le plus commun chez le chien? B. Pulmonic stenosis, subaortic stenosis, ventricular septal A. Dysplasie de la valve tricuspide, sténose pulmonaire, defect. communication interventriculaire C. PDA (patent ductus arteriosus), subaortic stenosis, pul- B. Sténose pulmonaire, sténose subaortique, communication monic stenosis. interventriculaire D. Aortic stenosis, atrial septal defect, ventricular septal C. Persistance du canal artériel, sténose subaortique, sténose defect. pulmonaire E. PDA, subaortic stenosis, ventricular septal defect. D. Sténose aortique, communication interauriculaire, com- munication interventriculaire E. Persistance du canal artériel, sténose subaortique, com- munication interventriculaire

quiz corner is generously sponsored by le test éclair est généreusement commandité par NEW! Rawhide Dental Chews Science and Compliance for Improved Dental Health Care

CVJ / VOL 61 / JANUARY 2020 11 FOR PERSONAL USE ONLY

4. A 4-year-old Thoroughbred horse is being evaluated because 4. On fait l’examen d’un cheval Thoroughbred âgé de 4 ans, à of polyuria and polydipsia. He is not azotemic. A water cause de polyurie et de polydipsie. Il ne souffre pas d’azo- deprivation test is performed to differentiate diabetes témie. Un examen par privation d’eau est réalisé pour dif- insipidus from primary polydipsia, and the horse fails to férencier le diabète insipide de la polydipsie primaire et il concentrate urine. Neurogenic diabetes insipidus is sus- n’y a pas de concentration de l’urine. On soupçonne alors pected. Which of the following is the most appropriate next un diabète insipide neurogène. Laquelle des épreuves sui- step in establishing the diagnosis? vantes est la plus appropriée maintenant pour établir le A. Measurement of plasma antidiuretic hormone (ADH). diagnostic? B. Modified water deprivation test. A. Mesure de la concentration d’hormone antidiurétique C. Measurement of plasma insulin concentration. plasmatique TESTÉCLAIR D. Measurement of plasma cortisol concentration. B. Test de privation d’eau modifié E. Measurement of glucose concentration in urine. C. Mesure de la concentration d’insuline plasmatique D. Mesure de la concentration de cortisol plasmatique 5. In cattle, the most characteristic lesion of mucosal disease E. Mesure de la concentration de glucose dans l’urine caused by BVD virus is which of the following? A. Sharply demarcated ulcers over Peyer’s patches. 5. Chez les bovins, laquelle des lésions suivantes est la lésion B. Marked thickening of the mucosa due to granulomatous la plus caractéristique de la maladie des muqueuses causée inflammation. par le virus de la diarrhée virale bovine? C. Segmental reddening of the ileum due to acute A. Ulcères très bien délimités sur les plaques de Peyer inflammation. B. Épaississement marqué de la muqueuse dû à une inflam- D. A fibrinonecrotic or pseudomembranous colitis. mation granulomateuse E. Gaseous distension of the cecum. C. Rougeur segmentaire de l’iléon due à une inflammation aiguë D. Colite fibrinonécrotique ou pseudomembraneuse E. Distension gazeuse du cæcum

(See p. 78 for answers./Voir les réponses à la page 78.)

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

12 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY FROM THE EDITOR MOT DU RÉDACTEUR EN CHEF

Happy 60th birthday CVJ! La RVC fête ses 60 ans!

Carlton Gyles

he cover of The Canadian a page couverture de La Revue vétérinaire canadienne T Veterinary Journal (The CVJ) is L (La RVC) célèbre la riche histoire de notre publication. an acknowledgment of the rich his- Nous sommes humblement fiers des progrès réalisés au cours tory of our journal. We are proud but not complacent about des 60 dernières années! its progress over the past 60 years. Lors d’une récente soirée de retrouvailles, mes anciens At a recent DVM class reunion, my classmates (having camarades de classe de médecine vétérinaire (qui se known each other for 60 years) shared a sense of joy60 and connaissent depuis 60 ans) ont exprimé un sentiment de caring for each other that comes from having lived together joie et de souci d’autrui qui découle du fait d’avoir vécu and having developed strong bonds that are both personal ensemble et développé des liens forts, à la fois personnels et and professional. I have lived with The CVJ for all of its professionnels. J’ai évolué avec La RVC pendant ses 60 ans 60 years and have developed similar bonds with previous d’existence, et j’ai tissé des liens similaires avec les leaders leaders and the current team. We work very hard to make précédents et l’équipe actuelle. Nous travaillons très fort the journal an effective communication tool that brings pour faire de notre publication un outil de communication new professional and scientific information and opinion to efficace apportant de nouvelles informations et opinions Canadian Veterinary Medical Association (CVMA) members. professionnelles et scientifiques aux membres de ­l’Association The team is led by Dr. Ron Lewis (chair of the Editorial canadienne des médecins vétérinaires (ACMV). L’équipe Committee), Drs. Bruce Grahn and Wayne McDonell est dirigée par le Dr Ron Lewis (président du comité de (associate editors), Ms. Heather Broughton (managing rédaction), les Drs Bruce Grahn et Wayne McDonell editor) and includes supporting staff (Ms. Stella Wheatley, (rédacteurs associés) ainsi que Mme Heather Broughton Ms. Kelly Gray-Sabourin and Ms. Laima Laffitte), assistant (directrice de la rédaction), et elle comprend le personnel de editors and writers. soutien (Mme Stella Wheatley, Mme Kelly Gray-Sabourin et Our profession is changing in many ways that enhance our Mme Laima Laffitte), les rédacteurs adjoints et les auteurs. service to society. Increased sophistication (especially in diag- Notre profession évolue à bien des égards, ce qui améliore nostic imaging, referral hospitals, preventive care, specialized notre service à la société. Une plus grande sophistication training, trained technicians) allows us to do more to promote (imagerie diagnostique, centres de référence, soins préven- the health and welfare of animals. Hand in hand with these tifs, formation spécialisée, techniciens formés) nous permet advancements is the need for continuing education to ensure de faire plus pour promouvoir la santé et le bien-être des that we keep up with the rapid pace of new developments. animaux. Parallèlement à ces progrès, il est nécessaire de

What Happened in 1960? • Joey Smallwood was premier of Newfoundland. • September 19 — The University of Calgary is • Robert Stanfield was premier of Nova Scotia. founded. • Tommy Douglas was premier of Saskatchewan. • December 20 — Ontario executed 10 000 cats due • July 1 — Status Indians are given the right to vote. to over population. • August 10 — The Canadian Bill of Rights is given • L’Anse aux Meadows, evidence of Viking colonization royal assent. of North America, is discovered in Newfoundland.

CVJ / VOL 61 / JANUARY 2020 13 FOR PERSONAL USE ONLY

The CVJ provides continuing education to several seg- poursuivre la formation continue pour pouvoir suivre le ments of the Canadian veterinary community. Practitioners rythme rapide des nouveaux développements. are at the top of the list of veterinarians whom we serve. La RVC offre aux médecins vétérinaires canadiens de la Regular columns, case reports and investigations that formation continue dans plusieurs domaines de la médecine describe new surgical techniques or treatments all provide vétérinaire. Les praticiens figurent en tête de liste des méde- the practitioner with information that is immediately use- cins vétérinaires que nous servons. Des chroniques, des rap- ful. Research articles typically address today’s questions and ports de cas et des études décrivant de nouvelles techniques provide answers that contribute to solutions in the future. chirurgicales ou de nouveaux traitements fournissent aux We also serve researchers at academic institutions and refer- praticiens des renseignements immédiatement utiles. Les ral clinics by providing an outlet for dissemination of the articles de recherche traitent généralement des questions new information they create and we make room for com- actuelles et apportent aussi des réponses qui contribueront mentaries that present new ideas and address challenges for aux solutions à l’avenir. Nous servons également les cher- our profession. cheurs des établissements d’enseignement et des centres de We are part of an international knowledge pool and we référence en fournissant un moyen de diffusion des nouvelles consider articles from all over the world, as long as they données qu’ils génèrent et nous faisons de la place pour les have relevance in a Canadian context. Not surprisingly, the commentaires qui présentent de nouvelles idées et répondent articles submitted represent the changing profession. There aux défis de notre profession. is increasing interest in the role of our profession in global Nous contribuons au pool international de connaissances issues such as One Health, antimicrobial stewardship and et examinons des articles du monde entier, dans la mesure où the environment. ils sont pertinents dans le contexte canadien. Sans surprise, As we look ahead we see new challenges and opportu- les articles soumis représentent l’évolution de la profession. nities. One challenge is holding the attention of readers Le rôle des médecins vétérinaires dans des enjeux mondiaux amidst the remarkable array of sources of information. tels que l’approche « Une santé », l’antibiogouvernance et Another challenge is to develop a business model consistent l’environnement suscite un intérêt croissant. with dwindling advertising revenues as we move into the L’avenir nous réserve de nouveaux défis et de nouvelles online world. A 3rd challenge is to maintain exclusivity opportunités. L’un de ces défis pour nous sera de retenir to our members in a world in which openness in scientific l’attention des lecteurs parmi le nombre considérable de publication is becoming the norm. Opportunities include sources d’information. Nous devrons aussi développer un the ability to make current and back issues of our journal modèle d’affaires compatible avec la diminution des revenus more readily available in a convenient format on several publicitaires alors que nous entrons dans l’univers virtuel. digital devices, inclusion of video clips that show motion Nous aurons également à maintenir l’exclusivité pour nos and activity, more extensive use of color in photographs membres dans un monde où l’ouverture dans la publica- and illustrations, and reduced time between acceptance of tion scientifique devient la norme. Les occasions à saisir an article and publication. comprennent la possibilité de rendre les numéros actuels Sixty years ago, Dr. Jim Henderson, president of the et précédents de notre journal plus facilement disponibles CVMA noted that continuing success of the journal would dans un format pratique sur plusieurs appareils numériques, depend on the support it received from members of the l’inclusion de vidéos montrant le mouvement et l’activité, CVMA. This prediction was accurate and we are grateful that une utilisation plus étendue de la couleur dans les photogra- we have received strong support of CVMA members over phies et les illustrations, et une réduction du temps écoulé the years. We value this support highly and regularly consult entre l’acceptation d’un article et sa publication. with members to seek your opinions and ideas. Il y a soixante ans, le Dr Jim Henderson, président de Dr. Henderson also noted that “Almost every veterinary l’ACMV, a prédit que le succès continu de la publication journal with which I am familiar is criticized, periodically dépendrait du soutien reçu de la part des membres de or continually, for publishing too little material of interest l’ACMV. Il avait raison, et nous sommes reconnaissants to the practitioner…” Dr. Henderson went on to express d’avoir reçu un solide appui des membres de l’ACMV au

...in 1960 • January 16 — Gordie Howe becomes the leading game (as well as being Maurice Richard’s final game) scorer in NHL history, passing Maurice Richard. was played in Maple Leaf Gardens in Toronto. • February 16 — The new National Gallery of Canada • November 26 — Ottawa Rough Riders won their building opens in Ottawa. 5th Grey Cup by defeating the Edmonton Eskimos 16 • April 14 — Montreal Canadiens won their to 6 in the 48th Grey Cup played at Vancouver’s Empire 12th (5th consecutive) Stanley Cup by defeating Stadium. Toronto, Ontario’s Ron Stewart became the the Toronto Maple Leafs 4 games to 0. The deciding first Canadian to win the game’s official MVP award.

14 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY confidence that the journal would achieve a balance of fil des ans. Nous accordons une grande importance à ce articles with immediate application and articles that add to soutien et consultons régulièrement nos membres pour leur the base of knowledge that will change practice in the future. demander leur avis et leurs idées. We occupy a specific niche in the knowledge transmission Le Dr Henderson avait également souligné que presque field and The CVJ aims to promote professional growth toutes les revues vétérinaires qu’il connaissait étaient cri- through a balance of clinical research papers, case reports, tiquées, périodiquement ou continuellement, pour avoir ethical discussions, practice management articles, and clini- publié trop peu de documents présentant un intérêt pour le cal updates. We are a part of the broad, lifelong continuing praticien. Il avait ensuite exprimé sa confiance que La RVC education our graduates seek to keep them up-to-date. atteindrait cet équilibre recherché entre les articles à appli- This time of celebration is an appropriate time to thank cation immédiate et ceux servant à ajouter à la base de all who contribute to The CVJ — the hundreds of writers, connaissances pouvant changer la pratique à l’avenir. Nous reviewers, associate and assistant editors, the staff, and the occupons un créneau spécifique dans le domaine de la trans- leadership of the CVMA. It is through your efforts that the mission du savoir. La RVC a pour objectif de promouvoir dream of the founding fathers of The CVJ lives on. le perfectionnement professionnel par un ensemble varié d’articles portant sur la recherche clinique, l’éthique et la gestion commerciale ainsi que des rapports de cas et des mises à jour cliniques. Nous offrons une part de cette for- mation continue diversifiée dont nos membres ont besoin pour maintenir leurs connaissances à jour. En cette période de célébration, je tiens à remercier tous ceux qui contribuent à La RVC – les nombreux auteurs, révi- seurs, rédacteurs adjoints et associés, membres du personnel et dirigeants de l’ACMV. C’est grâce à vos efforts que le rêve des pères fondateurs de La RVC se poursuit.

A birthday worthy of Champagne! Did you know that it is called a Beddian birthday when the age you are turning is the same as the last 2 digits of your birth year. The Canadian Veterinary Journal (The CVJ) was first published in 1960 and turns 60 in 2020. It's called a Beddian birthday after the man who first raised the issue, Bobby Beddia, who, sadly died fighting a fire, the same day he discussed this with a mathematician in his firehouse in New York City. To celebrate this special occasion, we opted for a special retro cover that reflects the first cover of The CVJ published in January 1960.

CVJ / VOL 61 / JANUARY 2020 15 FOR PERSONAL USE ONLY FROM THE EDITORIAL CHAIR MOT DU PRÉSIDENT DU COMITÉ DE RÉDACTION

A valuable and reliable Canadian resource Une ressource canadienne utile et fiable

Ron Lewis

n unprecedented, exponential explosion of scientific ne explosion d’information A information is accessible to veterinarians. Presently, U scientifique exponentielle sans there are in excess of 100 core scientific journals in over 35 précédent est maintenant accessible broad categories dealing with veterinary medicine; these aux médecins vétérinaires. De nos jours, il existe plus de include areas of specialization such as surgery, dermatology, 100 revues scientifiques dans plus de 35 grandes catégories and ophthalmology and may also be found in species-specific traitant de médecine vétérinaire; ces dernières comprennent 60journals. Several large online databases encompass many des domaines de spécialisation tels que la chirurgie, la der- more journals. Free online resources are also available, some matologie et l’ophtalmologie, et peuvent aussi être trouvées of which are peer-reviewed and others which are not. dans des publications consacrées à des espèces en particulier. Practitioners are called upon increasingly to become Plusieurs grandes bases de données en ligne rassemblent familiar with what were once diseases considered exotic to encore plus de périodiques. Des ressources en ligne gratuites Canada. We have seen several examples including recent sont également disponibles; certaines sont révisées par des outbreaks of Avian Influenza in BC; Bovine Spongiform pairs et d’autres ne le sont pas. Encephalopathy events in BC and Alberta; the spread of Les praticiens sont de plus en plus appelés à se familiariser Chronic Wasting Disease in the Prairie provinces; West Nile avec des maladies autrefois considérées comme exotiques Virus incursions across the country. We have also witnessed au Canada. Nous en avons vu plusieurs exemples, tels que major outbreaks of Foot-and-Mouth Disease in the UK and les éclosions récentes d’influenza aviaire en Colombie- Asia. Currently, the potential introduction of African Swine Britannique, les événements liés à l’encéphalopathie spon- Fever into Canada highlights a major threat to our swine giforme bovine en Colombie-Britannique et en Alberta, la industry and export markets. Many animal diseases are zoo- propagation de la maladie débilitante chronique dans les notic and One Health initiatives propel veterinarians to the provinces des Prairies, et des cas d’infection par le virus forefront where clients and media outlets seek information du Nil occidental à travers le pays. Nous avons également from veterinarians. Medical and societal concerns regarding été témoins d’épidémies majeures de fièvre aphteuse au antimicrobial resistance (AMR) highlight the significant role Royaume-Uni et en Asie. À l’heure actuelle, l’introduction veterinarians must play to respond to this challenge. potentielle de la peste porcine africaine au Canada met en This unprecedented expansion of scientific knowledge évidence une menace majeure pour notre industrie porcine rapidly becomes overwhelming. How can we, as a profes- et nos marchés d’exportation. De nombreuses maladies ani- sion and as individual practitioners, maintain currency to males sont des zoonoses et les initiatives relatives à l’approche ensure we continue to provide the best treatment possible « Une santé » poussent les médecins vétérinaires à l’avant-plan,

...in 1960 • August 5 — Arthur Meighen, politician and twelfth year of our Association, has been called 9th Prime Minister of Canada dies (b.1874). ‘The Year for Action.’ The establishment of our own • November 6 — The Nature of Things is launched Journal is doubtlessly one of the milestones in our on CBC TV (1960–1983). professional history. Let us all put forth extra effort to • The editor of The CVJ was James Archibald. strengthen our relationships both within and without • The president of the CVMA was George Fisher in the profession.” Jan. 1960 page 1. January when The CVJ was launched. “This, the

16 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY for the animals under our care? How do we respond to the car les clients et les médias cherchent à se renseigner auprès challenges of AMR and best inform our clients with regard de nous. De plus, les préoccupations médicales et sociales to zoonotic disease implications? If contacted by media relatives à la résistance aux antimicrobiens font ressortir le outlets, do we have the resources available that will allow us rôle important que doivent jouer les médecins vétérinaires to provide current information on “exotic” diseases and their dans l’antibiogouvernance. threat to Canadian livestock? Cette expansion sans précédent des connaissances scien- There are no easy answers to these questions and no single tifiques peut devenir oppressante. Comment pouvons-nous, best response. Information must be sought from a variety en tant que profession et en tant que praticiens individuels, of sources and the best sources will, of course, depend upon rester à jour pour nous assurer de continuer à offrir le meil- individual needs. While readily acknowledging my obvious leur traitement possible aux animaux que nous soignons? bias, I believe The CVJ is an extremely valuable resource, Comment pouvons-nous réagir aux difficultés associées à la most especially in the Canadian context. résistance aux antimicrobiens et renseigner adéquatement nos While The CVJ is a scientific journal and we take justifi- clients sur les implications liées aux maladies zoonotiques? able pride in the quality of the science, the News section Si les médias communiquent avec nous, disposons-nous des of the journal provides additional value. Within this issue, ressources nécessaires pour fournir de l’information à jour sur Dr. John Prescott states the value of The CVJ extends les maladies « exotiques » et la menace qu’elles représentent beyond the science content and most readers would prob- pour le bétail canadien? ably agree. Within the News section our sense of com- Il n’y a pas de réponse simple à ces questions, ni de munity is realized with stories of current events and, yes, réponse universelle. L’information doit être obtenue auprès even obituaries of colleagues. The bi-monthly Editorial de diverses sources, et les meilleures sources dépendront and President’s Message provide added valuable and, often évidemment des besoins individuels. Tout en reconnaissant insightful, information. Animal disease alerts provide mon parti pris évident, je pense que La RVC est une res- important updates and highlight where additional infor- source extrêmement utile, surtout dans le contexte canadien. mation may be readily found. Bien que La RVC soit une revue scientifique et que nous The discussion of Veterinary Medical Ethics, the Quiz soyons fiers de la qualité de son contenu scientifique, la sec- Corner, and Features columns are important sections of the tion des nouvelles offre une valeur ajoutée. Dans le présent journal that I hope most practitioners read and value. numéro, le Dr John Prescott affirme que l’intérêt de La RVC Chairing the Editorial committee of the CVMA for the s’étend au-delà de la science, et la plupart des lecteurs past 10 years I have seen first-hand the great work being seraient probablement d’accord avec lui. Dans la section des done to provide peer-reviewed science to our readership. nouvelles, notre sens de la communauté se concrétise par des The heart of the journal lies with the authors taking the récits d’actualité et, oui, même des notices nécrologiques de initiative to provide the time and effort required to write collègues. L’éditorial et le mot de la présidente, qui parais- the articles. Reviewers must be found to ensure the article sent en alternance tous les deux mois, fournissent aussi de meets scientific merit. Assistant and associate editors seek l’information précieuse et pertinente. Les alertes relatives aux out these valuable reviewers and provide another level of maladies animales constituent des mises à jour importantes scientific scrutiny. During the last 10 years, our profession et indiquent où de l’information additionnelle peut être has been especially fortunate to have the outstanding lead- facilement trouvée au besoin. ership provided by Dr. Carlton Gyles as Editor-in-Chief. La discussion sur l’éthique médicale vétérinaire, le test éclair The Editorial Committee, including CVMA staff, via an et les rubriques sont d’autres parties importantes de La RVC annual meeting in Ottawa and a Fall teleconference, helps que j’espère que la plupart des praticiens lisent et apprécient. resolve issues related to policy, content, advertising, and En tant que président du Comité de rédaction de l’ACMV new directions. au cours des dix dernières années, j’ai pu constater l’excellent It has been 10 years since the 50th anniversary edition travail accompli pour fournir à notre lectorat des données of The CVJ and, coincidentally, 10 years over which I have scientifiques examinées par des pairs. Le cœur de La RVC had the opportunity to observe and greatly appreciate the réside dans le fait que les auteurs prennent l’initiative de

...in 1960 • Outgoing CVMA president, J.A. Henderson at the 1959 • The CVMA Annual Convention was held in Halifax, CVMA Convention stated that “We have come to the Nova Scotia. conclusion that neither financial nor other difficulties in • John Diefenbaker was prime minister of Canada in the way of publishing a journal are insuperable and plans 1960 and a member of parliament for Prince Albert, are being activated for the monthly publication for an Saskatchewan. official CVMA Journal, commencing January 1960.”

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work — primarily by volunteers — that produces this excel- fournir le temps et les efforts nécessaires pour rédiger les lent publication. If you have information to contribute, articles. Les rédacteurs adjoints et les rédacteurs associés consider authoring an article or, if asked, help to review doivent ensuite trouver des réviseurs, dont le mandat est de a publication. veiller au respect des normes en matière de rigueur scien­ Congratulations to The CVJ and the many volunteers tifique, et apportent une contribution supplémentaire au and staff who have been responsible for achieving this 60th contrôle de la qualité des articles. Au cours des dix dernières milestone anniversary. années, notre profession a eu la chance de pouvoir compter sur le leadership remarquable du Dr Carlton Gyles en tant que rédacteur en chef. Le Comité de rédaction, y compris le personnel de l’ACMV, organise une réunion annuelle à Ottawa et une téléconférence à l’automne pour régler les questions liées aux politiques, au contenu, à la publicité et aux nouvelles orientations. Dix ans se sont écoulés depuis l’édition du cinquantième anniversaire de La RVC, et au cours de ces dix ans, j’ai eu l’occasion d’observer et d’apprécier grandement le travail – prin- cipalement réalisé par des bénévoles – qui permet de produire cette excellente publication. Si vous avez de l’information à communiquer, envisagez de rédiger un article ou, si on vous le demande, participez à la révision d’une publication. Félicitations à La RVC et aux nombreux bénévoles et membres du personnel qui lui ont permis d’atteindre ce jalon important et de célébrer son 60e anniversaire!

Un anniversaire digne d’être souligné avec du champagne! Saviez-vous qu’il s’agit d’un anniversaire spécial lorsque vous atteignez l’âge équivalant aux deux derniers chiffres de votre année de naissance? C’est le cas de La Revue vétérinaire canadienne (La RVC) cette année — elle a été publiée pour la première fois en 1960 et elle fête ses 60 ans en 2020! C’est ce qu’on appelle en anglais un anniversaire « Beddian », en l’honneur de l’homme qui l’a décrit pour la première fois, Bobby Beddia, un pompier de New York qui est malheureusement décédé des suites d’un incendie le jour même où il a parlé de son observation à un mathématicien. Pour célébrer cet anniversaire particulier, nous avons donc opté pour une page couverture rétro spéciale qui reflète la première page couverture de La RVC publiée en janvier 1960!

18 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY FROM A CONTRIBUTOR/REVIEWER MOT D’UN CONTRIBUTEUR/RÉVISEUR

A worldwide flagship Un fleuron mondial

Greg Harasen

en years ago, I had the pleasure number of countries from which those submissions originate. Tof wishing the The Canadian In that sense, and in its distribution electronically and oth- Veterinary Journal (The CVJ) a happy erwise, The Canadian Veterinary Journal has truly become a birthday on the occasion of its 50th anniversary. Being the worldwide flagship for the Canadian veterinary profession. occasionally self-absorbed individual that I am, I quickly Whatever road The CVJ may take, one thing will remain realized that the Journal’s January 1, 1960 inception closely the same. The support and active involvement of you, the corresponded to my own entry into the world little more60 reader, will be critical. Whether you take an active role in than 2 months later. The article I wrote a decade ago took a writing, reviewing, editing, or critiquing journal content, light-hearted look at how the Journal and I had weathered or only make a point of reading The CVJ, always remember our first half century. that this is YOUR journal! As an author, reviewer, colum- In what seems like a heartbeat, another decade has nist, and assistant editor I have tried to keep that in mind. elapsed, and it is again time for reflection. Drawing parallels Is what I’m writing or reviewing of relevance and interest to between the current state of the Journal and my own state the Canadian practitioner in Comox or Come By Chance? in life may reflect my own limited literary imagination, but This theme of reinvention applies to your humble servant it still seems apt. as much as it does to the journal. My first submission to reach Where the passage from my forties to my fifties 10 years these hallowed pages was a case report on feline multicentric ago was occasion for some good-natured prattle about fibrosarcoma in the May 1984 edition. I remember the thrill declining physical and mental prowess as compared to of seeing my work in print! In the spring of 2001, the late the ever-youthful CVJ, I find that my impending seventh Dr. Doug Hare clearly had a lapse in judgment by thinking decade is cause for more sober reflection. So, it is also with that Canadian veterinarians might read an orthopedics col- The Canadian Veterinary Journal. umn written by a non-boarded Saskatchewan Roughrider fan! Let’s start with the mere act of holding a “hard copy” jour- Eleven years and more than 80 articles later it was time for nal in your hands. Our sister journal, The Canadian Journal more self-reinvention. In recent years it has been my privilege of Veterinary Research, went to an “on-line only” format some to serve as an assistant editor, and now I eagerly look forward years ago. Other journals, and many lay publications, have to what path life may uncover beyond the veterinary profes- done the same. In an electronic era that The CVJ’s founders sion. I would be remiss if I did not thank a long list of editors could not have imagined, textbooks and printed journals and staff at The CVJ over the past 36 years. None supersedes are becoming increasingly obsolete. However, the need for the current Editor-in-Chief, Dr. Carlton Gyles, who has scientifically sound, peer-reviewed information remains as been a good friend and advisor, and who will lead this great important as ever and in the service of that goal the The CVJ publication in a distinguished fashion as it embarks on the will undoubtedly have to reinvent itself, probably multiple next chapter in its history. Let me also thank the most impor- times, over the next 60 years. tant people: you the readers. Without you there would be no The material submitted to The CVJ has continued to journal. Let me also remind you of your duty to continue to evolve in the last decade. Electronic submission has increased support The Canadian Veterinary Journal as a national and the number of articles considered for publication and the international voice in this great profession of ours.

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Our national record — both past and future Un témoin de notre histoire et de notre avenir

John Prescott

ooking over the last 60 years of The CVJ, I’m reminded issues, specialization, demand for vet- Lwhat a brilliant achievement it is. Every month a well- erinarians, animal welfare, and ethics. produced national veterinary journal arrives in our mail box, Journals have different roles and full of news about important national veterinary events, The CVJ balances many. What is most dynamic is the news discussion of important national issues, information on the section, the discussion of topical issues, the national focus, the science and the art of veterinary medicine, different per- editorial commentaries, and the letters to the editor. The CVJ 60spectives, advertisements, and information about different has managed to some extent to address the effect on letters of Canadian veterinarians, including the occasional obituary. the inevitable delay of being a monthly publication by carry- It is the national record, the go-to place for the veterinary ing the original letter and a “rebuttal” in the same issue, but profession in Canada. Historically, it is fascinating since it is monthly publication does delay the conversation. The CVJ is a critical record of events we’ve lived through and that shape fatter at 1350 pages compared to its first year of 586 pages. The the profession. The CVJ has documented the emergence of increase in size is because of greater advertising. Advertising new diseases, the angst around over-vaccination, the long revenue is critical to maintain a dynamic journal, as is the struggle to address antimicrobial resistance, the changing support from a strong readership base. I wonder whether the nature of the profession to increasing specialization, the many job advertisements at the back of the journal might be development of new veterinary colleges across the country, managed more on a website, to speed up their placement while reciprocity of licensure, pet care insurance, the disappear- the revenues still flow to the journal. ance of the “Ladies Auxiliaries” and dramatic rise of female What doesn’t come across in looking at The CVJ is the veterinarians, among much else. The CVJ has helped shape rise of the digital era. So much of this is in the invisible these changes, an example of a profession totally engaged background that underlies the operation of the journal, the in pushing for excellence and communicating at a high author submission process, the review process, the proofread- level with its readers. What is apparent is dynamic change, ing, among other items. This has speeded up operations. A and the dedication of hundreds of people to promoting the major decision some years back was to make The CVJ content profession and its contribution to their country. Some of the freely available for download through PubMed 6 months after issues discussed in the journal remain on-going: educational publication. This has increased the international visibility

Editorial credit: Shutterstock.com

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of the journal, although its scientific “Impact Factor” is still The future of The CVJ is inevitably tied to the future of the relatively low. It was a scary decision because it might have CVMA. It illustrates the political tension between the vision reduced readership, but most people don’t get The CVJ just of Canada as a nation and of Canada as a federation, and how for the science content. The science focus needs, however, this will be reflected in readership, support, and advertising to remain Canadian. Will all science publishing eventually revenues. The CVJ is the critical vehicle for all Canadian be “digital only” as is now the case for many mainstream veterinarians to communicate and exchange ideas, and to science journals? Maybe. But science content is only part of stay on top of important and numerous national issues. It is the role of The CVJ. One response to the digital era might nation-building in action. Thanks to the long-term editors, be to shrink the size of the science articles to 2 printed pages Doug Hare (1992–2008) and Carlton Gyles (2008–present), of an extended type of Abstract, and to put the full peer- for their skilled and steady hands on the tiller. Congratulations reviewed article on line with PubMed for download, giving to the many hundreds or even the thousands of Canadian immediate access to CVMA members through the CVMA veterinarians and others, to the editors and assistant editors, website. Authors would like this. This and the earlier sugges- and to the authors and the reviewers who have contributed tion might shrink the printed journal, if this would reduce to the on-going success of The CVJ. printing and mailing costs without loss of the strengths of The CVJ. A printed journal is still important, it’s so visible and easy to read.

...in 1960 • CVMA membership went from $10 to $20. • Canadian veterinary graduates were: 28 from • The National Examining Board tested 16 candidates. Université de Montréal and 39 from the University of • About 2600 copies of The CVJ were distributed Toronto (Ontario Veterinary College). monthly during its first year of operations. “When • Non-member subscription fees for The CVJ were $6. the CVMA Council met in July 1960 members were • A Letter to the Editor was published in the elated at what the journal’s editorial board had been February 1960 CVJ lamenting the announcement able to accomplish in so little time and moved to in Time magazine (September 28, 1959) of the commend and congratulate it on the tremendous “Mechanical Cow” and the possible ill effects to both effort expended.” One Voice, page 98. the veterinary profession and human taste buds.

CVJ / VOL 61 / JANUARY 2020 21 FOR PERSONAL USE ONLY Whatever and wherever you practice, the CVMA is with you every step of your way.

We speak for you on veterinary issues of We provide resources to help you achieve a national importance and protect the integrity meaningful career and personal wellness. of our profession.

As a CVMA member, you benefit from… As a CVMA member, you benefit from… • Engagement with Government and stakeholders to influence • The Canadian Veterinary Journal policy decisions • The Canadian Journal of Veterinary Research • International relations to provide the Canadian veterinary • Member e-newsletter ‘Online from 339’ perspective • CVMA national convention and CE • Media/public relations to provide trustworthy information and • CVMA National Issues Forum promote veterinary professionals • CVMA Summit • Position statements addressing animal welfare and national • CVMA Emerging Leaders Program veterinary issues • CVMA Canadian Veterinary Reserve • Member consultations on key veterinary issues • LifeLearn products (preferred pricing) • Leadership initiatives on antimicrobial stewardship and surveillance, cannabinoids, telemedicine • MyVetStore.ca™ CVMA web store solution for clinics • Administration of national veterinary exams to ensure uniform • Practice owner’s economic survey certification of professional credentials • Individual practice diagnostic and valuation report • Accreditation of veterinary colleges and veterinary technician • Provincial suggested fee guide programs • Associate compensation and benefits report • Compensation report for non-DVM staff • Compensation report for DVMs outside private practice We put money in your pocket to increase • Practice management articles and career/business resources your profitability. • CVMA specialized group insurance program • CVMA mentoring program As a CVMA member, you benefit from… • VetLaw Online™ legal advice column • GoodLife Fitness (discount) • CVMA Green Veterinary Practice and self-audit tool • CVMA Petcard™ Program – financing options for your clients • Veterinarian health and wellness resources • Moneris™ payment processing services (preferred pricing) • Early career DVM resource hub • HRdownloads™ (discount) • Guidelines for the successful employment of new graduates • Mont Tremblant SkiMax/GolfMax (discount) • Guidelines for the legitimate use of compounded drugs • Hotels worldwide discount program • CVMA Guidelines for Veterinary Antimicrobial Use (online • The Personal Insurance for home/auto/travel (preferred pricing) database) • National and Enterprise car rental (discount) • Therapeutic decision cascade poster • Scotiabank® business banking and lending solutions • Animal abuse resources for practitioners • Classified ads in The CVJ (discount) • Preventive healthcare, nutritional assessment and client • Clinician’s Brief™ (free global digital edition) education tools and resources • Plumb’s Veterinary Drugs™ (subscription discount) • Animal Health Week, National Tick Awareness Month and Mental • Staples Advantage™ business products Health in Vet Med Awareness Week campaigns • Adtel® telephone hold service and digital signage (preferred pricing) • Petro-Canada SuperPass™ fuel/diesel discount • CVMA Annual Convention (registration discount) Visit our website or contact us to learn how to get • WSAVA World Congress and WVA Congress (registration discount) more value from your membership.

CanadianVeterinaryMedicalAssociation CANADIAN VETERINARY MEDICAL ASSOCIATION 339 Booth Street, Ottawa (Ontario) K1R 7K1 @CanVetMedAssoc T • (800) 567-2862 • (613) 236-1162 [email protected] CVMAACMV canadianveterinarians.net @cvma.acmv CVMA 2019/11 FOR PERSONAL USE ONLY

NEWS | NOUVELLES

CVMA Call for Nominations Quebec Council Member (July 13, 2020–December 31, 2023) Appel de candidatures pour l’ACMV Membre du Conseil pour le Québec (du 13 juillet 2020 au 31 décembre 2023) he current CVMA Council member for the province of a Dre Enid Stiles, actuellement membre du Conseil de l’ACMV TQuebec, Dr. Enid Stiles, will become CVMA president Lpour la province de Québec, deviendra présidente de l’ACMV during the 2020 CVMA Convention in Quebec City. Therefore, lors du congrès 2020 de l’ACMV qui aura lieu à Québec l’été pro- nominations are hereby invited to succeed Dr. Stiles as CVMA chain. Par conséquent, les personnes intéressées à succéder à la Council member for the province of Quebec, the term com- Dre Stiles à titre de membre du Conseil de l’ACMV pour la province mencing the day after the convention closes (July 13, 2020) and de Québec sont invitées à soumettre leur candidature. Le mandat ending December 31, 2023. débutera le lendemain de la clôture du Congrès (le 13 juillet 2020) The CVMA General By-law provides for the election of a et se terminera le 31 décembre 2023. CVMA Council member in provinces where CVMA dues are Le règlement général de l’ACMV prévoit l’élection d’un membre not collected by the provincial association. A member of the du Conseil de l’ACMV dans les provinces où les cotisations à l’ACMV CVMA is eligible for election to CVMA Council if he or she: ne sont pas perçues par l’association provinciale. Pour être éligible i) is a resident in the province for which he or she is nominated; au Conseil de l’ACMV, le candidat doit : i) être un résident de la pro- ii) is nominated by 2 CVMA members in good standing who vince pour laquelle il est proposé; ii) être proposé par deux membres reside in that province; iii) consents to the nomination; and, en règle de l’ACMV résidant dans cette province; iii) consentir à la iv) is in good standing in the CVMA. nomination; iv) être un membre en règle de l’ACMV. The election will ONLY be conducted electronically. L’élection se fera UNIQUEMENT par voie électronique. Each nomination must be endorsed by 2 CVMA members in Chaque candidature doit être approuvée par deux membres en good standing and countersigned with the nominee’s electronic règle de l’ACMV et contresignée avec la signature électronique du signature. All CVMA members in Quebec will be notified and candidat. Tous les membres de l’ACMV au Québec seront avisés et provided with instructions on how to register their vote elec- recevront des instructions sur la façon de voter par voie électro- tronically if there is more than one candidate. We ask nominees nique s’il y a plus d’un candidat. Nous demandons aux candidats to send us a recent photograph as well as a short biography. de nous envoyer une photo récente ainsi qu’une courte biographie. Nominations must be submitted by completing the form pro- Les candidatures doivent être soumises en remplissant le vided for this purpose. Members can download the fillable PDF formulaire prévu à cet effet. Les membres peuvent télécharger le form at (www.canadianveterinarians.net/cvma-bylaws) and send formulaire PDF à remplir à l’écran (www.veterinairesaucanada.net/ it to the CVMA secretariat by e-mail ([email protected]) cvma-bylaws) et l’envoyer au secrétariat de l’ACMV par courriel before May 3, 2020. ([email protected]) avant le 3 mai 2020.

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N 2020 CVMA Awards — Last Call! Nominations Close January 31, 2020 Prix de l’ACMV 2020 – Dernier appel! Les candidatures sont acceptées jusqu’au 31 janvier 2020 ach year, through the Canadian Veterinary Medical haque année, des médecins vétérinaires sont récompensés EAssociation’s (CVMA’s) national veterinary awards program, Cpour leurs contributions exceptionnelles à la médecine vété- veterinarians are honored for their exceptional contributions to rinaire dans le cadre du programme national de reconnaissance de veterinary medicine. We encourage you to nominate deserving l’Association canadienne des médecins vétérinaires (ACMV). Nous colleagues for their hard work and dedication to the profession. vous encourageons à proposer la candidature de collègues méri- “Winning the CVMA Practice of the Year Award was such an tants pour leur travail acharné et leur dévouement à la profession. honor,” says Dr. Trina Bailey, owner of the Veterinary Specialty « Remporter le prix de pratique de l’année de l’ACMV a été un Centre of Newfoundland and Labrador (VSCNL). “There is no grand honneur pour moi », a déclaré la Dre Trina Bailey, proprié- greater recognition of hard work and vision than such acknowl- taire du VSCNL (Veterinary Specialty Centre of Newfoundland edgement from your peers and clients. The entire staff of the and Labrador). « C’est très gratifiant de voir ainsi nos efforts et VSCNL appreciates such a powerful endorsement of our vision notre vision reconnus par nos pairs et nos clients. L’ensemble du of providing expert care close to home.” personnel du VSCNL est touché de recevoir un tel appui à notre The VSCNL received the CVMA Practice of the Year mission de fournir des soins spécialisés dans notre région. » Award in 2019 for its devotion to providing specialty care in Le VSCNL a reçu le prix de la pratique de l’année de l’ACMV en Newfoundland and Labrador. Dr. Bailey and her staff helped fill 2019 en raison de son dévouement à fournir des soins spécialisés a gap in advanced animal care as the VSCNL is the only referral à Terre-Neuve-et-Labrador. La Dre Bailey et son personnel ont hospital and emergency centre in the province. contribué à combler un besoin en matière de soins plus poussés Award nominees (excluding those nominated for Honorary pour les animaux, car le VSCNL est le seul hôpital de référence Membership) must be current CVMA members; however, non- et centre d’urgence de la province. members can submit nominations. Les candidats proposés pour les prix de l’ACMV (à l’exception CVMA Awards will be presented during the CVMA de ceux qui sont nommés pour le titre de membre honoraire) Convention in Quebec City, Quebec from July 9 to 12, 2020. doivent être des membres en règle de l’ACMV, mais leur can- All recipients receive a plaque and free registration to the didature peut être soumise par des personnes qui ne sont pas Convention. membres de l’ACMV. Nominations are accepted until January 31, 2020 for the Les prix de l’ACMV seront remis lors du congrès de l’ACMV qui following awards: se tiendra dans la ville de Québec, au Québec, du 9 au 12 juillet • CVMA Humane Award 2020. Tous les lauréats recevront une plaque et une inscrip- (Sponsored by Merck Animal Health) — $1000 prize money tion gratuite au Congrès de l’ACMV. • Merck Veterinary Award Les candidatures sont acceptées jusqu’au 31 janvier 2020 (Sponsored by Merck Animal Health) — $1000 prize money pour les prix suivants : • Small Animal Practitioner Award • Prix humanitaire de l’ACMV (Sponsored by Petsecure Pet Health Insurance) — $1000 prize (commandité par Merck Santé animale) – bourse de 1000 $ money • Prix vétérinaire Merck • CVMA Practice of the Year Award (commandité par Merck Santé animale) – bourse de 1000 $ (Sponsored by Scotiabank) — $1000 prize money • Prix du praticien des petits animaux • CVMA Industry Award (commandité par Petsecure assurance maladie pour • CVMA Life Membership ­animaux) – bourse de 1000 $ • CVMA Honorary Membership • Prix de la pratique de l’année de l’ACMV (commandité par la Banque Scotia) – bourse de 1000 $ • Prix de l’industrie de l’ACMV • Membre à vie de l’ACMV • Membre honoraire de l’ACMV

24 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY

Nomination packages must be submitted by January 31, Les dossiers de candidature doivent être envoyés au bureau N 2020 via e-mail ([email protected]), by fax to de l’ACMV d’ici le 31 janvier 2020 par courriel (communications@ 613-236-9681, or by mail to the CVMA office at 339 Booth cvma-acmv.org), télécopieur (613-236-9681) ou courrier (339, rue Street, Ottawa, ON K1R 7K1. Booth, Ottawa, ON, K1R 7K1). Nomination packages must include a completed nomination Ils doivent inclure un formulaire de candidature dûment form, an outline of the nominee’s key professional accomplish- rempli, un aperçu des principales réalisations professionnelles ments, and letters of support (newspaper articles and articles du candidat et des lettres d’appui; des articles de journaux ou written by the nominee can be included if applicable). des articles écrits par le candidat peuvent également être soumis Please visit the CVMA Awards section, under About CVMA, le cas échéant. of the website (www.canadianveterinarians.net) for complete Vous trouverez dans la section Prix de l’ACMV de notre site nomination guidelines, award descriptions, nomination forms, Web (www.veterinairesaucanada.net), sous l’onglet À propos de and past award recipients. l’ACMV, les directives de mise en candidature, les descriptions des prix, les formulaires de nomination et les listes des récipiendaires précédents.

Exciting! Inspiring! Motivating! 2020 CVMA Convention — July 9 to 12 Excitant! Inspirant! Motivant! Congrès de l’ACMV du 9 au 12 juillet 2020 ith registration opening January 15th, if you haven’t a période d’inscription commence le 15 janvier! Si vous n’avez Walready familiarized yourself with the CVMA Lpas déjà consulté le document promotionnel du Congrès de Convention’s promotional brochure, now available online, now l’ACMV, maintenant accessible en ligne, il est temps de le faire, car is the time to do so as some events are limited in seating and pour certains événements, le nombre de places est limité et une require pre-registration. préinscription est nécessaire. The CVMA Summit entitled “Climate Change, One Health Le Sommet de l’ACMV, dont le thème sera les changements and Veterinary Medicine” will take place Thursday morning, climatiques, l’approche « Une santé » et la médecine vétérinaire, July 9, and will be chaired by Dr. Enid Stiles, CVMA president- aura lieu le jeudi 9 juillet en avant-midi et sera présidé par la elect. The National Issues Forum will be held in the afternoon Dre Enid Stiles, présidente élue de l’ACMV. Le Forum sur les for the 5th consecutive year and will focus on “Veterinary enjeux nationaux se tiendra dans l’après-midi pour la cinquième Medicine in Natural Disasters.” année consécutive et portera sur la médecine vétérinaire lors de Join your colleagues at the CVMA Annual General Meeting catastrophes naturelles. and Awards Ceremony on Thursday, July 9, where your peers Joignez-vous à vos collègues lors de l’assemblée générale will be recognized and be presented with awards for their annuelle et de la cérémonie de remise des prix de l’ACMV, le jeudi 9 juillet, pendant laquelle vos pairs seront récompensés pour leurs réalisations dans la profession vétérinaire. N’oubliez pas d’indiquer que vous voulez votre billet gratuit pour le dîner au moment de votre inscription. Cette année, des ateliers pratiques et spécialisés seront offerts tout au long du Congrès, dont quatre le jeudi 9 juillet. Des ate- liers sur les extractions dentaires simples et complexes et les blocs nerveux chez les chiens seront à nouveau proposés par le Dr Alexander Reiter et la Dre Sue McTaggart, un atelier de chirurgie orthopédique sera animé par le Dr Brian Beale et des ateliers de dermatologie auront lieu le matin et l’après-midi avec le Dr Vincent Defalque et la Dre Sophie Gilbert. Le Congrès de l’ACMV offrira deux cours (conférences appro- fondies) le vendredi 10 juillet présentés par le Dr Éric Norman Carmel et la Dre Mylène Auger. Celui de l’avant-midi portera sur l’échographie et celui de l’après-midi sera axé sur la radiographie abdominale. Enfin, le dimanche 12 juillet, les médecins vétérinaires et les techniciens peuvent apprendre des concepts importants de soins vitaux de base et avancés dans le cadre d’ateliers de certifi- Dr./Dre Enid Stiles cation « RECOVER » animés par la Dre Erin Spencer.

CVJ / VOL 61 / JANUARY 2020 25 FOR PERSONAL USE ONLY

N achievements in the veterinary profession. Your complimentary Étant donné que ces activités nécessitent une préinscription lunch ticket must be selected at the time of your registration. et que le nombre de places est limité, nous vous encourageons This year, hands-on labs and specialty workshops will be à consulter le site Web du Congrès pour lire la description des available throughout the week starting with 4 being offered séances de formation continue offertes et à vous inscrire rapide- on Thursday, July 9. “Basic and Advanced Dental Extractions ment pour vous assurer de ne rien manquer! Des conférences de and Nerve Blocks in Dogs” will once again be offered by formation continue sont aussi prévues du vendredi 10 juillet au Dr. Alexander Reiter and Dr. Sue McTaggart, the orthopedic dimanche 12 juillet sur divers sujets concernant les animaux de surgery lab will be facilitated by Dr. Brian Beale, and derma- compagnie, les ruminants, les chevaux, le bien-être animal, la santé tology workshops both in the morning and afternoon, will be publique et l’approche « Une santé », et pour la première fois en offered by Dr. Vincent Defalque and Dr. Sophie Gilbert. 2020, le mieux-être professionnel. The CVMA Convention will offer 2 masterclasses (in-depth Enfin, l’équipe du Congrès de l’ACMV est ravie de lancer le nou- lectures) on Friday, July 10, presented by Dr. Eric Norman veau site Web et l’application du Congrès (EventBuddy) ce mois-ci. Carmel, and Dr. Mylene Auger. The morning session will Restez au courant de tous les détails de l’événement en visitant review “Ultrasound Cases,” and the afternoon class will be focus- le site Web du Congrès ou en téléchargeant l’application (www. ing on “Abdominal Radiography.” Finally, on Sunday, July 12, veterinairesaucanada.net/science-knowledge/annual-convention). veterinarians and technicians can learn the important concepts Au plaisir de vous voir à Québec! of basic and advanced life support in a workshop presented by (par Sarah Cunningham, responsable du Congrès de l’ACMV) Dr. Erin Spencer. Since these hands-on labs, workshops and masterclasses require pre-registration and have limited seating, we encourage you to peruse the convention website to review the available continuing education (CE) sessions and register early to ensure that you don’t miss out! CE sessions are offered from Friday, July 10 through to Sunday, July 12 and include the following tracks: companion animal, ruminant, equine, animal welfare, public health/one health, and new for 2020, professional wellness. And lastly, the CVMA Convention team is excited to launch the new convention website and app called EventBuddy this month. Stay up-to-date with the latest event details by visiting the convention website, or by downloading the Convention app at (www.canadianveterinarians.net/science-knowledge/annual- convention). See you in Quebec City! (by Sarah Cunningham, Manager, Conventions)

26 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY

The CVMA Welcomes Dr. Kathy Keil to its Veterinary Wellness N Advisory Group L’ACMV souhaite la bienvenue à la Dre Kathy Keil au sein de son Groupe consultatif sur le bien-être des médecins vétérinaires he CVMA is pleased to welcome Dr. Kathy Keil as a mem- ACMV est heureuse d’accueillir la Dre Kathy Keil à titre Tber of its Veterinary Wellness Advisory Group. L’ de membre de son Groupe consultatif sur le bien-être des Dr. Keil studied cognitive and neuropsychology in her under- médecins vétérinaires. graduate and graduate psychology degrees prior to attending La Dre Keil a fait des études de premier cycle et des études veterinary school. She has training in Mental Health First Aid, supérieures en psychologie cognitive et en neuropsychologie safeTALK suicide awareness, ASIST suicide intervention, and avant de s’inscrire en médecine vétérinaire. Elle a suivi un cours is licensed to teach safeTALK. de premiers soins en santé mentale ainsi qu’une formation safe- She regularly teaches suicide awareness and basic intervention TALK sur la prévention du suicide et une formation ASIST sur les skills to veterinary professionals, and suggests ways for them to interventions en cas de suicide. Elle est aussi autorisée à donner take care of their own mental well-being. la formation safeTALK. She is a member of the Alberta Veterinary Medical Elle enseigne régulièrement aux médecins vétérinaires des Association Member Wellness Committee and with veterinary techniques de base en intervention et en prévention du suicide, technical services with Merck Animal Health. She is the leading ainsi que des façons de préserver leur bien-être mental. force behind the Merck-CVMA It’s Time to Talk about Mental Elle est membre du comité sur le bien-être des médecins Health in Veterinary Medicine Awareness Campaign. vétérinaires de l’Alberta Veterinary Medical Association et elle fait partie de l’équipe des Services techniques de Merck Santé animale. Elle est également la force motrice de la campagne Il est temps de parler de santé mentale en médecine vétérinaire mise en œuvre par Merck et l’ACMV.

Dr./Dre Kathy Keil

CVJ / VOL 61 / JANUARY 2020 27 FOR PERSONAL USE ONLY “The Best CE Value in Canada” April 24 – 26, 2020 Halifax Marriott® Harbourfront Hotel Halifax, NS www.apvc.ca

APVC @APVC20 and #APVC20

Veterinarians Dr. Ameet Singh Dr. Michele Gaspar • Suture Choices, Seroma Prevention and Secure • Analyzing Analytes: Getting the Most From Your Cats Knots! Bloodwork • Urinary Surgery for the Practitioner: Cystotomy, • Sneezing, Snorking, Coughing & Wheezing: Upper and Perineal & Scrotal Urethrostomy Lower Respiratory Dx in Cats • Cholecystectomy: Biliary surgery for the practitioner! • Beyond Hairballs – Feline GI Dx and Hepatobiliary & • Current Mgmt. of Brachycephalic Obstructive Airway Pancreatic Disorders Disease • It’s More (Maybe) than CKD: Feline Renal Disease • GI Surgery: Tips and Tricks to Reduce Complications Dr. Louis-Philippe de Lorimier • Common Surgical Procedures of the Head & Neck: Salivary Gland Removal & Laryngeal Paralysis • Cannabis and Pets: a Pot of Gold? • Controversies in Gonadectomy: Why? How? When? • Let’s Talk About Sacs (anal) • The Many Faces of Lymphoma Dr. Judy Rochette • Diagnosing Cancer: What’s New? • Decisions, Decisions. Does This Tooth Need • Cancer Therapy: Sometimes There are Side Effects Extracting? • Unforgiveable: What Every Vet Should Know & Do • What’s Black & White & Read All Over? Regarding Cancer Dental Radiographic Interpretation incl. Challenging • Cancer Drug Repositioning: Old Drugs, New Tricks Cases Dr. Jinelle Webb • The Young and the Old. Dental Pathology or Variation of Normal? • Leptospirosis in the Dog…and Cat! • And Now it’s Your Turn. Critical Review of Home • A Review of Diabetes Mellitus in Cats and Dogs Care Products Including Dental Diets • An Overview of Canine Hyperadrenocorticism • Dogs are NOT Big Cats. CUPS, Eosinophilic • Endoscopy Advice for the General Practitioner Granulomas and Resorptive Lesions • 2019 AAHA Canine Lifestage Guidelines Session • Complicated Dental Cases and All that Go With them Part I & II (Tiny Dogs, Brachycephalic, etc.)

Join more than 850 other delegates, exhibiting companies and a world class list of speakers in an environment of true maritime hospitality

For further information contact: Dr. Courtney Sherlock,Chair • APVC Committee on Arrangements PO Box 310, Eastern Passage, NS, B3G 1M6 Email: [email protected] FOR PERSONAL USE ONLY

A COMPLETE PACKAGE FOR THE ENTIRE VETERINARY TEAM

Animal Health Technicians Business Management Monique Feyrecilde Susan Savage • The Science of Learning: Classical Conditioning, • Employee & Leadership Engagement Desensitization, Operant Conditioning and ABC’s of • Engagement Based on Strengths Leadership Behaviour • Critical Competencies for a Star Practice Manager • The Science of Learning: Applied Knowledge, Case Workshop PartI&II Examples for Behaviour Dr. Cindy Adams • Preventing Behavioural Relinquishment in 2020 – • The Science of Compliance: Examination of the Talk Canine and Feline that Helps or Hinders our Ability to Treat PartI&II • Helping Clients Understand Anxious Pets • Leading with Integrity: A Personal & Professional • Cooperative Care: Pet Owner and Veterinary Team Workshop for Veterinary Leaders PartI&PartII Working Together For Better Treatment Part I • Cooperative Care: Pet Owner and Veterinary Team Support Staff Working Together For Better Treatment Part II • Fun With Dental Instrumentation Debbie Lawrence • Current Dental Cleaning Techniques • Communication: Four Common Styles & Understanding Non-Verbal Cues Tasha McNerney • Listening Techniques & Understanding Conflict. • Ins and Outs of the Anesthetic Machine Strategies for Building Effective Customer • Avoiding the Hypos in Veterinary Anesthesia Interactions in 2020 (Hypothermia/Hypotension) Monique Feyrecilde • Choose Your Own Adventure: Anesthetic Case Studies • Pet's Eye View of a Clinic Visit • Breed Specific Considerations for Anesthesia • Practical Behaviour Modifications and Nail Trim • Top Anesthesia Myths Magic! • After Anesthesia: Ways We Can Help with Acute and Chronic Pain Mgr. Support Staff, Tech & Vet Candice Hoerner Dr. Michele Gaspar • Am I Imagining Things? • Mindful Practice: Attending to Ourselves Our Clients How to recognize and chart oral pathology & Our Patients • Dental Info for Technicians • Burning Bright, Not Burning Out X-ray Vision for the Super Hero • Using Mindfulness: Healthy Professional & Personal • Fun With Dental Instrumentation Lives • Current Dental Cleaning Techniques David Andrews • Anesthesia Management in the Dental Patient • Organizational Culture & Resilience Workshop • The Dental Concierge: How to Advocate for the Pet Part I & II and the Practice with Gold Standards Dr. Cindy Adams • Check MEOWT: Top Feline Oral Health Conditions • How to Build a Relationship, Discover What Clients Wet Lab (Technicians - Half Day) Want & How to Work Toward a Joint Mgmt. Plan Part I & II • Mining your patient’s liquid gold - Urinalysis • Toward Human Sustainability: How to Enable More Thriving at Work Fees Veterinarians Full $435 (3 days) Managers Full $335 (3 days) Technicians & Vet’s Assistants Full $235 (3 days) Support Staff Full $185 (2 days) Wet Lab Techs $175 (½ day) FOR PERSONAL USE ONLY Case Report Rapport de cas

Diabetic remission in a cat treated with an implantable pump to deliver insulin

Chiara Crinò, Francesca Iavazzo, Filippo Ferri, Luigi M. Coppola, Elena Salesov, Thomas A. Lutz, Claudia E. Reusch, Eric Zini

Abstract — A diabetic cat was referred because of poor metabolic control and difficulties the owner experienced injecting insulin. A pump, telemetrically controlled with a smartphone, was implanted subcutaneously to deliver insulin. Before implantation, the pump reservoir was filled with a rapid-acting human recombinant insulin. The insulin was administered through continuous infusion or periodic boluses over 2 weeks while the cat was hospitalized and over another 2 weeks after discharge from the hospital. Adjustments of insulin dosage were performed based on blood glucose concentrations measured with a continuous blood monitoring system (CGMS). The cat achieved diabetic remission that is still lasting after 1 year. The treatment protocol adopted in this cat contributed to achieving remission. The owner’s unwillingness to inject insulin into an uncooperative cat was circumvented with the implantable pump. Key clinical message: The implantable subcutaneous pump, telemetrically controlled by a smartphone, easily allowed the clinician to modify the type of administration and the amount of insulin delivered; the concurrent use of a CGMS allowed detection of sudden changes in blood glucose while limiting stress to the cat.

Résumé — Rémission du diabète chez un chat traité avec une pompe implantable pour administrer l’insuline. Un chat diabétique fut référé pour cause de pauvre contrôle métabolique et des difficultés rencontrées par le propriétaire pour injecter l’insuline. Une pompe, contrôlée par télémétrie avec un téléphone intelligent, fut implantée sous-cutané afin d’injecter l’insuline. Avant l’implantation, le réservoir de la pompe fut rempli avec une insuline humaine recombinante à action rapide. L’insuline était administrée par infusion continue ou des bolus périodiques pendant une période de 2 semaines alors que le chat était hospitalisé et pendant un 2 semaines supplémentaires après avoir obtenu son congé de l’hôpital. Des ajustements du dosage de l’insuline furent effectués sur la base des concentrations de glucose sanguin mesurées par un système continu de surveillance du sang (CGMS). Une rémission du diabète fut possible pour ce chat et persiste toujours après 1 an. Le protocole de traitement adopté chez ce chat a contribué à atteindre cette rémission. La réticence du propriétaire à injecter l’insuline chez un chat non-collaborateur fut contournée par une pompe implantable. Message clinique important : La pompe implantable sous-cutanée, contrôlée par télémétrie avec un téléphone intelligent, a facilement permis au clinicien de modifier le type d’administration et la quantité d’insuline donnée; l’utilisation concomitante d’un CGMS a permis la détection de changements soudains dans la glycémie tout en limitant le stress au chat. (Traduit par Dr Serge Messier) Can Vet J 2020;61:30–34

Istituto Veterinario di Novara, Strada Provinciale 9, 28060 Granozzo con Monticello (NO), Italy (Crinò, Iavazzo, Ferri, Zini); Department of Animal Medicine, Production and Health, viale dell’Università 16, 35020 Legnaro (PD), University of Padova, Italy (Coppola, Zini); Clinic for Small Animal Internal Medicine (Salesov, Reusch, Zini); and Institute of Veterinary Physiology (Lutz), Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 260, 8057 Zurich, Switzerland. Address all correspondence to Dr. Eric Zini; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

30 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY

he mainstay of treatment in diabetic cats is subcutaneous T injection of insulin and feeding a low-carbohydrate diet. With adequate therapy, approximately half of the cats with diabetes mellitus (DM) achieve remission and, therefore, do not need insulin injections to maintain normoglycemia. When

remission occurs, it is within 6 mo of diagnosis in more than REPORT CASE 90% of the cases (1). This favorable outcome is more likely if hyperglycemia, causing b-cell dysfunction and loss in cats (2), is promptly and strictly controlled allowing reversal of glucose toxicity (1,2). However, if owners are unwilling to inject insulin or cats are not amenable to injections, remission is unlikely and poorly controlled DM ultimately leads to early death. Insulin pumps, external or implantable, have been developed for diabetes treatment in humans. External pumps have a display that allows the user to enter dosage information, and usually deliver insulin through a cannula inserted into the subcutane- ous tissues through a hand-held controller to adjust rates (3,4). Implantable pumps have been used in humans with type 1 DM Figure 1. Implantable pump to deliver insulin (top left). The blue in which an external pump failed to achieve acceptable glycemic area on the lower part of the pump is the diaphragm for filling the control due to an erratic or limited absorption of insulin from 1-mL reservoir; a 1-mL syringe was used for this purpose. The tube on the right side of the pump is the catheter that delivers the subcutaneous tissue. These pumps are surgically implanted insulin; the catheter was cut before implantation to avoid kinking into the subcutaneous tissue and insulin is delivered into the and obstruction. The diameter of the pump is 2.5 cm, similar to peritoneal cavity via a catheter. Studies have shown that the use a 1-euro coin (bottom right). of external or implantable insulin pumps is superior to multiple daily subcutaneous insulin injections for glycemic control in pump for telemetrically controlled insulin release was proposed humans with type 1 or type 2 DM (3,4). and written informed consent was obtained. Furthermore, To date, insulin pumps have not been used in diabetic cats. because it has been shown that strict glycemic control can Implantable pumps may be more practical and could provide decrease the subsequent dosage of insulin and chances of remis- owners with a method that eliminates restraint of cats and sion are more likely during the first 6 mo from diagnosis of DM injection of insulin. (1,5), the aim of using the pump was to perform an intensive The present study describes the use of an implantable pump insulin treatment protocol in order to achieve this favorable telemetrically controlled through a smartphone, to deliver outcome. insulin in a diabetic cat that had become uncompliant to sub- We used an implantable pump (Ithetis; Antlia SA, Lausanne, cutaneous injections. Switzerland) that had been developed to deliver drugs in labora- tory animals and was smaller than the pump originally employed Case description in healthy cats (6). The new pump has a diameter of 2.5 cm A 10-year-old, spayed female, domestic shorthair cat was (the original pump had major axis of 4.2 cm), a reservoir of referred because of poorly controlled DM. Persistent polyuria 1 mL and a battery lasting for up to 2 mo (Figure 1). For and polydipsia were reported by the owner, and large swings of implantation of the pump, a 3 3 5 cm area of skin in the blood glucose concentrations [i.e., between 2.5 and 30 mmol/L; dorsal neck was clipped and surgically prepared. A small inci- reference range (RR): 3.5 to 7.8 mmol/L] and glycosuria were sion of 1.5 cm was made under short general anesthesia, and documented by the referring veterinarian. The cat had been a 3-cm subcutaneous pouch was created to accommodate the diagnosed with DM 4 mo earlier and, at the time of presenta- pump, with the reservoir placed ventrally; the pump was not tion, was receiving subcutaneous injections of porcine insulin secured to the subcutaneous tissue through sutures. The skin zinc suspension (Caninsulin: MSD Animal Health, Segrate, was closed with 4 absorbable sutures. The whole procedure Michigan, USA), at the dosage of 4 IU, twice daily. In the last lasted 20 min. Before implantation, the pump reservoir was month the owner was unable to inject insulin regularly because filled with 1 mL of a human rapid-acting recombinant insulin the cat had become uncompliant. (Insuman Implantable 400 IU/mL; Sanofi-Aventis, Frankfurt On admission, the cat was overweight, with a body weight of am Main, Germany), through a 1-mL syringe connected to 7 kg. The biochemical profile and urinalysis showed hypergly- a 28-G needle, under aseptic conditions. The above insulin cemia (blood glucose concentration: 27.4 mmol/L), increased is produced via recombinant DNA technology in Escherichia serum fructosamine concentration (520 mmol/L; RR: 190 to coli and was developed for continuous intra-peritoneal insulin 365 mmol/L), and glycosuria. Blood tests and urinalysis were infusion in humans with type 1 DM through an implantable otherwise unremarkable. Abdominal ultrasonography and radio- pump (7). Insuman Implantable is a sterile, neutral (pH 7.5) graphs of the thorax were normal. solution supplied in vials of 10 mL with 400 IU of insulin per Due to the frantic behavior of the cat and the owner’s dif- mL. The solution contains phenol as an antimicrobial preserva- ficulty in injecting insulin, the subcutaneous implantation of a tive, trometamol as a buffering agent to stabilize the pH, and

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Figure 2. Blood glucose curve achieved with the continuous Figure 3. Histology of the subcutaneous surgical pouch glucose monitoring system during day 3. The 2 red arrows show (hematoxylin and eosin, magnification 3100). The luminal side when the insulin boluses were stopped, the blue arrow shows of the cystic space is delineated by mesenchymal fusiform when the insulin boluses were restarted (at 0.08 IU) and the cells without signs of atypia and moderate amounts of fibrous 2 green arrows show when there were stepwise increases of tissue (pseudocapsule). Mild multifocal perivascular lymphocytic insulin dosage (at 0.10 IU and 0.12 IU). Food was administered infiltrates are present in the fibrous tissue. Normal adipose tissue at 8 am and 8 pm. surrounds the pouch (top left and bottom right).

poloxamer 171, which is a surfactant that prevents aggregation is 0.01 mL/bolus. Drug delivery from the pump can be modified of insulin and increases its stability. The product has a shelf life whenever it is necessary. of 24 mo when stored at 2°C to 8°C, protected from light, and The insulin administration was started with a continuous it is stable for 8 wk at 37 6 2°C (7). The vial was taken from rate infusion of 1.25 mL/h (0.5 IU/h). However, after 5 h the refrigerator 6 h before use, and immediately before being from the beginning of the infusion, blood glucose had fallen to injected in the pump, it was gently shaken 3 times for 30 s each 3 mmol/L; insulin infusion was stopped, and food was provided time, as advised by the manufacturer. to the cat. The continuous rate infusion of insulin was restarted Following implantation of the pump, a continuous glu- after 3 h, and gradually reduced to 0.62 mL/h (0.25 IU/h) for cose monitoring system (CGMS) (G4 Dexcom: Medtronic, 16 h and then to 0.4 mL/h (0.16 IU/h) for 6 h. Thereafter, Minneapolis, Minnesota, USA), that had been validated at the boluses of 0.15 to 0.35 mL (0.06 to 0.14 IU) were provided authors’ institution, was used. The sensor was injected in the during the next 11 d using the following protocol: i) if blood subcutaneous tissue of the thorax, at the 6th intercostal space, glucose concentration was between 5 and 9 mmol/L, boluses midway between the sternum and the spine, by means of a 22-G of insulin with equal dosage were provided every hour; ii) if needle (8). The transmitter was connected to the sensor and blood glucose concentration was , 5 mmol/L or . 5 mmol/L fixed to the skin with tape. For calibration, blood glucose con- but dropping rapidly and expected to decrease to , 5 mmol/L centration was measured from the inner pinna with a portable within 2 to 3 h, boluses of insulin were stopped; iii) if blood blood glucose meter (AlphaTRAK2: Abbott Animal Health, glucose concentration increased to . 9 mmol/L following a Abbott Park, Illinois, USA). The sensor and the transmitter of previous interruption, boluses of insulin with the last dosage the CGMS as well as the surgical suture were covered with a were restarted; and iv) if blood glucose concentration was soft bandage; the monitor of the CGMS was fixed to the cage . 9 mmol/L and continued to increase, the dosage of each bolus door (the sensor and the monitor have to be within a distance was increased by 0.05 mL (0.02 IU) every 2 to 3 h (Figure 2). of 6 m). The CGMS displays blood glucose measurements every During the last 2 d, boluses of 0.20 mL (0.08 IU) were provided 5 min. Notably, the monitor shows glucose concentrations every 4 h. Blood glucose concentrations were assessed every between 2.2 and 22.2 mmol/L; concentrations beyond this range 15 to 45 min on the monitor of the CGMS. The CGMS was are correctly recorded by the CGMS but need to be downloaded calibrated more frequently than every 12 h if the glucose curve to be checked. The CGMS is calibrated every 12 h. showed rapid or unexpected swings. During the whole period of After anesthesia, the cat was hospitalized in the intensive hospitalization, the cat underwent only 1 episode of moderate care unit. Insulin infusion was started approximately 2 h after hypoglycemia (blood glucose of 2.5 mmol/L) requiring infusion implantation of the pump, as soon as the cat was completely of a glucose bolus (dose: 250 mg). The episode was not associ- awake and blood glucose with the CGMS had reached a con- ated with clinical signs. centration of 22 mmol/L. The insulin pump is telemetrically Following implantation of the pump, the cat was monitored controlled by an application installed on a smartphone. The twice daily for discomfort (pruritus, vocalization, pain during device allows the setting up of 3 different administration proto- neck palpation, increased respiratory rate), local and systemic cols, including continuous or periodical rate infusion, or single signs of inflammation (erythema, erosions, bleeding, purulent boluses. The maximum flow rate is 100 mL/h and the minimum discharge, increased rectal temperature, lethargy, anorexia)

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­possibly associated with the device. After 2 wk of hospitaliza- boluses scheduled during 2 mo from implantation of the pump tion, the cat was discharged with blood glucose concentrations could not be performed in 5 cats because the machinery of between 6 and 8 mmol/L. At the time of discharge the CGMS the pump stopped working. In the other 5 cases no significant was removed but the pump was left in place. The owner’s change in insulin glargine concentrations was recorded and cap- daughter was taught how to measure blood glucose from the illary blood glucose did not decrease; this failure was probably inner pinna with a portable glucose meter, at least twice daily. caused by the loss of stability of insulin glargine over time. It was REPORT CASE The owner was contacted every day in order to receive all glu- assumed that some part of the pump had caused an inactivation cose measurements and information about the cat. During the of the insulin glargine molecule (6). following 2 wk the cat’s capillary blood glucose concentrations In the diabetic cat herein, implantation of the pump was varied between 3 and 7 mmol/L; therefore, the pump was not quick and easy to perform, and the device was well-tolerated. programmed to administer boluses of insulin. No adverse reactions were documented locally or systemically One month after implantation of the pump, the cat did not during the hospitalization period and during the 2 wk following show any detectable signs of discomfort; well-being, thirst, appe- discharge. Moreover, no overt inflammation was detected micro- tite, and physical examination, including skin and subcutaneous scopically in the subcutaneous tissues at the site of implantation. tissue at the surgical site, were normal. A complete blood cell In humans, abscess formation, skin ulceration, hematoma, count and biochemical profile yielded normal blood glucose and pain at the implantation site have been described (10). In (6 mmol/L) and fructosamine (265 mmol/L) concentrations. addition, the pump implanted did not malfunction during the The insulin pump was removed under short general anesthesia treatment period and at the time of its removal the machinery and the surgical wound was closed with non-absorbable sutures was still functioning correctly. The technical improvements that were removed after 10 d. During the procedure, a biopsy of recently made to the pump were probably responsible for the the subcutaneous pouch surrounding the pump was collected. success. Still, it is worth noting that, in contrast to the previous The histopathological examination showed mild fibrosis with study, the pump was used for only 1 mo. It cannot be excluded only mild signs of inflammation (Figure 3). that problems may have occurred if it were to be used for a lon- During removal of the pump, the reservoir was inadvertently ger period or if refilling of the reservoir had become necessary. damaged by the surgeon. An unknown amount of insulin An interesting feature of the new pump used in this cat is leaked in the subcutaneous tissue causing severe hypoglycemia the possibility of controlling insulin delivery by an applica- (2 mmol/L) and weakness. Glucose infusion was provided tion installed on a smartphone. Therefore, it was easy for the for 10 h in order to maintain euglycemia (total dose: 1.25 g). attending clinician to modify the type of administration or the Immediately after removal of the pump, the functionality of the amount of insulin delivered at any time. The concurrent use of device was confirmed by programming a bolus that yielded a a CGMS limited the stress to the cat and identified episodes of visible drop of insulin solution. After 2 days of hospitalization, hypoglycemia and hyperglycemia. blood glucose values were normal, and the cat was discharged In this report a type of human recombinant insulin never without insulin treatment. Following implantation of the pump tested in cats was used. This insulin remains stable at body and its removal antibiotic prophylaxis and anti-inflammatory temperature for more than 1 mo, partly due to the surfactant in treatment were not required. the solution. In humans with type 1 DM this type of insulin has After 1 y of follow-up the cat is still in diabetic remission. been used for more than a decade without significant side effects (7). The most commonly reported issues related to its use along Discussion with implantable pumps are infection of the surgical pocket, Current cornerstone of DM management in cats consists of skin erosion, abnormal healing of the implantation site, and subcutaneous insulin injections. However, injecting insulin in formation of insulin antibodies. In the cat in this report, no side cats may be challenging for some owners due to the difficulty effects were documented with either the insulin or the pump. in restraining the cat, lack of time, or aversion to injections (6). Investigations were not carried out to determine whether insulin In the present case, the owner had become reluctant to inject antibodies had developed; however, based on the fact that relapse and the cat was uncooperative. As less than 6 mo had passed of DM had not occurred, if antibodies were present, they may from diagnosis of DM, the cat was a suitable candidate for an not substantially reduce the action of endogenous insulin. implantable pump to deliver insulin. This would allow the In conclusion, this report is the first to describe the use of an cat to receive an intensive insulin protocol aimed at optimally implantable pump in a diabetic cat for subcutaneous delivery controlling blood glucose concentrations and, possibly, achiev- of an insulin designed to remain stable at body temperature ing remission. for a long period. The pump worked correctly and insulin Previous studies in humans with type 1 and type 2 DM was effective during the entire treatment period. The owner’s have shown that insulin pumps provide better glycemic control unwillingness to inject insulin and the uncooperative behavior compared to multiple subcutaneous injections (3,4,9). In cats, of the cat were circumvented by using the implantable pump. only 1 study has been carried out on the use of implantable The treatment protocol adopted in this cat contributed to pumps (6). In particular, the administration of insulin glargine achievement of remission. The results should encourage further to 10 healthy cats by an earlier generation of the present studies on a larger number of cats in order to assess the safety implantable pump was followed by an increase in plasma insu- and efficacy of the device and of the insulin preparation in this lin glargine levels only following the first bolus (6). Successive species. Cost may limit the use of this treatment option, as the

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2-week period of hospitalization and care, and pump and insulin 4. Beato-Víbora P, Chico-Ballesteros A, Giménez M, et al. A national may approximate $3000 USD. In addition, the current pump survey on the efficacy and safety of continuous subcutaneous insulin infusion in patients with type 1 diabetes in Spain. Diabetes Res Clin is not suitable for long duration of treatment and it is unclear Pract 2018;137:56–63. whether refilling would be possible with the pump still in place. 5. Hafner M, Dietiker-Moretti S, Kaufmann K, et al. Intensive intrave- nous infusion of insulin in diabetic cats. J Vet Intern Med 2014;28: Acknowledgments 1753–1759. 6. Zini E, Padrutt I, Macha K, et al. Use of an implantable pump for The authors are grateful to Antlia SA for supplying the implant- controlled subcutaneous insulin delivery in healthy cats. Vet J 2017; able pump and to Sanofi-Aventis for supplying the insulin used 219:60–64. 7. Schaepelynck P, Riveline JP, Renard E, et al. Assessment of a new insu- in this study. CVJ lin preparation for implanted pumps used in the treatment of type 1 diabetes. Diabetes Technol Ther 2014;16:582–589. References 8. Hafner M, Lutz TA, Reusch C, Zini E. Evaluation of sensor sites for

RAPPORTCAS DE continuous glucose monitoring in cats with diabetes mellitus. J Feline 1. Zini E, Hafner M, Osto M, et al. Predictors of clinical remission in cats Med Surg 2013;15:117–123. with diabetes mellitus. J Vet Intern Med 2010;24:1314–1321. 9. Hu Y, Li L, Xu Y, et al. Short-term intensive therapy in newly diag- 2. Zini E, Osto M, Franchini M, et al. Hyperglycaemia but not hyperlipi- nosed type 2 diabetes partially restores both insulin sensitivity and daemia causes beta-cell dysfunction and beta-cell loss in the domestic b-cell function in subjects with long-term remission. Diabetes Care cat. Diabetologia 2009;52:336–346. 2011;34:1848–1853. 3. Pickup JC, Reznik Y, Sutton AJ. Glycemic control during continuous 10. van Dijk PR, Logtenberg SJ, Groenier KH, Haveman JW, Kleefstra N, subcutaneous insulin infusion versus multiple daily insulin injections Bilo HJG. Complications of continuous intraperitoneal insulin infu- in type 2 diabetes: Individual patient data meta-analysis and meta-­ sion with an implantable pump. World J Diabetes 2012;3:142–148. regression of randomized controlled trials. Diabetes Care 2017;40: 715–722.

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34 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Case Report Rapport de cas

Spontaneous mural gallbladder hematoma in a dog

Olivia Jerrems, Carlos H. de Mello Souza, Vincent Wavreille, Benjamin I. Davids

Abstract — A 12-year-old spayed female Maltese dog was evaluated because of a 12-hour history of vomiting, mucoid diarrhea, and anorexia. There was no history of trauma or injury. Abdominal ultrasound revealed a well- defined mass associated with the gallbladder. Abdominal computed tomography (CT) confirmed a non-contrast enhancing mass emanating from the gallbladder wall causing separation of the serosal and mucosal margins. Exploratory celiotomy followed by cholecystectomy was performed. Histology of the gallbladder mass was consistent with a mural hematoma and there were no signs of significant inflammation or neoplasia present. The patient remained clinically normal in the 3 months after surgery and is reported to be alive and well 4 years after the procedure. Key clinical message: To the author’s knowledge, this is the first reported case of a spontaneous mural hematoma of the gallbladder in the veterinary literature.

Résumé — Hématome pariétal spontané chez un chien. Une chienne de race Maltese âgée de 12 ans fut évaluée à la suite d’une histoire de vomissements, diarrhée mucoïde et anorexie depuis 12 heures. Il n’y avait aucune histoire de trauma ou blessure. L’échographie abdominale a révélé une masse bien définie associée à la vésicule biliaire. La tomodensitométrie (CT) abdominale confirma une masse non-contrastante prenant origine dans la paroi de la vésicule biliaire et causant une séparation des bords de la séreuse et de la muqueuse. Une céliotomie exploratoire suivie d’une cholécystectomie furent effectuées. L’examen histologique de la masse était compatible avec un hématome pariétal et il n’y avait aucun signe d’inflammation significative ou de néoplasie. La chienne est demeurée cliniquement normale durant les 3 mois suivant la chirurgie et on rapporte qu’elle est toujours vivante et bien 4 ans après la chirurgie. Message clinique important : À la connaissance de l’auteur, ceci serait le premier cas rapporté d’un hématome pariétal spontané de la vésicule biliaire dans la littérature vétérinaire. (Traduit par Dr Serge Messier) Can Vet J 2020;61:35–38

Case description chemistry tests performed at the referring veterinarian’s clinic included: a platelet concentration of 654 3 103/mL [refer- 12-year-old spayed female Maltese dog was referred to ence range (RR): 147 to 423 3 103/mL], serum potassium the University of Florida Small Animal Emergency and A of 3.4 mmol/L (RR: 3.8 to 5.3 mmol/L), serum chloride of Critical Care service because of a 12-hour history of vomiting, 94 mmol/L (RR: 102 to 120 mmol/L), alanine aminotransferase mucoid diarrhea, and anorexia. The owners reported no his- (ALT) . 1000 U/L (RR: 21 to 97 U/L), alkaline phosphatase tory of trauma, injury, or drug/toxin exposure. Abnormalities (ALP) 531 U/L (RR: 15 to 164 U/L), and gamma-glutamyl observed on complete blood (cell) count (CBC) and serum transferase (GGT) 48 U/L (0 to 5 U/L). Treatment at the refer- ring veterinarian comprised buprenorphine (Buprenex; Reckitt Small Animal Clinical Sciences, College of Veterinary Medicine, Benckiser, Slough, UK) 0.02 mg/kg body weight (BW), IM University of Florida, Gainesville, Florida 32608, USA. and acepromazine (PromAce; Boehringer Ingelheim Vetmedica, Address all correspondence to Ms. Olivia Jerrems; e-mail: St. Joseph, Missouri, USA), 0.03 mg/kg BW, IM, maropitant [email protected]. (Cerenia; Zoetis, Parsippany, New Jersey, USA), 1.2 mg/kg Use of this article is limited to a single copy for personal study. BW, SC, and famotidine (Pepcid; Merck & Co., Kenilworth, Anyone interested in obtaining reprints should contact the New Jersey, USA), 1.2 mg/kg BW, SC, vitamin B12 (Cyano­ CVMA office ([email protected]) for additional cobalamin; Rochem International, Hauppauge, New York, copies or permission to use this material elsewhere. USA), 0.08 mg/kg BW, IM, and Lactated Ringers Solution

CVJ / VOL 61 / JANUARY 2020 35 FOR PERSONAL USE ONLY RAPPORTCAS DE

Figure 1. Abdominal ultrasound showing a well-defined, round, heterogenous mass within the right division of the liver, which measured 1.7 cm in diameter and was causing compression of the gallbladder.

(Medline, Tolleson, Arizona, USA), 30 mL/kg BW, SC, before referral. On presentation at the University of Florida, the dog was bright, alert, and responsive. On physical examination, rectal temperature was 38°C, heart rate was 140 beats/min, and respi- ratory rate was 40 breaths/min. Mucous membranes were pink Figure 2. An abdominal CT scan showing a 19 mm 3 24 mm 3 and capillary refill time was , 2 s. The patient had a body con- 16 mm soft tissue attenuating, non-contrast enhancing mass that dition score of 8/9. Additional findings were: sinus arrhythmia, emanated from the gallbladder wall. soft abdomen on palpation, and mild conscious proprioceptive placing deficits in the right hind limb. These proprioceptive The dog was taken to the Emergency and Critical Care deficits were presumed secondary to a C4-C5 ventral slot pro- service the next day because of continued anorexia and a new cedure, which was performed 3 mo before presentation. onset of mucoid diarrhea. At this time, the dog was admitted On abdominal ultrasound, a well-defined, round, heteroge- for extended care. nous mass within the right division of the liver, which measured Pertinent abnormalities comprised an ALP of 650 U/L (RR: 1.7 cm in diameter, appeared to be causing compression of the 8 to 114 U/L), an ALT of 1845 U/L (RR: 18 to 64 U/L), and an gallbladder. The mass did not appear to be vascularized on color AST of 63 U/L (RR: 15 to 52 U/L). All other chemistry values Doppler flow. Hepatocellular carcinoma and biliary carcinoma were within the normal reference ranges. On blood gas analysis,

were considered most likely, with hepatoma, extramedullary pH was 7.476 and pCO2 was 26.2 mmHg. hematopoiesis, and hematoma, gallbladder carcinoids, and Treatment at this stage comprised maropitant (Cerenia; gallbladder mural mass being less likely (Figure 1). Additionally, Zoetis), 1 mg/kg BW, IV, q24h and Plasmalyte 148 with 20 mEq there were multiple well-defined, round, hypoechoic nodules KCl/L (Medline), 60 mL/kg BW, IV/day. Metronidazole (Flagyl; throughout the liver, measuring up to 6 mm in diameter. Pfizer, New York, New York, USA) was also given at 10 mg/kg Within the splenic parenchyma, along the visceral margin, a BW, IV, q12h to treat empirically for clinical signs consis- well-defined, oval, hyperechoic nodule was present, measuring tent with large bowel diarrhea. N-Acetylcysteine (Acetodote; 2.4 mm in length. Fine-needle aspirates were obtained of the Cumberland Pharmaceuticals, Nashville, Tennessee, USA) was liver mass and nodules, with no evidence of complications. The given at 70 mg/kg BW, IV, q6h to treat for possible acetamino- gastric and pyloroduodenal lymph nodes were mildly rounded, phen toxicity, although there was a very low likelihood of such heterogenous, and enlarged, measuring up to 5 mm in height. exposure. The dog was kept on this protocol, with the addition The cranial aspect of the right lobe of the pancreas was mildly of acepromazine (PromAce; Boehringer Ingelheim), 0.02 mg/kg hyperechoic, with normal margins, shape, and peripancreatic BW, IV, as needed for anxiety, throughout the weekend and was mesentery. transferred to the oncology department at the beginning of the The dog was discharged awaiting fine-needle aspirate results week for further evaluation of suspected neoplasia of hepatic or and was prescribed 27 mg/kg BW S-adenosylmethionine with biliary origin. 2.7 mg/kg BW Silybin (Denamarin; Nutramax, Lancaster, An abdominal CT scan was performed 72 h after initial South Carolina, USA) and maropitant (Cerenia; Zoetis), presentation. In the gallbladder, there was an approximately 2.4 mg/kg BW, PO, q24h. The diagnosis at the time of dis- 19 mm 3 24 mm 3 16 mm soft tissue attenuating, non- charge was primary neoplasia of hepatic or biliary origin, contrast enhancing mass that emanated from the gallbladder although the possibility of a gallbladder mural mass could not wall causing separation of the serosal and mucosal margins. The be excluded based on the ultrasound alone. result was the impression of an eccentric, non-circumferential,

36 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 4. Post-operative photograph showing the gallbladder hematoma.

Figure 3. Intra-operative photograph showing the gallbladder hematoma and right medial liver lobe nodules. Discussion Based on presenting complaints, initial serum chemistry values combined with ultrasound and CT imaging, and the lack of well-defined mass within the wall of the gallbladder (Figure 2). trauma, this patient was believed to have a gall bladder tumor. The regional lymph nodes were within normal limits. Adenomas are the most common benign tumors associated with Based on the findings, a gallbladder wall mass originating the gallbladder (1) and gallbladder carcinomas are the most from the muscularis was suspected as the most likely diagnosis; common malignant tumors (2). Hemobilia and hemoholecyst however, benign etiologies such as hematoma could not be ruled secondary to gallbladder carcinoids have been reported in only out. Surgical cholecystectomy was recommended. A CBC and 2 cases in dogs (3); these patients exhibited upper gastrointes- serum biochemistry were repeated 72 h after the initial blood tinal bleeding, abdominal pain, and extrahepatic biliary duct analysis and revealed a packed cell volume of 39% (RR: 41% to obstruction resulting in jaundice. Diagnosis in both of these 60%), total protein of 68 g/L (RR: 57 to 79 g/L), and a platelet patients was made on histopathology of the gallbladder. Bile concentration of 610 3 103/mL (RR: 147 to 423 3 103/mL). duct carcinoma of the gallbladder is rare and associated with Serum chemistry abnormalities included an ALP of 367 U/L high rates of systemic metastasis: in 1 study, almost 90% of cases (RR: 15 to 164 U/L), ALT of 590 U/L (RR: 21 to 97 U/L), presented with systemic metastasis with lymph nodes, lungs, and and blood urea nitrogen 0.7 mmol/L (RR: 2.9 to 8.9 mmol/L), peritoneum representing the most common sites (4). Surgical glucose 7.4 mmol/L (RR: 4.4 to 6.7 mmol/L). Since the liver excision is the treatment of choice for bile duct tumors (5,6) enzyme values had improved and clinical signs had resolved, the {Morrell, 2002, A carcinoid tumor in the gallbladder of a dog}, owners were given the option of continuing medical therapy and although local recurrence or distant metastasis is expected within monitoring the patient for improvement. The owners elected to 6 mo after therapy (4). proceed with surgery and the patient was scheduled for chole- Anaphylaxis may also be a consideration given the imaging cystectomy and liver biopsies. findings. Although gallbladder hematoma has not been reported The gallbladder was removed via blunt dissection and cautery in canine anaphylaxis, it may be possible following the massive and two 5-mm punch biopsies were taken of the nodules on the release of histamine and resulting hepatic venous congestion that right medial liver lobe (Figures 3, 4). occurs when dogs experience anaphylaxis (7). This is an unlikely Histopathological evaluation of the liver nodules identified cause in this case due to the dog’s bright clinical presentation nodular hyperplasia. The gallbladder lumen contained a dark red with no signs of shock, as well as no gallbladder wall edema to black gelatinous material approximately 19 mm 3 24 mm 3 found on histopathology. 16 mm in size. Segmentally, separating the serosa and smooth In the case reported here, the improving liver enzyme activi- muscle layers of the wall was a focal large lake of hemorrhage ties over 72 h were surprising considering the suspected diag- that subtly blended into a small amount of granulation tissue nosis. A conservative approach was offered to the owner, which and the lamina propria. Small numbers of lymphocytes, plasma included continuing medical management and repeat abdominal cells, and macrophages infiltrated the lamina propria. The gall- ultrasound. Despite this, the owners elected to proceed with the bladder mass was diagnosed as a mural hematoma. exploratory celiotomy and cholecystectomy. Recovery was uneventful and the patient was discharged the Mural gallbladder hematomas are rare in humans (8,9) and, following day. Post-operative medications included amoxicil- to the authors’ knowledge, have not been reported previously in lin and clavulanic acid (Clavamox; Zoetis), 19.5 mg/kg BW, the veterinary literature. In humans, gallbladder hematomas are PO, q12h for 7 d and tramadol (Ultram; Johnson & Johnson, often associated with blunt force or iatrogenic trauma (10–12). New Brunswick, New Jersey, USA), 3.8 mg/kg BW, PO, q6 to In this patient, there were no skin abrasions, areas of swelling, 8h as needed for pain. The patient remained clinically normal or bruising to suggest a blunt trauma event. No pain could in the 3 mo after surgery and is reported to be alive and well be elicited at any point during the physical examination. The 4 y after the procedure. owners also stated that the patient was never outside unattended

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and had not become loose prior to the onset of symptoms. She References also had not undergone a recent surgical abdominal procedure. . 1 Baba AI, Catoi C. Tumors of the liver and gallbladder. In: Comparative Due to these reasons, trauma was ruled out as a cause of the Oncology. Bucharest, Romania: The Publishing House of the Romanian hematoma. Medical causes of gallbladder hematoma include Academy, 2007:9.1–9.64. Available from: https://www.ncbi.nlm.nih. gov/books/NBK9548 Last accessed July 25, 2019. cholecystitis, cholelithiasis, hepatic or biliary tumors, vascular 2. Shaffer EA. Gallbladder cancer: The basics. Gastroenterol Hepatol (N Y) abnormalities, or coagulopathy (13,14). In this case, the reduc- 2008;4:737–741. tion in liver enzyme activities with metronidazole treatment 3. Lippo NJ, Williams JE, Brawer RS, Sobel KE. Acute hemobilia and hemocholecyst in 2 dogs with gallbladder carcinoid. J Vet Intern Med may support the possibility of cholecystitis; however, this is 2008;22:1249–1252. considered doubtful in the absence of neutrophilic inflammation 4. Liptak JM, Dernell SD, Withrow SJ. Liver tumors in cats and dogs. within the gall bladder. In humans, rupture of an aneurysm of Compend Contin Educ Pract Vet 2004:50–57. 5. Morrell CN, Volk MV, Mankowski JL. A carcinoid tumor in the gall- the hepatic or cystic artery has been a rare yet reported cause bladder of a dog. Vet Pathol 2002;39:756–758. RAPPORTCAS DE of hemocholecyst (15,16). 6. Neer TM. A Review of disorders of the gallbladder and extrahepatic Since spontaneous hematoma was not a top differential prior biliary tract in the dog and cat. J Vet Intern Med 1992;6:186–192. 7. Quantz JE, Miles MS, Reed AL, White GA. Elevation of alanine trans- to surgery, no coagulation testing was done on this patient. aminase and gallbladder wall abnormalities as biomarkers of anaphylaxis Clinically significant coagulopathy as the main cause of the in canine hypersensitivity patients. J Vet Emerg Crit Care 2009;19: gallbladder hematoma was less likely considering the unre- 536–544. 8. Tan SW, Lai SK, Ng KW, Chen P, Chen KH, Jiang CF. Intramural markable physical examination, the stable blood parameters, gallbladder hematoma mimicking gallbladder neoplasm in a 33-year-old the lack of unexpected hemorrhage during and following male. J Chin Med Assoc 2005;68:146–149. surgery, and the excellent recovery of this patient. There was 9. Jung YM, Son BK, Ahn SB, Dong HK, Kim EK. Intramural gallblad- der hematoma mimicking gallbladder neoplasm in a 55-year-old male no evidence of trauma or tissue damage that could explain this patient. J Korean Surg Soc 2011;81:216–220. patient’s thrombocytosis; therefore, a physiologic response due 10. Wang IT, Tsai MT, Huang CY, et al. Isolated gallbladder hematoma after to inflammatory conditions was the most likely explanation for a blunt abdominal trauma: Case report. Crit Ultrasound J 2015;7:A27. 11. Kauzlaric D, Barmeir E. Sonography of intraluminal gallbladder hema- the thrombocytosis in this case. toma. J Clin Ultrasound 1985;13:291–294. In humans, intramural hematomas have been reported to 12. Mohanty D. Delayed rupture of gallbladder following blunt abdominal resolve within 3 to 6 mo (17). Because the liver enzyme values trauma. Maedica 2014;9:266–268. 13. Kim KH, Kim TN. Etiology, clinical features, and endoscopic man- had improved, and the clinical signs resolved, it is possible that agement of hemobilia: A retrospective analysis of 37 cases. Korean J the dog herein would have had a successful outcome without Gastroenterol 2012;59:296–302. cholecystectomy. However, intramural gallbladder hematomas 14. Kawamura H, Abe Y, Hasuo K, Ueno N. Diagnosis of hemorrhage from the gallbladder with the use of contrast-enhanced sonography. can mimic any of the diseases previously discussed that result J Ultrasound Med 2005;24:1583–1586. in the appearance of echogenic masses within the lumen of the 15. Agrawal HS, Anderson RE. Hemocholecyst: A case report. Arch Surg gallbladder (8,9,18). Therefore, a definitive diagnosis of gall- 1967;94:286–289. 16. Horsburgh AG, Levi AJ. Haematocele of the gall bladder, Brit J Surg bladder hematoma cannot reliably be made from imaging alone. 1963;50:844. For a patient with signs highly suspicious for a mural gall- 17. Heldner MR, Nedelcheva M, Yan X, et al. Dynamic changes of intra- bladder hematoma that is otherwise stable, medical management mural hematoma in patients with acute spontaneous internal carotid artery dissection. Int J Stroke 2015;10:887–892. may be acceptable. With this case report, a benign differential 18. Scharling ES, Geisinger KR. Case of the day. Hemobilia: Intraluminal can be added to the list when discussing disease potential with gallbladder hematoma. J Ultrasound Med 1993;12:244–245. pet owners. However, in this patient’s case, neoplasia was sus- pected and could not be ruled out, even though liver enzyme values were improving. In such cases, exploratory laparotomy and potential cholecystectomy is recommended (6). CVJ

38 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Case Report Rapport de cas

Mycobacterium porcinum causing panniculitis in the cat

Allison Cox, Tyler J. Udenberg

Abstract — A 4-year-old domestic shorthair cat was presented with a 7-month history of nodules and draining fistulous tracts of the ventral abdomen. Histopathological examination of affected tissue revealed acid-fast bacilli stained by the Ziehl-Neelsen procedure. Deep tissue culture confirmed infection with a rapidly growing mycobacterium, and gene sequencing characterized the organism as Mycobacterium porcinum. Treatment with pradofloxacin and doxycycline resulted in clinical resolution of the lesions. On continued antibiotic therapy 7 months later, there was no local recurrence nor were there clinical signs associated with distant spread of the infection. This is the first clinical description of a feline infection with this organism. Key clinical message: This is the first clinical description of mycobacterial panniculitis in a cat due to genetically characterized Mycobacterium porcinum. This case report highlights a disease entity that can present a diagnostic and therapeutic challenge to clinicians.

Résumé — Panniculite chez un chat causée par Mycobacterium porcinum. Un chat domestique à poil court âgé de 4 ans fut présenté avec une histoire d’une durée de 7 mois de nodules et de trajets fistulaires drainants à l’abdomen ventral. Un examen histopathologique des tissus affectés a révélé la présence de bacilles alcoolo-acido- résistants par coloration de Ziehl-Neelsen. Une culture des tissus profonds confirma l’infection par des mycobactéries à croissance rapide, et le séquençage génétique caractérisa l’organisme comme étant Mycobacterium porcinum. Un traitement avec de la pradofloxacine et de la doxycycline permit une résolution clinique des lésions. Sept mois plus tard, à la suite d’une antibiothérapie continue, il n’y avait aucune récurrence locale ni de signe clinique associé avec une dissémination de l’infection. Ceci est la première description clinique d’une infection féline associée à ce microorganisme. Message clinique important : Ceci est la première description clinique d’une panniculite à mycobactérie chez un chat associée à Mycobacterium porcinum caractérisé génétiquement. Ce rapport de cas met en évidence une maladie qui peut représenter un défi diagnostique et de traitement pour les cliniciens. (Traduit par Dr Serge Messier) Can Vet J 2020;61:39–43

ycobacteria are widespread, aerobic, non-spore-forming, bacteria is the most common presentation (1,2). Rapidly grow- M non-motile bacilli that are implicated as a cause of vari- ing mycobacteria are so called due to their ability to grow on ous clinical syndromes in cats, dogs, cattle, and humans. This appropriate media within 7 d of incubation. These organisms, includes localized cutaneous disease, pyogranulomatous lobar also classified as atypical or non-tuberculous mycobacteria, pneumonia, and very rarely, disseminated systemic infections display a predilection for adipose tissue sites due to the high (1–3). Of these, localized infections of the skin and subcutis triglyceride content which provides energy for growth (1). Feline (mycobacterial panniculitis) caused by rapidly growing myco- mycobacterial panniculitis most typically affects the inguinal and ventral abdominal fat pads following traumatic skin dam- age and subsequent wound inoculation, and tends to occur North West Veterinary Dermatology Services, 1380 Kootenay in immunocompetent individuals (1,2,4,5). Integumentary Street, Vancouver, British Columbia V5K 4R1. breaches such as bite wounds, penetrating foreign bodies, Address all correspondence to Dr. Allison Cox; e-mail: injections, or surgery can allow these bacteria to overcome host [email protected] defenses (1,2,4). Lesions can develop over a prolonged clinical Use of this article is limited to a single copy for personal study. course and can initially appear as circumscribed nodules with Anyone interested in obtaining reprints should contact the focal thickening of the subcutis, progressing to the development CVMA office ([email protected]) for additional of punctate fistulae (2). Atypical mycobacteriosis is considered copies or permission to use this material elsewhere. non-zoonotic, though rare transmission of rapidly growing

CVJ / VOL 61 / JANUARY 2020 39 FOR PERSONAL USE ONLY

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10 mm 10 mm

Figure 1. A — Histology of pyogranulomatous inflammation (Hematoxylin-eosin stain; original magnification 3100) encapsulating mycobacterial rods (arrow) within a lipocyst. B — Ziehl-Neelsen staining of acid-fast bacilli (Mycobacterium porcinum) (arrow) within the panniculus surrounded by neutrophils and macrophages.

mycobacteria has been documented (6). Defining the mycobac- drains was performed in the affected area (8). Post-surgical treat- terial species involved with culture and molecular techniques is ments included metronidazole (Summit Veterinary Pharmacy, necessary to distinguish from potentially zoonotic mycobacterial Aurora, Ontario), 12.5 mg/kg BW, PO, q12h for 6 d and species (7). The rapidly growing mycobacteria are ubiquitous in enrofloxacin (Baytril; Bayer Canada, Mississauga, Ontario), nature, especially in water and wet soil, and are non-pathogenic 2.5 mg/kg BW, PO, q24h for a total of 17 d. Two months after for animals under normal circumstances (1,5). The disease has surgery, a relapse of the lesions occurred. Based on a differential a low incidence and it can present diagnostic and therapeutic diagnosis of eosinophilic granuloma complex, prednisolone challenges due to the prolonged clinical course, lack of pathog- (prednisolone; Rafter 8 Products, Calgary, Alberta) was started nomonic histopathological changes, and failure to culture many at 0.44 mg/kg BW, PO, q12h for 7 d, then 0.44 mg/kg BW mycobacteria. The case report here highlights the disease process q24h for 7 d; this was subsequently increased to 0.86 mg/kg BW and is the first characterization of a feline infection genetically q12h for relief of pruritus, and this treatment was continued confirmed to be due to Mycobacterium porcinum. until referral. One month before referral, blood tests including a complete Case description blood (cell) count (CBC) and serum biochemistry profile A 4-year-old, 5.6 kg, spayed, female domestic shorthair cat was were performed. The hemogram detected mild reticulocytosis referred for investigation of draining nodules affecting the skin [66.4 3 103/mL; reference range (RR): 3 to 50 3 103/mL] of the ventral abdomen. Seven months previously, the cat had with an erythrocyte count within the reference range (red been presented to the referring veterinarian for evaluation of blood cell count 8.3 3 1012/L; RR: 7.1 to 11.5 3 1012/L). an abdominal wound. The cat had been rescued from Portugal The leukocyte count was within the reference range (5.6 3 1 mo before the development of skin lesions, and otherwise 109/L; RR: 3.9 to 19.0 3 109/L) and the platelet count was appeared to be in good health, with no history of trauma or 289 3 109/L; RR: 155 to 641 3 109/L. Biochemical blood tests recurrent infections. There was also no history of illness of showed an elevated blood glucose (12.1 mmol/L; RR: 4.0 to the owners or other pets in the same household. Following 9.7 mmol/L) suspected to be consistent with a stress response, initial assessment of the abdominal wound by the referring mild hypochloremia (108 mmol/L; RR: 114 to 126 mmol/L), veterinarian, the cat was treated with cefovecin (Convenia; and mildly elevated alkaline phosphatase (92 IU/L; RR: 12 to Zoetis Canada, Kirkland, Quebec), 8 mg/kg body weight (BW), 59 IU/L) with a total bilirubin within the normal reference SC, once, and meloxicam (Metacam; Boehringer Ingelheim range (1.6 mmol/L; RR: 0 to 5.13 mmol/L). A tissue biopsy Canada, Burlington, Ontario), 0.01 mg/kg BW, SC, then was also collected from the affected region at the time of blood 0.05 mg/kg BW, PO, q24h for 5 d. In the 2 wk following this testing. Dermatohistopathology of the tissue samples revealed treatment, the cat developed multiple draining fistulous tracts a pyogranulomatous dermatitis and panniculitis with fibrosis of the abdominal fat pad. Treatment was then initiated with and intralesional rod-shaped bacteria (Figure 1A). Acid-fast amoxicillin clavulanic acid (Clavaseptin; Vétoquinol Canada, (Ziehl-Neelsen) staining revealed moderate numbers of acid-fast Lavaltrie, Quebec), 9.7 mg/kg BW, PO, q12h for 14 d, along bacilli both extracellularly (Figure 1B) and intracellularly within with cleansing of the affected areas using a 1% chlorhexidine macrophages. Periodic Acid Schiff (PAS) staining was negative solution q12h. Two weeks later, following further progression for fungal elements. Prior to referral, amoxicillin clavulanic acid of the draining lesions on the abdomen, surgical debridement (Clavaseptin; Vétoquinol Canada), 13 mg/kg BW, PO, q12h, for and primary closure (PDS; Ethicon, Johnson and Johnson, 14 d, and enrofloxacin (Baytril; Bayer Canada), 5.2 mg/kg BW, Bridgewater, New Jersey, USA) with placement of Penrose PO, q12h for 7 d, were also added to the treatment.

40 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY

A B CASE REPORT CASE

Figure 2. A — The ventral abdomen of a 4.5-year-old female spayed domestic shorthair cat following a relapse of draining lesions representative of mycobacterial panniculitis. B — The ventral abdomen of the cat at a 7-month post-treatment follow-up.

Seven months after the initial presentation, the cat was cycline. Corynebacteria are Gram-positive bacilli that can be presented for a dermatologic opinion. On presentation, the cat cultured as normal flora from the cat (9). Anaerobic and fungal was found to be afebrile (37.4°C; RR: 36.7°C to 38.9°C) and in cultures were negative for growth. good body condition. No systemic clinical signs were reported The skin lesions continued to progress in the 4 wk following by the owner. Examination of the skin revealed firm, fibrotic initial presentation, leading to the development of approximately nodules on the lateral sides of the abdominal fat pad extending 10 new draining tracts on the ventral abdomen (Figure 2A). dorsally to the level of the lateral abdomen. There was palpable As mycobacterial culture results were still pending, an empiric edema of the right lateral abdomen, and the ventral abdomen change of antibiotics to pradofloxacin (Veraflox; Bayer Canada), displayed a few foci of ulceration consistent with early fistulous 7.7 mg/kg BW, PO, q24h, and doxycycline (Summit Veterinary tract formation. Cytologic examination of impressions from Pharmacy), 9.7 mg/kg BW, PO, q12h was started based on the the ventral abdomen, stained with a commercial modified poor response to initial treatments. Wright’s stain (DipQuick; Jorgensen Laboratories, Loveland, To culture for mycobacteria, the skin samples were pre- Colorado, USA) were assessed on 1003 oil immersion power treated with 1.5% KOH as a decontaminant before inoculating and revealed neutrophils and epithelioid histiocytes. An in-clinic separately onto modified Middlebrook 7H11 agar (with pyru- SNAP enzyme-linked immunosorbent assay (ELISA) for feline vate and glycerol), Stonebrink’s medium, Löwenstein–Jensen leukemia virus and feline immunodeficiency virus (IDEXX medium, and mycobacterium growth indicator tube (MGIT; Laboratories, Westbrook, Maine, USA) was negative. Becton Dickinson, Baltimore, Maryland, USA). After 5 d of Based on the finding of acid-fast bacilli and pyogranuloma- incubation at 37°C, substantial growth was observed on all tous inflammation on previous dermatohistopathology, deep media. Antimicrobial susceptibility testing as recommended tissue biopsies were collected for a macerated tissue culture to for nontuberculous mycobacteria (10) indicated susceptibil- attain a definitive diagnosis of mycobacterial panniculitis and ity to moxifloxacin (a third-generation fluoroquinolone) but target antibiotic treatment. For sample collection, the cat was resistance to doxycycline at an MIC of . 6 mg/mL. For spe- sedated with midazolam (Midazolam; Sandoz, Boucherville, cies identification, DNA from the isolate was extracted using Quebec), 0.2 mg/kg BW, IV, and butorphanol (Torbugesic; Quick-DNA kit (Zymo Research, Irvine, California, USA). Zoetis Canada), 0.2 mg/kg BW, IV, and anesthetized with The isolate was then sequenced at the 16S rRNA and the rpoB propofol (Propoflo 28; Zoetis Canada), 3.2 mg/kg BW, IV. regions of the genome, as it has been demonstrated that rpoB Pending the results of tissue culture and the suspected myco- gene sequencing provides higher discriminatory power to distin- bacterial etiology, the cat was started on antibiotic treatments guish nontuberculous mycobacteria species and subspecies (11). of marbofloxacin (Zeniquin; Zoetis Canada), 4.4 mg/kg BW, The gene sequences were deposited in GenBank and compared PO, q24h, and clarithromycin (Apo-Clarithromycin; Apotex, with known 16S rRNA and rpoB sequences using BLAST. The Toronto, Ontario), 11 mg/kg BW, PO, q12h. Prednisolone was 16S rRNA (825 bp) sequence had a 100% match with M. porci- gradually tapered with a 50% dose reduction every 2 wk until num and M. neworleansense (both members of the Mycobacterium it was stopped. fortuitum third biovariant complex). The sequence of the rpoB The skin samples were sent to a local reference laboratory gene (693 bp) showed a 99% match with M. porcinum. No for aerobic, anaerobic, and fungal cultures, and to a laboratory other identification methods were applied. Culture isolation specializing in the isolation of mycobacteria for mycobacterial and gene sequencing was performed by the National Veterinary cultures. Aerobic cultures were positive for Corynebacterium Services Laboratories, United States Agriculture Department in species, which was susceptible to both clarithromycin and doxy- Ames, Iowa, USA.

CVJ / VOL 61 / JANUARY 2020 41 FOR PERSONAL USE ONLY

In the ensuing weeks, pending the final mycobacterial culture like lymphadenitis (21). It was further characterized as being results, the cat’s draining tracts had resolved, and no new lesions similar to M. fortuitum in 1983 and deposited in the American were forming with the prescribed combination of pradofloxacin Type Culture collection (ATCC) as type strain ATCC 33776 and doxycycline. Additional susceptibility testing with prado- (22). Mycobacterium porcinum has since been further classified floxacin could not be performed by the testing laboratory at this as a member of the third biovariant group of the M. fortuitum time, but the isolate was susceptible in vitro to moxifloxacin complex, including 4 other isolates: M. boenickei, M. houstonense, (a human third-generation fluoroquinolone equivalent), and M. neworleansense, and M. brisbanense (23). Mycobacterium por- the patient was responding well to pradofloxacin. Pradofloxacin cinum infections in humans have been isolated from wounds, has been demonstrated to be effective for treatment of rapidly central catheter infections (with or without bacteremia), in growing mycobacteria (12). The isolate was resistant in vitro to pneumonitis, and in peritonitis associated with peritoneal dialysis doxycycline but the decision was made to continue the doxycy- (23–26). M. porcinum has also been isolated from bovine bulk RAPPORTCAS DE cline based on the patient’s positive progress and in an effort to milk supply, and infections have been linked to contaminated prevent relapse by continuing all treatments that had resulted in community and hospital water sources (24,27). Mycobacterium clinical improvement. Doxycycline was selected initially as it is porcinum has been previously isolated from 2 cats in Australia, commonly recommended to treat rapidly growing mycobacteria though not clinically characterized in the affected individuals (12). with a combination of one or more oral antibiotics due to poten- Atypical mycobacterial infections in cats can be seen at any tial for antimicrobial resistance to develop with fluoroquinolone age (range: 2 to 12 y) and there appears to be a predilection monotherapy (1,12,13). Interestingly, the susceptibility results for overweight females to be affected (4,28). As mycobacte- indicated susceptibility to the previously used clarithromycin, ria display a tropism for lipid-rich tissue, localization to the and an intermediate susceptibility to ciprofloxacin (spectrum of inguinal fat pad is observed in the preponderance of affected activity similar to marbofloxacin). The reason for the patient’s cats, as in this case (4). The distinguishing characteristic of all lack of response to the previous combination of antibiotics is Mycobacterium species are the thick, hydrophobic cell walls unknown, although immunosuppression from the initial empiric which are rich in mycolic acids and render the organisms acid- use of prednisolone may have played a role in the poor response fast when stained with Ziehl-Neelsen or Fite-Faraco stain (1). to marbofloxacin and clarithromycin. This highlights the impor- This cell wall provides a substantial contribution to the hardi- tance of ruling out infection before initiating empiric treatment ness of the organism, allowing survival within phagocytes, and with prednisolone, as glucocorticoids are contraindicated in the resulting in the typical granulomatous immune response by treatment of mycobacterial panniculitis. In general, very good hosts (1). When presented with a cat displaying 1 or more non- agreement has been observed in previous studies between in vitro healing abscesses localizing to the abdomen, especially those susceptibility testing and in vivo response to antimicrobials in failing to respond to standard antimicrobial therapy and wound the treatment of mycobacterial panniculitis in cats (14). management, mycobacterial panniculitis should be considered At both a 5-month and a 7-month follow-up, the cat had as a top differential diagnosis. If suspected, fine-needle aspirates residual alopecia, scarring, and palpable fibrotic bands within for cytology and biopsies for histopathology (including acid-fast the subcutis, but no appreciable nodules or draining tracts had staining), with macerated tissue cultures for aerobic, anaerobic, reformed (Figure 2B). Treatment of mycobacterial panniculitis fungal, and mycobacterial organisms should be pursued to is recommended for a minimum of 3 to 12 mo, with therapy obtain a definitive diagnosis and to rule out other subcutane- continuing at least 1 to 2 mo after affected tissues look and feel ous infections, such as deep mycosis. A more rapid identifica- completely normal (1,15). As such, treatment recommendations tion technique includes fine-needle aspiration of subcutaneous were to continue daily doxycycline and pradofloxacin therapy as nodules through previously disinfected intact skin, followed prescribed until another recheck scheduled 4 mo later. by inoculation of material directly into mycobacterial culture media or blood culture medium within a few minutes of sample Discussion collection (1). Cytological preparations of fine-needle samples Mycobacterial infections remain an uncommon cause of cuta- can also rapidly identify organisms with acid fast staining, or as neous infection in cats, however, international prevalence is “negative images” on modified Wright-stained (Diff-Quik) slides variable (4,13,14). Cats appear to be at greater risk of develop- (29). Owners should be counselled that some mycobacteria may ing infection with rapidly growing mycobacteria than other fail to be cultured, and this does not preclude mycobacterial domestic species, especially if involved in hunting or fight- infection (13,28). Additionally, acid-fast rods may be difficult ing, which can increase opportunities for wound inoculation to identify on histopathology, and have not been identified (4,14). The opportunistic rapidly growing mycobacteria more in some samples that later cultured positive for mycobacteria commonly identified in feline pyogranulomatous panniculitis (4,28). Reference laboratories with experience in the culture and include Mycobacterium smegmatis, M. fortuitum, M. chelonae, detection of mycobacteria should be selected (1,28). and M. phlei (1,5,15). Infections involving other rapidly growing Species identification and susceptibility data for rapidly grow- mycobacteria species have also been documented in cats, includ- ing mycobacteria can significantly impact antimicrobial selec- ing M. abscessus, M. flavescens, M. thermoresistibile, M. goodii, tion, and antibiotic resistance in rapidly growing mycobacteria M. mageritense, and M. alvei (12,16–20). is increasingly common (1,5). When a tentative diagnosis of Mycobacterium porcinum is a rarely encountered RGM, first mycobacterial panniculitis is made, it is advantageous to start isolated in 1973 from porcine lymph nodes showing tuberculosis- empirical antimicrobial treatment with one or more antibiotics

42 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY considered widely effective for rapidly growing mycobacteria 7. Weese JS, Fulford MB. Bacterial diseases. In: Weese JS, Fulford M, eds. prior to susceptibility results to avoid a progression of the condi- Companion Animal Zoonoses. 1st ed. Ames, Iowa, USA: Blackwell Publishing, 2011:164–173. tion (1). This involves consideration of the general susceptibility 8. Owen LJ. Surgical drains. In: Langley-Hobbs SJ, Demetrious J, patterns established by retrospective data for RGM. In general, Ladlow J, eds. Feline Soft Tissue and General Surgery. 1st ed. members of the M. fortuitum group are identified more com- Philadelphia, Pennsylvania: Elsevier/Saunders, 2014:117–123. 9. Older CE, Diesel A, Patterson AP, et al. The feline skin microbiota: The monly in North America but have a worldwide distribution; bacteria inhabiting the skin of healthy and allergic cats. PLoS ONE REPORT CASE previous characterizations of M. fortuitum infections indicate 2017;12:e0178555. they are often susceptible to clarithromycin and pradofloxacin 10. Clinical and Laboratory Standards Institute. Susceptibility testing of mycobacteria, nocardiae, and other aerobic actinomycetes; Approved (1,12,14,20). Treating at the high end of the antibiotic dosing Standard — 2nd ed. CLSI document M240A2. Wayne, Pennsylvania: range is recommended as subcutaneous tissues are not well- CLSI, 2011. perfused, and this may impact antimicrobial diffusion from 11. de Zwaan R, van Ingen J, van Soolingen D. Utility of rpoB gene sequencing for identification of nontuberculous mycobacteria in the the blood to organisms in the panniculus (1). Owners should Netherlands. J Clin Microbiol 2014;52:2544–2551. be prepared for a regimen of 1 or more antibiotics administered 12. Govendir M, Norris JM, Hansen T, et al. Susceptibility of rapidly over several months in the management of mycobacterial pan- growing mycobacteria and Nocardia isolates from cats and dogs to pradofloxacin. Vet Microbiol 2011;153:240–245. niculitis (1,14,30). Some experienced clinicians recommend 13. Gunn-Moore DA. Feline mycobacterial infections. Vet J 2014;201: en bloc surgical resection of affected tissue in correlation with 230–238. antimicrobial therapy, given that adequate levels of the antimi- 14. Malik R, Wigney DI, Dawson D, Martin P, Hunt GB, Love DN. Infection of the subcutis and skin of cats with rapidly growing myco- crobial agent may not be reached in the involved tissues (1,14). bacteria: A review of microbiological and clinical findings. J Feline Med However, animals treated in a preliminary fashion using oral Surg 2000;2:35–48. antibiotics can progressively respond to the extent that surgery 15. Ålander-Damsten YK, Brander EE, Paulin LG. Panniculitis, due to Mycobacterium smegmatis, in two Finnish cats. J Fel Med Surg 2003;5: can be avoided, or can then be focused on more localized recal- 19–26. citrant lesions if medical therapy has plateaued (1). Surgery 16. Jassies-van der Lee A, Houwers DJ, Meertens N, van der Zanden without appropriate antimicrobial therapy also risks the spread AGM, Willemse T. Localized pyogranulomatous dermatitis due to Mycobacterium abscessus in a cat: A case report. Vet J 2009;179:304–306. of lesions and subsequent relapse, as in this case. 17. Beccati M, Peano A, Gallo MG. Pyogranulomatous panniculitis caused In summary, some patients may require long-term antibiotic by Mycobacterium alvei in a cat. J Small Anim Pract 2007;48:664. therapy to maintain remission, and relapse may be seen following 18. Vishkautsan P, Reagan KL, Keel MK, Sykes JE. Mycobacterial pan- niculitis caused by Mycobacterium thermoresistibile in a cat. JFMS Open discontinuation of treatment (1,5). The prognosis for mycobacte- Rep 2016;2:1–7. rial panniculitis with rapidly growing mycobacteria is considered 19. Jang SS, Hirsh DC. Rapidly growing members of the genus guarded; however, this condition is becoming increasingly treat- Mycobacterium affecting dogs and cats. J Am Anim Hosp Assoc 2002;38: 217–220. able as molecular techniques enhance identification of organisms, 20. Horne KS, Kunkle GA. Clinical outcome of cutaneous rapidly grow- and our ability to recognize, diagnose, and manage this condition ing mycobacterial infections in cats in the south-eastern United States: continues to evolve and improve (1). This paper highlights a A review of 10 cases (1996–2006). J Feline Med Surg 2009;11:627–632. 21. Tsukamura M, Nemoto H. A taxonomic study of Mycobacterium intra- patient with a good response to treatment following a definitive cellulare isolated from swine. Jpn J Microbiol 1973;17:91–98. diagnosis of the infection, and provides clinical characterization 22. Tsukamura M, Nemoto H, Yugi H. Mycobacterium porcinum sp. nov., a of a genetically confirmed M. porcinum infection in a cat. porcine pathogen. Int J Syst Bacteriol 1983;33:162–165. 23. Han XY, Dé I, Jacobson KL. Rapidly growing mycobacteria: Clinical Acknowledgments and microbiologic studies of 115 cases. Am J Clin Pathol 2007;128: 612–621. The authors thank the National Veterinary Services Laboratory 24. Brown-Elliott BA, Wallace RJ, Tichindelean C, et al. Five-year out- in Ames, Iowa for assistance with isolation of this organism. The break of community- and hospital-acquired Mycobacterium porcinum infections related to public water supplies. J Clin Microbiol 2011;49: authors also thank the patient’s owners for their permission to 4231–4238. share photographs in the publication of this novel infection. 25. Wallace RJ, Brown-Elliott BA, Wilson RW, et al. Clinical and labo- ratory features of Mycobacterium porcinum. J Clin Microbiol 2004; CVJ 42:5689–5697. 26. Patil R, Patil T, Schenfeld L, Massoud S. Mycobacterium porcinum References peritonitis in a patient on continuous ambulatory peritoneal dialysis. 1. O’Brien CR, Fyfe JA, Malik R. Mycobacterial infections. In: Greene CE, J Gen Intern Med 2011;26:346–348. ed. Infectious Diseases of the Dog and Cat. 4th ed. St. Louis, Missouri: 27. Taddei R, Barbieri I, Pacciarini ML, Fallacara F, Belletti GL, Arrigoni N. Elsevier/Saunders, 2012:515–521. Mycobacterium porcinum strains isolated from bovine bulk milk: 2. Miller WH, Griffin CE, Campbell KL. Mycobacterial infections. Implications for Mycobacterium avium subsp. paratuberculosis detec- In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, tion by PCR and culture. Vet Microbiol 2008;130:338–347. Missouri: Elsevier, 2013:207–212. 28. Gunn-Moore DA, McFarland SE, Schock A, et al. Mycobacterial dis- 3. Machado G, Gressler LT, Siqueira FM, Balzan C, Brum JS, de Vargas ease in a population of 339 cats in Great Britain: II. Histopathology of AC. Bovine pyogranulomatous mastitis caused by Mycobacterium goodii. 225 cases, and treatment and outcome of 184 cases. J Feline Med Surg JMM Case Reports 2015;2:e004150. 2011;13:945–952. 4. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Opportunistic mycobacte- 29. Maygarden SJ, Flanders EL. Mycobacteria can be seen as “negative rial infection caused by rapidly growing mycobacteria. In: Skin Diseases images” in cytology smears from patients with acquired immunodefi- of the Dog and Cat: Clinical and Histopathologic Diagnosis. 2nd ed. ciency syndrome. Mod Pathol 1989;2:239–243. Oxford, UK: Blackwell Science, 2005:283–288. 30. García-Agudo L, García-Martos P. Clinical significance and antimicro- 5. Lemarie SL. Mycobacterial dermatitis. Vet Clin North Am Small Anim bial susceptibility of rapidly growing mycobacteria. In: Vilas-Méndez Pract 1999;29:1291–1301. A, ed. Science Against Microbial Pathogens: Communicating Current 6. Phan TA, Relic J. Sporotrichoid Mycobacterium marinum infection of Research and Technological Advances. 1st ed, Vol 1. Badajoz, Spain: the face following a cat scratch. Australas J Dermatol 2010;51:45–8. Formatex Research Center, 2010:363–377.

CVJ / VOL 61 / JANUARY 2020 43 FOR PERSONAL USE ONLY Case Report Rapport de cas

Diagnostic imaging of a basihyoid bone fracture and partial avulsion of the medial pterygoid muscle in a horse

Brittany Veerasammy, Massimo Delli-Rocili, Monica Jensen, Nicola Cribb, Alex zur Linden

Abstract — A 3-year-old gelding was presented for further evaluation and treatment of a swelling over the left mandible and inability to eat and drink. Radiographs of the mandible were unremarkable. Computed tomography (CT) of the head demonstrated a fracture of the basihyoid bone and partial avulsion of the medial pterygoid muscle. Ultrasound examination was performed to establish a baseline and confirmed the fracture. The gelding was managed conservatively, recovered uneventfully, and was able to return to training after 4 months of rest. Key clinical message: Computed tomography and ultrasonography in the horse provided information about injury to the basihyoid bone and insertion of the medial pterygoid muscle.

Résumé — Diagnostic par imagerie d’une fracture de l’os basihyoïde et avulsion partielle du muscle ptérygoïde médial chez un cheval. Un cheval hongre âgé de 3 ans fut présenté pour évaluation et traitement d’enflure du mandibule gauche et inhabilité à manger et à boire. Des radiographies du mandibule ne montraient rien de particulier. La tomodensitométrie (CT) de la tête a montré une fracture de l’os basihyoïde et une avulsion partielle du muscle ptérygoïde médial. Une échographie fut effectué afin d’établir un seuil de base et confirmer la fracture. L’hongre a été géré de manière conservatrice, a récupéré sans complication, et a pu retourner à l’entraînement après 4 mois de repos. Message clinique important : La tomodensitométrie et l’échographie chez un cheval ont fourni de l’information sur une blessure à l’os basihyoïde et à l’insertion du muscle ptérygoïde médial. (Traduit par Dr Serge Messier) Can Vet J 2020;61:44–48

ractures of the hyoid apparatus are unusual in the horse. end articulates with the ceratohyoid bone (4). The caudal border F One case of a fracture of the lingual process of the basihy- carries on either side the thyrohyoid bone, and the rostral border oid bone has been reported (1). That horse displayed abnormal carries the lingual process. The basihyoid, lingual process, and behavior and headshaking when ridden. The lingual process thyrohyoid bones are fused and have been compared to a fork was removed surgically, and the horse recovered. More fre- with a short handle (4). The paired genioglossus and geniohy- quently, fractures of the stylohyoid bone have been reported oideus muscles act upon the basihyoid bone to pull it rostrally. (2). This diagnosis is often associated with temporohyoid The sternohyoideus muscle inserts on the basihyoid bone and osteoarthropathy, which can be associated with neurological and lingual process and, in combination with the sternothyroideus non-­neurological signs (3). To our knowledge, a fracture of the muscle, pulls the basihyoid bone caudally (5). In horses it is body of the basihyoid bone has not been previously reported. thought that the net effect of caudal and rostral traction on The basihyoid bone acts as a point of attachment for the the basihyoid bone is to produce a ventral displacement of the genioglossus, geniohyoideus, sternohyoideus, and sternothyor- basihyoid bone (5). When this occurs, the lateral muscles of oideus muscles that increase the diameter of the nasopharynx. the nasopharynx expand slightly to increase airway patency (5). Consisting of a short transverse bar compressed dorsoventrally, Extrinsic muscles that attach to the basihyoid bone also con- the basihyoid bone is part of the hyoid apparatus and at each trol movement of the tongue and epiglottis. The geniohyoideus

Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario N1G 2W1. Address all correspondence to Dr. Brittany Veerasammy; e-mail: [email protected] Dr. Veerasammy’s current address is North Carolina State College of Veterinary Medicine, 1060 William Moore Drive, Raleigh, North Carolina, 27606 USA. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

44 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY muscle protrudes the tongue. The hyoglossus muscle, which Several attempts made by the horse to drink water were originates in part on the lingual process of the basihyoid bone observed and much of the water was seen to come back out and inserts on the dorsum of the tongue, retracts and depresses of the mouth. Upon offering pelleted feed and hay, it was also the base of the tongue (5). The bilobed hyoepiglotticus muscle, noted that the horse was unable to prehend and masticate the which originates on the basihyoid bone and inserts on the ven- material. tral border of the epiglottis, depresses the epiglottis ventrally and Head radiographs were performed under sedation with xyla- REPORT CASE increases the dimensions of the upper airway (6). zine (Rompun; Bayer Animal Health, Mississauga, Ontario), The medial pterygoid muscle occupies a position on the 0.5 mg/kg BW, IV, and butorphanol (Torbugesic; Zoetis Animal medial aspect of the ramus of the mandible, similar to that of Health, Kirkland, Quebec), 0.1 mg/kg BW, IV, and included the masseter laterally. It originates from the pterygoid fossa lateral projections of the whole head, a ventrodorsal projec- of the sphenoid bone and inserts on the medial aspect of the tion of the rostral skull, a right ventral to left dorsal oblique mandible (7). It acts together with other muscles to raise the projection to highlight the left mandible, and paired oblique mandible and singly to produce lateral movement of the jaw projections of the temporomandibular joints (rostral 45° ventral (8). To the best of our knowledge, avulsion of this muscle has 30° lateral, caudal dorsal lateral oblique) (11). At the ventral not been previously described in the horse. aspect of the left ramus of the mandible there was a moderate Computed tomography, radiography, endoscopy, and ultra- soft tissue swelling without evidence of bony trauma to explain sonography have all been used to assess structures of the hyoid the clinical findings. apparatus (8). Radiography and endoscopy are reported to The horse did not object to opening of the mouth for an be useful for the dorsal structures of the hyoid apparatus (9), oral examination. However, manipulation of the tongue was and ultrasonography has been described to image the ventral resented. A laceration of the left gingival margin on the buccal parts of the apparatus including the lingual process and the side of the maxilla was seen at the level of tooth 207, which was base of the basihyoid bone (10). Computed tomography is a thought to account for the blood dripping from the mouth. cross-sectional imaging modality that allows us to eliminate the An intravenous catheter was placed in the right jugular vein variable of superimposition, which is a major factor in imaging and the gelding was administered intravenous fluids (lactated this anatomical area. As such, it identifies many abnormali- Ringer’s solution; Baxter, Mississauga, Ontario) at a maintenance ties that may be missed with endoscopy, ultrasonography, or rate of 2 mL/kg BW per hour overnight to maintain hydration. radiology. Computed tomography offers the most comprehen- Five days of treatment with flunixin meglumine (Banamine; sive assessment of the bony structures and articulations and Merck Animal Health, Kirkland, Quebec), 1.1 mg/kg IV, allows treatment strategies to be more curtailed to individual q12h, sodium penicillin G (Procillin; Bimeda, Cambridge, horses (8). Ontario), 22 000 IU/kg BW, IV, q6h, and trimethoprim- This report describes the clinical presentation, diagnostic sulfa (Tribrissen; Merck Animal Health), 24 mg/kg BW, IV, imaging, and treatment of a fractured basihyoid bone and partial q12h, was initiated. Cold compresses were applied to the facial avulsion of the medial pterygoid muscle in a horse. swelling every 4 h along with diclofenac (Surpass; Boehringer Ingelheim, Burlington, Ontario), which was applied topically Case description 4 times daily to the affected area. The horse was offered soaked A 3-year-old, 560-kg, Thoroughbred gelding was presented to pelleted feed only overnight due to the dysphagia seen on the Ontario Veterinary College, Health Sciences Centre (OVC- presentation. HSC) for further evaluation and treatment of a swelling over The hind pastern laceration was explored and radiographed the left mandible. The morning of presentation, the gelding was and determined not to involve any structures other than skin. found in the stall having difficulties eating and drinking, pos- It was bandaged daily throughout the period of hospitalization. sibly having been cast overnight. Mild hemorrhage was observed The following day, the facial swelling had decreased signifi- coming from the mouth. The gelding was administered an cantly, and the horse tolerated palpation of this area. The horse antibiotic [procaine penicillin 10 000 IU/kg body weight (BW), was now able to drink water and the ability to prehend soaked IM] and an analgesic (flunixin meglumine, 1.1 mg/kg BW, IV) pelleted feed was improved. However, the time taken to finish by the referring veterinarian. the ration was subjectively prolonged. Upon presentation to the OVC-HSC, the horse was anxious Videoendoscopic examination of the guttural pouches but all vital parameters were within normal limits. The horse revealed a smaller space than usual within the medial compart- appeared clinically well hydrated despite having difficulties ment of the left guttural pouch, suggestive of external com- drinking water. Significant firm swelling was noted on the head pression on the medial and ventral walls. The endoscope was extending from the caudal border of the left mandible to the subsequently placed inside the mouth and the area of disruption facial crest. The horse was mildly averse to palpation of the swol- of the mucosa on the buccal side of the left mandible was again len area and blood was dripping from the mouth. The left eye observed. The bleeding had ceased by this time. appeared sunken due to the swelling and a moderate blepharitis As a result of the decreased masticatory function, the previ- was present. The left eye was stained with fluorescein to assess ous inability of the horse to swallow water, the external swell- for ulcers and was negative to uptake. A small laceration was ing noted alongside the medial wall of the guttural pouch, present on the medial aspect of the right hind pastern. No other and the laceration of the gingival margin, a fracture of the abnormalities were detected during the physical examination. mandible and/or a bone of the hyoid apparatus was suspected.

CVJ / VOL 61 / JANUARY 2020 45 FOR PERSONAL USE ONLY RAPPORTCAS DE

Figure 2. 3D reformatted CT images of the hyoid apparatus Figure 1. Computed tomography images of the head in demonstrating the right-sided basihyoid bone fracture that is a bone algorithm and bone window (WW 700, WL 3740). minimally displaced. A — Dorsal view with rostral at the top of the A — Transverse image at the level of the basihyoid bone that has image and the right side of the mandible on the right side of a complete, minimally displaced fracture on the right side (white the image. B — Rostral view with the right side of the patient arrow). B — Dorsal reformatted image at the level of the basihyoid on the left side of the image. bone that shows a complete fracture of the right side of the basihyoid bone (white arrow). C — Transverse image at the level of fourth premolars. A mild amount of gas is present in the buccal soft tissues (white arrowhead) overlying tooth 308, with a mildly irregular periosteum of the left mandible (small black arrow). The soft tissues on the ventrolateral aspect of the left ramus of the left cheek is mildly to moderately thickened (*) compared to the mandible were mildly uniformly thickened (6.5 cm thickness right side. A small amount of mucus is present in the left rostral compared to 4.5 cm on the right) (Figure 1C). Multifocally in maxillary sinus (X). D — Small avulsion fracture (black arrow) at the ventromedial aspect of the left mandible, at the insertion of the soft tissues from the first cheek tooth (306) to the ramus the medial pterygoid muscle. of the mandible there was a mild amount of gas and numerous tiny bubbles, and several hypodense areas in the soft tissues Computed tomography was elected to completely evaluate the that did not contrast enhance (Figure 1C). Adjacent to this gas, deep oropharyngeal and laryngeal structures and acquire greater the periosteal surface of the mandible was mildly roughened. detail of structures previously assessed. With each day during This thickened tissue exhibited mild homogenous contrast hospitalization, the horse slowly regained masticatory function enhancement. as the facial swelling decreased. The mineralized fragment on the medial aspect of the right Two days after presentation, a CT examination of the head ramus was consistent with a partial avulsion of the medial under general anesthesia was performed. Xylazine (Rompun; pterygoid muscle. The gas in the soft tissues was thought to be Bayer Animal Health), 0.5 mg/kg BW, IV was administered as most likely secondary to the oral laceration. Given the suspected premedication. General anesthesia was induced with ketamine trauma, the soft tissue thickening was thought to indicate cel- (Vetalar; Bioniche, Belleville, Ontario), 2 mg/kg BW, IV, lulitis or edema, and the periosteal roughening on the lateral and guaifenesin (Sedivet; Boehringer Ingelheim, Burlington, aspect of the ramus was consistent with reactive periostitis. Ontario), 0.1 mg/kg BW, IV. An endotracheal tube was placed Two days after the CT scan an ultrasonographic evaluation of and anesthesia was maintained with inhalant isoflurane. The the fracture was performed to provide a baseline for follow-up horse was positioned in dorsal recumbency for the CT scan evaluation (Figure 3). The right aspect of the basihyoid bone (16-slice detector, GE Brightspeed CT scanner, GE Healthcare, was fractured, with mild overriding displacement (0.3 cm) Milwaukee, Wisconsin, USA). The CT study revealed a mini- (Figure 3A). A small focal hypoechoic region was noted adjacent mally displaced fracture of the right side of the basihyoid bone to the fracture, consistent with edema. A small mineralized with sharp margins (Figures 1A, B; Figure 2). On the medial fragment was located on the medial aspect of the ramus of the aspect of the left ramus of the mandible a small (3 3 5 mm), mandible ventrally (0.5 cm in length), consistent with the small triangular, mineralized fragment was present adjacent to the avulsion fragment noted on the CT (Figure 3B). The soft tissues insertion of the left medial pterygoid muscle (Figure 1D). The on the ventrolateral aspect of the left ramus of the mandible

46 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY CASE REPORT CASE

Figure 3. Ultrasound image of the basihyoid bone in a transverse plane with the right side of the image corresponding with the right side of the patient (A) and the medial aspect of the left mandible in a transverse plane with the left side of the patient at the left side of the image (B). The right side of the basihyoid bone has a small step defect (white arrow) and is mildly overriding. Ventral to this fracture is a focal hypoechoic region in the soft tissues, consistent with edema. A small avulsion fragment of the medial aspect of the left mandible is present in the soft tissues (between the measurement calipers).

were mildly uniformly thickened and hypoechoic consistent reported tongue function to be excellent. Further evaluation with edema and/or cellulitis. A small, medially rounded, soft with ultrasound or CT examination at the OVC-HSC was tissue dense and non-contrast enhancing nodule was noted at offered but declined. the lateral aspect of the rostral maxillary sinus that was primarily The horse went back into training at this time. A telephone attributed to mucus. consultation with the referring veterinarian 10 mo after dis- charge revealed that the horse trained well, without any evi- Treatment dence of upper airway abnormalities including noise or exercise The gelding recovered uneventfully from the CT scan and intolerance. No difficulties eating or drinking were observed at was discharged after 6 d of hospitalization. A 7-day course of any point. The horse raced once and placed third but was then trimethoprim sulfamethoxazole (Tribrissen, 160 mg/800 mg; retired from racing due to an unrelated orthopedic issue. The Merck Animal Health) was selected for continued treatment of left mandible remained thickened compared to the right, but the hind limb laceration and the facial swelling. A tapering dose no clinical problems were associated with it. of phenylbutazone (Buzone 1 g tablet; Vétoquinol, Lavaltrie, Quebec) was given twice daily for 3 d and then once daily for Discussion another 3 d, to provide an anti-inflammatory drug and analgesia Computed tomography and ultrasonography were effective for the fracture. in diagnosing a fracture of the basihyoid bone and avulsion The owner and referring veterinarian were instructed to of the medial pterygoid muscle in the horse reported herein. keep the horse on stall rest for 3 to 4 mo and allow turnout Computed tomography is particularly useful in the head where into a small paddock, provided that the horse was quiet. In the the anatomy is complex and there is superimposition of bone, short-term, 3 to 4 wk of stall rest was recommended to allow soft tissues, and gas-filled structures (8). It has been used the wound on the pastern to heal. Short, hand-walks could to assess the hyoid apparatus of the horse in both research also be given for about 10 min twice a day until the follow-up and clinical settings (8,12). Previously, CT has been used for ultrasound 12 wk from the date of discharge. Diet consisted of diagnosis of stylohyoid and lingual process fractures as it is primarily mashes made up of a complete pelleted feed for the able to scan in both longitudinal and transverse planes (1,2). first wk. Hay ration was to be increased gradually provided that To our knowledge, muscle avulsion has not previously been no signs of quidding, decreased appetite, or difficulty masticat- diagnosed by means of CT of the head, but multiple other ing were observed. reports of diagnosis of soft tissue abnormalities of the head The local veterinarian performed a repeat ultrasound exami- of the horse exist (8). Ultrasonography has previously been nation 13 wk after discharge from the OVC-HSC. The basi- reported as useful for assessment of the ventral hyoid appa- hyoid bone could not be fully assessed as the veterinarian was ratus (10). It is recommended that a microconvex transducer using a linear transducer with a footprint that was too wide to be used to enable good skin contact and to be able to place achieve adequate skin contact. The veterinarian noted at this the instrument at right angles intermandibularly. Evidence time that the mandible was still thickened but it was difficult of the medial pterygoid avulsion fracture was also seen on to distinguish bony from soft tissue swelling. The veterinarian ultrasonography.

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In retrospect, the authors have considered whether the diag- of healing is unknown in this case without follow-up diagnostic nosis could have been made without the use of CT. This would imaging. However, the absence of the aforementioned clinical have eliminated the need for general anesthesia. While it is pos- signs and the ability of the horse to place in a race suggest that sible that it could have, the rarity of the fracture and the lack conservative management was an appropriate choice. of specificity of the clinical signs did not point exclusively to a In conclusion, CT and ultrasonography were effective in fracture of this location. Therefore the CT had a useful role as diagnosing a fracture of the basihyoid bone and avulsion of the a survey tool in this case. In addition, the diagnosis could have medial pterygoid muscle in the horse. Conservative management been made using CT alone in this case, which is more time resulted in a favorable outcome in this horse. efficient and sometimes less costly than using a ­combination of other diagnostic imaging techniques. Furthermore, the authors Acknowledgments consider it most likely that a CT scan would have been war- The authors gratefully acknowledge Dr. Andre Macko and RAPPORTCAS DE ranted even if the diagnoses had been made initially on ultra- Dr. Sarah Shaw for their contributions to this case. CVJ sonography to ensure there was no other trauma sustained to other structures of the head. References The final diagnosis correlates well with the clinical signs. 1. Rohwerder B, Buss A, Boening KJ. Computed tomographic diagnosis: Traumatic lingual process fracture and surgical resection. Equine Vet The reluctance to masticate can be explained by trauma to the Educ 2017;29:589–593. medial pterygoid muscle, which is involved in the movements 2. Chalmers HJ, Cheetham J, Dykes NL, Ducharme NG. Computed required for mastication (4). It is also possible that the horse was tomographic diagnosis — Stylohyoid fracture with pharyngeal abscess in a horse without temporohyoid disease. Vet Radiol Ultrasound reluctant to eat due to pain on swallowing emanating from the 2006;47:165–167. fractured basihyoid bone. The lingual process emanating from 3. Walker AM, Sellon DC, Cornelisse CJ, et al. Temporohyoid osteo- basihyoid bone is embedded in the root of the tongue and it is arthropathy in 33 horses (1993–2000). J Vet Intern Med 2002;16: 697–703. possible that the action of swallowing would create movement 4. Sisson S. Equine myology. In: Sisson and Grossman’s The Anatomy of of the fracture. Pain on swallowing has been described as a the Domestic Animals. 5th ed. Vol 1. Toronto, Ontario: WB Saunders, symptom in humans with fracture of the basihyoid bone (13). 1975:376–453. 5. Ducharme NG, Cheetham J. Pharynx. In: Equine Surgery. 5th ed. St. The pain on manipulation of the tongue, as noted on physical Louis, Missouri: Elsevier, 2018. examination, is also likely related to this. 6. Holcombe SJ, Cornelisse CJ, Berney C, Robinson EN. Electromyo­ The displacement of the medial and ventral wall of the gut- graphic activity of the hyoepiglotticus muscle and control of epiglottis position in horses. Am J Vet Res 2002;63:1617–1621. tural pouch may have been due to swelling in the region. 7. Kuryszko JK, Lyczewska-Mazurkiewicz S. Equine masticatory organ Healing from conservative management has been reported in Part III. Acta Bioeng Biomech 2004;6:25–31. previous reports of hyoid bone fractures. In the report of the lin- 8. Manso-Díaz G, Garcia-Lopez JM, Maranda L, Taeymans O. The role of head computed tomography in equine practice. Equine Vet Educ gual process fracture, healing tissue was noted histologically on 2015;27:130–145. the end of the removed fragment (1). Conservative management 9. Hilton H, Puchalski SM, Aleman M. The computed tomographic is also employed in fractures of the hyoid apparatus in humans appearance of equine temporohyoid osteoarthropathy. Vet Radiol Ultrasound 2009;50:151–156. (13). Fixation of the hyoid apparatus has been described in cows, 10. Chalmers HJ, Cheetham J, Yeager AE, Ducharme NG. Ultrasonography following splitting of the basihyoid bone surgically to access of the equine larynx. Vet Radiol Ultrasound 2006;47:476–481. the pharynx. A stainless-steel suture was used in the stabiliza- 11. Ebling AJ, McKnight AL, Seiler G, Kircher PR. A complementary radiographic projection of the equine temporomandibular joint. Vet tion in that situation (14). In the horse reported herein, it was Radiol Ultrasound 2009:385–391. considered that the fracture margins were in close enough prox- 12. Cornelisse CJ, Rosenstein DS, Derksen FJ, Holcombe SJ. Computed imity that secondary bone healing would take place. Potential tomographic study of the effect of a tongue-tie on hyoid apparatus position and nasopharyngeal dimensions in anesthetized horses. Am J complications that could have developed had healing not taken Vet Res 2001;62:1865–1869. place include exercise intolerance and upper respiratory noise 13. Gupta R, Clarke D, Wyer P. Stress fracture of the hyoid bone caused by from a decreased airway diameter due to improper anatomy or induced vomiting. Ann Emerg Med 1995;26:518–521. 14. Gaughan EM, Provo-Klimek J, Ducharme NG. Surgery of the bovine functioning of the basihyoid bone. Problems with swallowing respiratory and cardiovascular systems. In: Farm Animal Surgery. 1st ed. and mastication may also have been apparent. The actual degree St. Louis, Missouri: Saunders, 2004:141–159.

48 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Case Report Rapport de cas

Intravenous lipid emulsion to treat suspected cocaine toxicosis in a dog

Kirsty Royle, Carsten Bandt

Abstract — A 6-month-old puppy was treated for suspected cocaine toxicosis. Supportive care was initiated but clinical signs worsened and treatment with intravenous lipid emulsion (ILE) was instituted. Clinical signs rapidly resolved in response to treatment with ILE.

Résumé — Émulsion lipidique intraveineuse pour traiter une suspicion de toxicose à la cocaïne chez un chien. Un chiot âgé de 6 mois fut traité pour une suspicion de toxicose à la cocaïne. Un traitement de support fut initié mais les signes cliniques se sont aggravés et un traitement avec une émulsion lipidique intraveineuse (ILE) fut mis en place. Les signes cliniques se sont rapidement résolus en réponse au traitement avec ILE. (Traduit par Dr Serge Messier) Can Vet J 2020;61:49–52

ntravenous lipid emulsion (ILE) has been used to treat a ILE are also important in determining whether ILE would be I variety of toxicoses in both humans and animals. These beneficial (2,14). toxicants include local anesthetics and other lipophilic drugs, To the authors’ knowledge, there are no previous reports on such as lidocaine, bupivacaine, ivermectin, baclofen, synthetic the use of ILE in domestic animals in a case of cocaine toxicosis. cannabinoid, bromethalin, moxidectin, ibuprofen, naproxen, permethrin, diltiazem, and 25 hydroxyvitamin D (1–12). Case description Cocaine is both a local anesthetic and a lipophilic drug, with A 6-month-old male intact German shepherd cross dog weigh- a log P of 2.28 (13). Given these properties it is reasonable to ing 18.2 kg was presented to the emergency service for suspected think that ILE would be beneficial in cases of cocaine toxicosis. illicit drug toxicosis. The patient was described to be previously Log P is the octanol water partition coefficient of a drug in the healthy. He had been out on a walk approximately 30 min neutral form. This has been shown, in humans and in animal before presentation. He was not observed to have ingested any- models, to be a good predictor of the efficacy of ILE to treat a thing on the walk, but he is a scavenger and there was a history drug overdose. Generally, drugs with Log P . 1 are thought to of needles and syringes with suspected illicit drugs in the area be lipophilic. Other factors that are thought to contribute to in which he was walked. On arriving home from the walk he the partitioning effect and lipophilicity of a drug include the became restless and was pacing and panting excessively. He was pH of the drug and electrostatic interactions with the negatively presented to the emergency service. charged phospholipid layer of the ILE. Intravenous lipid emul- On presentation he was pyrexic (40.1°C), mildly tachycardic sion has been shown to be helpful in toxicities caused by drugs (heart rate 160 beats/min) and hypertensive [blood pressure with a low log P (such as baclofen and N-methylamphetamine) 181/153 (166) mmHg] (Cardell Veterinary Monitor; Midmark, so these alternative factors determining the lipophilicity of Tampa, Florida, USA). He was bright and alert but was noted to a drug as well as some of the other mechanisms of action of be agitated and restless. Mild ptyalism was present. Neurological examination revealed bilateral mydriasis with decreased pupil- lary light reflexes; there was no ataxia and no other neurological Canada West Veterinary Specialists, 1988 Kootenay Street, deficits. No tremors were observed. Urine was collected via Vancouver, British Columbia V5M 4Y3. a urinary catheter for a urine drug screen (Rapid Response, Address all correspondence to Dr. Carsten Bandt; e-mail: 1 panel, Drugs of Abuse; BTNX, Markham, Ontario). The urine [email protected] drug screen was positive for cocaine and phencyclidine (PCP). The authors have no affiliations or financial involvement with A complete blood (cell) count (CBC), chemistry panel, elec- any organization or entity with a financial interest in, or in trolytes, and blood gas were found to be within normal limits financial competition with, the subject matter or materials (True North Veterinary Diagnostics, Langley, British Columbia; discussed in this article. ABL 800 Flex; Radiometer, London, Ontario). An 18-gauge IV Use of this article is limited to a single copy for personal study. catheter was placed (18GA 1.16IN; Becton Dickinson Infusion Anyone interested in obtaining reprints should contact the Therapy Systems, Sandy, Utah, USA) and the dog was started CVMA office ([email protected]) for additional on balanced isotonic crystalloid solution (Isolyte S; B. Braun of copies or permission to use this material elsewhere. Canada, Scarborough, Ontario) at 62 mL/h [after a 10 mL/kg

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body weight (BW) fluid bolus]. Emesis was not induced due to to have poor systemic bioavailability when given orally. In this the severity of his agitation. Maropitant citrate (Cerenia; Zoetis, study comparing oral and intravenous administration of cocaine Kirkland, Quebec), 1 mg/kg BW, IV, was given to prevent the area under the plasma time concentration curve was 4 times vomiting associated with activated charcoal administration. The higher for intravenous compared to oral administration (23). dog was offered 2 g/kg BW activated charcoal, mixed with a few Treatment for cocaine toxicosis is supportive, there is no tablespoons of food (Charac-50; Omega Laboratories, Montreal, reversal agent. Treatments used in the management of cocaine Quebec) which he readily ingested. This was repeated every 6 h toxicosis are varied and include benzodiazepines, calcium for 2 additional doses. The pyrexia resolved after 3 h of fluids. channel blockers, nitric oxide-mediated vasodilators, a and His heart rate improved to 132 beats/min at this time, but he b-blockers, a2-agonists, antipsychotics, ILE, and sedatives, remained hypertensive with a blood pressure of 186/118 (132) such as propofol (15,24). mmHg. At this time he seemed less agitated and had settled in Despite the common usage reported in humans there are RAPPORTCAS DE a dark and quiet environment. only infrequent reports of cocaine toxicosis in domestic pets Six hours after presentation he became agitated again. This in the literature (15–17). There are some published studies of coincided with shift change and the ICU becoming much busier experimental canine models of cocaine toxicosis (25,26). and louder. He developed ataxia and fine head tremors and The largest case series evaluating suspected cocaine toxico- some facial twitching was noted. Bilateral mydriasis remained. sis in domestic animals included 19 dogs. The prevalence of The dog developed a marked sinus tachycardia, especially suspected cocaine toxicosis in that study was 0.03% of total when stimulated (up to 190 beats/min). His rectal tempera- cases presenting to the ER. In these cases, similar clinical signs ture increased to 39°C. A urine drug screen was repeated and were reported and included hyperexcitability, muscle trem- remained positive for cocaine, but was now negative for PCP. ors, seizures, ataxia, altered mentation, excessive vocalisation, His intravenous fluid rate was increased to 120 mL/h. He was mydriasis, hypersalivation, vomiting, tachycardia, hyperthermia, given 1 dose of methocarbamol (Methocarbamol 100 mg/mL; and hypertension. Sixteen of the 19 dogs were hospitalized for Summit Veterinary Pharmacy, Aurora, Ontario), 50 mg/kg treatment, which included fluid therapy, activated charcoal, BW, IV, with no improvement in his clinical signs. Given the benzodiazepines, phenobarbital (1 patient received a load- progressive clinical signs, treatment with ILE (Intralipid 20%; ing dose), acepromazine, mannitol, esmolol, and propofol Fresenius Kabi Canada, Toronto, Ontario) was started. He was (2 patients received constant rate infusions). All patients sur- administered a bolus of ILE, 2 mL/kg BW over 1 min, followed vived to discharge, although 1 was discharged against medical by a constant rate infusion of 0.25 mL/kg BW per min for advice. The median length of hospitalization was 15 h (range: 30 min. Within 15 min of starting the ILE the dog was noted 10 to 30 h). Two patients still had clinical signs at the time of to have normal mentation and resolution of the agitation. No discharge (15). lipemia was noted in the serum after treatment with ILE. A few Intravenous lipid emulsion has been described with increas- hours after starting the ILE he was noted to be normal with no ing frequency for use in multiple toxicoses in human and further ataxia or tremors. He was discharged a few hours later veterinary medicine. The mechanisms of action of ILE have with no ongoing concerns. been previously described in detail elsewhere and are thought to be multifactorial. These include the creation of a “lipid sink” Discussion which sequesters lipophilic drugs into this lipid compartment, Cocaine is an illicit drug that has previously been reported to improves cardiovascular function via the provision of an energy cause toxicosis in domestic pets (15–17). It is a Schedule 1 drug substrate for the myocardium, and increases intracellular calcium under the Canadian Controlled Drugs and Substances Act (18). levels (2,3,9,12–14). Intravenous lipid emulsion has previously Results from the Canadian Tobacco and Alcohol Drugs Survey been documented for use with local anesthetic toxicoses causing reveal that cocaine is the third most commonly abused substance cardiovascular instability (9,10,12) as well as other lipophilic after alcohol and marijuana (18). The reported incidence of drugs previously listed. Myocardial mitochondria are known cocaine use in the survey was 2% of the population in 2017 to be impaired with cocaine toxicosis so this increase in energy (this is increased from 1% of the population in the 2015 survey) substrate for the mitochondria may be an important component (19). Cocaine is available as a white powder that is insufflated or of how ILE works in cocaine toxicosis (22). injected, or as a freebase form, known as “crack” cocaine, which Adverse effects related to ILE are uncommon. Reported can be smoked or injected (18). At lower doses cocaine inhibits adverse effects include hyperlipidemia, pancreatitis, corneal catecholamine reuptake at sympathetic nerve terminals caus- lipidosis, hemolysis, fluid overload, hypersensitivity, and phle- ing stimulation of the sympathetic nervous system. At higher bitis. In humans, other adverse effects include Acute Respiratory doses cocaine acts like a local anesthetic (class I anti-arrhythmic Distress Syndrome (ARDS), acute kidney injury, embolism, agent) by blocking myocardial sodium and potassium (adenosine fat overload syndrome (hyperlipidemia, hemolysis, jaundice, triphosphate) channels causing cardiovascular depression and seizures, prolonged clotting time, thrombocytopenia), and sepsis vasodilation (13,20,21). It also causes cardiovascular mitochon- secondary to contamination of the bag or delivery system. It is drial dysfunction and long-term cardiovascular damage (22). also possible that ILE may interfere with the activity of lipid The half-life of cocaine in a dog model after oral administra- soluble medications that the patient is receiving (2,3). tion of 4 mg/kg BW of cocaine was 85.2 min with peak plasma There are several rat models in which the effect of ILE on levels seen at 83.6 min post-ingestion. Cocaine has been shown cocaine toxicosis was investigated (13,27,28). One study of

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ILE treatment for cocaine toxicosis showed decreased cocaine- Intravenous lipid emulsion has been an effective treatment induced cardiovascular collapse and decreased hypotensive in humans and animals for local anesthetic systemic toxicosis effects with pre-treatment with ILE. The mortality rates were (LAST) and has also been used as part of the treatment for also significantly lower in the ILE group compared to a con- many different lipophilic toxicants. Some previous studies and trol group (13). In another rat model of treatment with ILE reports suggest that ILE may be helpful with cocaine toxicosis. after cardiac arrest induced by intravenous cocaine there was The patient described herein was suspected to have clinical REPORT CASE no improvement in outcome after treatment with ILE (27). signs related to cocaine toxicosis, although other toxins cannot A third study, also looking at pre-treatment with ILE prior to be ruled out. The dog responded quickly to treatment with ILE intravenous cocaine overdose, found that ILE attenuated the with no adverse effects noted and complete resolution of all severe hypotension noted after injection of cocaine, and reduced clinical signs with no further drug therapy required. cocaine-induced cardiac toxicosis in isolated rat hearts (28). In conclusion, cocaine toxicosis has been previously shown There are a few case reports in humans describing the use to have an excellent prognosis. However, strong sedatives, beta- of ILE for treatment of cardiovascular instability secondary blockers, and anti-epileptic therapy, sometimes at very high to cocaine toxicosis. One patient was presented in a comatose doses, may be required to manage the clinical signs. Intravenous state with seizures and marked cardiovascular instability. The lipid emulsion may be a useful alternative or adjunctive treat- patient was treated with ILE and showed rapid improvement ment for patients with severe clinical signs associated with in cardiovascular parameters (29). Another report also describes suspected cocaine toxicosis, and in patients which either do the use of ILE in the case of a patient who was comatose with not respond to traditional therapy, or, in which these tradi- status epilepticus after smoking a large amount of crack cocaine. tional therapies may be contraindicated due to pre-existing The wide complex tachycardia and hypotension present were disease. Intravenous lipid emulsion may also help to decrease unresponsive to magnesium sulphate and sodium bicarbonate. the incidence of myocardial damage in severe cases of cocaine Treatment with ILE was instituted and within 10 min resolution toxicosis. CVJ of the tachycardia and hypotension was seen (30). Both of these patients survived to discharge. However, there is 1 case report References of unsuccessful treatment with ILE in another severe cocaine 1. Kaplan A, Whelan M. The use of IV lipid emulsion for lipophilic drug overdose with wide complex tachycardia (31). toxicities. J Am Anim Hosp Assoc 2012;48:221–227. The urine multidrug screen used in this patient evaluates 2. Fernandez A, Lee JA, Rahilly L, Hovda L, Brutlag AG, Engebretsen for the presence of benzoylecgonine, an inactive metabolite K. The use of intravenous lipid emulsion as an antidote in veterinary toxicology. J Vet Emerg Crit Care 2011;21:309–320. of cocaine. This drug test has good sensitivity and specificity 3. Gwaltney-Brant S, Meadows I. Intravenous lipid emulsions in veterinary in humans but has not been validated for use in animals (15). clinical toxicology. Vet Clin North Am Small Anim Pract 2018;48: False positive results are rarely reported with cocaine toxicosis, 933–942. 4. Williams K, Wells RJ, McLean MK. Suspected synthetic cannabinoid but could include coco leaf tea, salicylates, and fluconazole toxicosis in a dog. J Vet Emerg Crit Care 2015;25:739–744. (15,32). The clinical signs in this case were consistent with 5. Heggem-Perry B, McMichael M, O’Brien M, Moran C. Intravenous cocaine toxicosis. Phencyclidine (PCP) is reported to have a lipid emulsion therapy for bromethalin toxicity in a dog. J Am Anim Hosp Assoc 2016;52:265–268. higher incidence of false positive results on urine drug screens. 6. Bolfer L, McMichael M, Ngwenyame TR, O’Brien MA. Treatment Substances reported to cause false positive results more com- of ibuprofen toxicosis in a dog with intravenous lipid emulsion. J Am monly include dextromethorphan, tramadol, venlafaxine, and Anim Hosp Assoc 2014;50:136–140. 7. Maton BL, Simmonds EE, Lee JA, Alwood AJ. The use of high-dose 3,4-methylenedioxypyrovalerone (MDPV, otherwise known as insulin therapy and intravenous lipid emulsion to treat severe, refractory “bath salts”) (33,34). Phencyclidine can be positive in urine drug diltiazem toxicosis in a dog. J Vet Emerg Crit Care 2013;23:321–327. screens for 2 wk after exposure, so the second negative screen 8. Heggem-Perry B, McMichael M, Rick M, Jewell E. Reduction of serum 25-hydroxyvitamin D concentrations with intravenous lipid emulsion for PCP most likely indicates that the initial result was a false in a dog. Can Vet J 2016;57:1284–1286. positive (35). Clinical signs seen with PCP toxicosis include 9. Rothschild L, Bern S, Oswald S, Weinberg G. Intravenous lipid emul- muscle rigidity, erratic walking, ptyalism, nystagmus, and at sion in clinical toxicology. Scand J Trauma Resusc Emerg Med 2010; 18:51–58. higher doses loss of consciousness, miosis, and hypertension 10. Gosselin S, Hoegberg LCG, Hoffman RS, et al. Evidence-based rec- (21). Following the second urine drug screen, clinical signs at ommendations on the use of intravenous lipid emulsion therapy in this time were most consistent with cocaine toxicosis, although poisoning. Clin Toxicol (Phila) 2016;54:899–923. 11. Herring JM, McMichael MA, Corsi R, Wurlod V. Intravenous lipid other toxicants causing similar clinical signs could not be ruled emulsion therapy in three cases of canine naproxen overdose. J Vet out. Blood or urine tests (using gas chromatography-mass spec- Emerg Crit Care 2015;25:672–678. trometry) to confirm the cocaine ingestion were not submitted 12. Weinberg GL. Lipid emulsion infusion: Resuscitation for local anes- thetic and other drug overdose. Anesthesiology 2012;117:180–187. in this case due to cost constraints. 13. Carreiro S, Blum J, Hack JB. Pretreatment with intravenous lipid emul- Although there are some published data to support the sion reduces mortality from cocaine toxicity in a rat model. Ann Emerg use of ILE in cocaine toxicosis, these include only a few case Med 2014;64:32–37. 14. Fettiplace MR, Weinberg G. The mechanisms underlying lipid resuscita- reports and rat models; therefore, the use of ILE as treatment tion therapy. Reg Anesth Pain Med 2018;43:138–49. for cocaine toxicosis is not currently recommended in humans. 15. Thomas EK, Drobatz KJ, Mandell DC. Presumptive cocaine toxicosis Further data are required to assess the efficacy of this treatment in 19 dogs: 2004–2012. J Vet Emerg Crit Care 2014;24:201–207. 16. Barfield DM, Pegrum SA, Snow D, Malik R. Pupillary dilation, tachy- and to determine whether it may interfere with other standard cardia and abnormal behaviour in a young cat. Diagnosis: Cocaine treatments (24). intoxication. J Feline Med Surg 2007;9:265–270.

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17. Frazier K, Colvin B, Hullinger G. Postmortem diagnosis of accidental 27. Chai PR, Hack JB. Intravenous lipid emulsion in the resuscitation of cocaine intoxication in a dog. Vet Hum Toxicol 1998;40:154–155. cocaine-induced cardiovascular arrest in a rat model. Am J Emerg Med 18. Canadian Centre on Substance Use and Addiction. Cocaine. Canadian 2016;34:1452–1454. Drug Summary, Summer 2017. Available from: https://www.ccsa.ca/ 28. Fettiplace MR, Pirchurko A, Ripper R, et al. Cardiac depression sites/default/files/2019-04/CCSA-Canadian-Drug-Summary-Cocaine- induced by cocaine or cocaethylene are alleviated by lipid emulsion 2019-en.pdf Last accessed November 11, 2019. more effectively than by sulfobutylether b-cyclodextrin. Acad Emerg 19. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): Summary Med 2015;22:508–517. of results for 2017. Available from: https://www.canada.ca/en/health- 29. Jakkala-Saibaba RJ, Morgan PG, Morton GL. Treatment of cocaine canada/services/canadian-tobacco-alcohol-drugs-survey/2017-summary. overdose with lipid emulsion. Anaesthesia 2011;66:1168–1170. html Last accessed June 27, 2019. 30. Arora NP, Berk WA, Aaron CK, Williams KA. Usefulness of intravenous 20. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. lipid emulsion for cardiac toxicity from cocaine overdose. Am J Cardiol Circulation 2010;122:2558–2569. 2013;111:445–447. 21. Llera RM, Volmer PA. Toxicologic hazards for police dogs involved in 31. Kundu R, Almasri H, Moza A, Ghose A, Assaly R. Intravenous lipid drug detection. J Am Vet Med Assoc 2006;228:1028–1032. emulsion in wide complex arrhythmia with alternating bundle branch

RAPPORTCAS DE 22. Graziani M, Sarti P, Arese M, Magnifico MC, Badiani A, Saso L. block pattern from cocaine overdose. Kardiol Pol 2013;71:1073–1075. Cardiovascular mitochondrial dysfunction induced by cocaine: 32. Neerman MF. Drugs of abuse: Analyses and ingested agents that can Biomarkers and possible beneficial effects of modulators of oxidative induce interferences or cross-reactivity. Lab Med 2006;37:358–361. stress. Oxid Med Cell Longev 2017;2017:3034245 33. Neerman MF, Uzoegwu CL. Is dextromethorphan a concern for causing 23. Parker RB, Laizure C. The effect of ethanol on oral cocaine pharma- a false positive during urine drug screening? Lab Med 2010;41:457–460. cokinetics reveals an unrecognized class of ethanol-mediated drug 34. Saitman A, Park HD, Fitzgerald RL. False-positive interferences of com- interactions. Drug Metab Dispos 2010;38:317–322. mon urine drug screen immunoassays: A review. J Anal Toxicol 2014; 24. Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardio- 38:387–396. vascular toxicity: A systematic review. Clin Toxicol (Phila) 2016;54: 35. Volmer PA. “Recreational” drugs. In: Peterson ME, Talcott PA, eds. 345–364. Small Animal Toxicology. 2nd ed. St. Louis, Missouri: Elsevier Saunders, 25. Wilson LD, Malik M, Willson H. Cocaine and ethanol: Combined 2006:273–311. effects on coronary artery blood flow and myocardial function in dogs. Acad Emerg Med 2009;16:646–655. 26. Wilson LD, Shelat C. Electrophysiologic and hemodynamic effects of sodium bicarbonate in a canine model of severe cocaine intoxication. J Toxicol Clin Toxicol 2003;41:777–788.

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52 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Article

Comparison of single, fixed-time artificial insemination in weaned sows using 2 different protocols to synchronize ovulation

Lima Rodrigues, Rocio Amezcua, Glen Cassar, Terri O’Sullivan, Robert Friendship

Abstract — The present study evaluated 2 fixed-time artificial insemination (FTAI) techniques in sows in 2 herds. At weaning, sows were assigned to 1 of 3 treatment groups: Group 1 received intramuscular injections of 600 IU of equine chorionic gonadotropin followed 3 days later by 5 mg of porcine luteinizing hormone; Group 2 received a 200-mg intravaginal dose of triptorelin acetate 4 days post-weaning; and Group 3 were heat checked daily and double-mated when observed in heat. Groups 1 and 2 were bred once at a fixed-time independent of estrous behavior. Time of ovulation was monitored by ultrasound in a subset of sows from each group. Both FTAI techniques resulted in sows farrowing within short intervals, leading to the weaning of pigs that tended to be older and heavier compared with controls. The use of FTAI, however, was associated with a trend to reduced reproductive performance compared with controls in 1 herd.

Résumé — Comparaison d’une insémination artificielle unique à temps déterminé chez des truies sevrées en utilisant deux protocoles différents pour synchroniser l’ovulation. La présente étude a évalué deux techniques d’insémination artificielle à temps déterminé (FTIA) chez des truies dans deux troupeaux. Au sevrage, les truies étaient assignées à un des trois groupes de traitement : Groupe 1 recevait par injection intramusculaire 600 UI de gonadotrophine chorionique équine suivi 3 jours plus tard de 5 mg d’hormone lutéinisante porcine; le Groupe 2 recevait par voie intravaginale une dose de 200 mg d’acétate de triptorelin 4 jours post-sevrage; et pour le Groupe 3 les chaleurs étaient vérifiées quotidiennement et il y avait double saillie lorsque les truies étaient observées en chaleur. Les truies des Groupe 1 et 2 furent saillies une fois à un temps déterminé indépendamment du comportement œstral. Le moment de l’ovulation était surveillé par échographie dans un sous-groupe de truies de chacun des groupes. Les deux techniques de FTAI ont résulté en des truies dont la mise-bas est survenue dans des intervalles rapprochés, entrainant le sevrage de porcelets qui avaient tendance à être plus âgés et plus lourds comparativement aux témoins. Toutefois, dans un des troupeaux l’utilisation de FTIA était associée avec une tendance à une diminution des performances de reproduction comparativement aux témoins. (Traduit par Dr Serge Messier) Can Vet J 2020;61:53–56 Introduction 24 h while they remain in standing heat, which usually involves n important aspect of swine production is reproductive at least 2 inseminations per estrus period (4,5). If insemination A efficiency. Maximizing sow productivity and fully utilizing is performed too early or too late relative to ovulation, it will available farrowing crates require that the sows return to estrus result in decreased fertility (6,7). With the help of hormonal promptly after weaning (1). It is especially true for producers treatment protocols, ovulation can be manipulated so that it is operating batch farrowing systems, that the variation in time predictable, allowing for fixed-time artificial insemination (FTAI) from weaning to rebreeding be consistent and predictable. The to be performed (8). As the name suggests, single FTAI allows for wean-to-estrus interval, the duration of estrus, and the estrus-to- a single insemination to be performed at a specific predetermined ovulation interval affect the sow-to-sow variation with regard to time resulting in reproductive performance that is comparable the timing of conception (2,3). In addition, the onset of estrus is to the traditional multiple inseminations (9). When an FTAI not a reliable predictor for time of ovulation (3). Since optimal protocol is followed, all weaned sows are bred at a specific time fertility is achieved by insemination during the 24-hour period without determining the time of onset of signs of standing heat prior to ovulation, it is general practice to inseminate sows every or judging the quality of the signs of estrus. An FTAI protocol may result in labor savings because it eliminates the need to heat Department of Population Medicine, University of Guelph, check sows daily from weaning until breeding. In addition, the Guelph, Ontario N1G 2W1. use of FTAI synchronizes breeding among a batch of sows which Address all correspondence to Dr. Robert Friendship; e-mail: should result in sows farrowing within a short time period, thus [email protected] creating a uniform group of similar aged pigs at weaning. This Use of this article is limited to a single copy for personal study. will also allow for more efficient use of labor at farrowing and Anyone interested in obtaining reprints should contact the during the first few days of neonatal care (10). CVMA office ([email protected]) for additional At present, there are at least 2 options available to Canadian copies or permission to use this material elsewhere. pork producers interested in FTAI. One protocol requires the

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injection of equine chorionic gonadotropin (eCG) at weaning 58 sows were required in each group. Data recorded included: followed by an injection of porcine luteinizing hormone (pLH) sow identification, parity, treatment group, batch number, 3 d later (4), and the second protocol involves an intravaginal treatment date, breeding date(s), farrowing date, room and pen dose of a gonadotropin-releasing hormone (GnRH) agonist, number, piglet birth weights, total number of piglets born, lit- triptorelin acetate, 4 d after weaning (10). The objectives of this ter characteristics, weaning date, litter size, and piglet weight study were to compare the reproductive outcomes of weaned at weaning. sows bred by 2 different FTAI protocols and a control group Additionally, in a subset of 10 sows per treatment group on bred by conventional means (detection of estrus and using Farm 2, the time of ovulation was monitored by transabdominal multiple matings), and to determine if FTAI protocols result ultrasonography (Honda HS-1600 scanner; Honda Electronics,

ARTICLE in farrowings within a short time span to facilitate efficient Tokyo, Japan) to confirm the time of ovulation (12). Ultrasound allocation of human resources and uniform weaning weights. examination was conducted at 8-hour intervals starting on Day 4 following weaning and at 6-hour intervals on Days 5 and 6 Materials and methods until ovulation was complete. This research trial was approved by the Animal Care Committee of the University of Guelph, in accordance with the guidelines Data analysis set forward by the Canadian Council of Animal Care. Data were entered into Microsoft Excel for PC 2007 (Microsoft, This experiment was conducted on weaned Landrace 3 Redmond, Washington, USA), imported into Stata (Stata/SE Yorkshire sows on 2 farms. Both farms weaned pigs at approxi- 14.2 for Mac; Stata Corp, College Station, Texas, USA), and mately 3 wk of age and it was predetermined that any sows validated before analysis commenced. Significance was deter- with a lactation length shorter than 18 d would be excluded mined at P , 0.05. Descriptive statistics such as means and from the trial. Farm 1 is a 300-sow operation which practices standard deviations were calculated. The proportion of pigs with monthly batch farrowing, uses purchased pooled-semen from a weaning weight of , 4.5 kg in each group was also determined a commercial boar stud, and historically has good farrowing on each farm to further examine the variation in piglet size. rates (. 80%). Farm 2 is a 700-sow unit that performs weekly Differences in the likelihood of farrowing, litter size, and farrowing, uses fresh pooled-semen collected on-farm, and piglet weaning weight between the group assignments were historically achieves a farrowing rate below the industry norm modelled separately by farm. The likelihood of farrowing (, 80%). On each farm, systematic random sampling was used (1 = yes, 0 = no) was compared using a logistic regression model. to assign sows at weaning to 1 of 3 treatment groups. Sows in Litter size (count) representing the total born was analyzed using Group 1 were injected intramuscularly (IM) with 600 IU of a multi-level mixed effects Poisson regression model with batch eCG (Pregnecol; Vétoquinol, Lavaltrie, Quebec) at weaning modelled as a random effect. Weaning weights of piglets (con- and 80 h later were injected IM with 5 mg of pLH (Lutropin; tinuous) were compared using multi-level mixed effects linear Vétoquinol). A single insemination of approximately 3 billion regression models. Pen and room were modelled as random sperm was performed 36 h after administration of pLH. Sows effects and batch was modelled as a fixed effect. The time of in Group 2 received a 2-mL intravaginal dose of triptorelin ovulation in sows was reviewed and the ranges from the time acetate (OvuGel; 100 mg triptorelin per mL; Elanco, Guelph, the first sow farrowed in the batch until the time the last sow Ontario) 96 h following weaning to induce ovulation. A single farrowed in each treatment group were measured. insemination of approximately 3 billion sperm was performed 24 h after the administration of triptorelin acetate. Sows in Results Group 3 served as the control group and were handled in a Farm 1 conventional manner post-weaning, using boar exposure for The numbers of sows assigned to each treatment were 61, 61, estrus detection twice daily. Sows in Group 3 received an and 66 for Groups 1, 2 and 3, respectively. All sows in Group 3 insemination of approximately 3 billion sperm when discovered on each farm were mated twice at 24 h intervals. Descriptive in strong standing heat and a second insemination 24 h later if statistics for performance parameters are presented in Table 1. the sow was still in standing heat. In all cases, inseminations of After controlling for parity, the regression model indicated that fresh, pooled-semen were performed by the staff on each farm Group 3 sows had, on average, 1.14 times more piglets (total) in the presence of a boar to stimulate estrous behavior. On both born per sow than did Group 2 sows (P = 0.02). After control- farms a foam-tipped insemination rod was used to deliver semen ling for the other variables in the model, the regression model into the cervix. For sows in Groups 1 and 2, the estrous behav- showed that the piglets in Groups 1 and 2 were heavier at wean- ior was not assessed, but rather, breeding was carried out at a ing than piglets in Group 3 (P , 0.05). The range of farrowing fixed-time. dates, from the date the first sow farrowed in the batch until Sample size was calculated to determine a difference in the the date the last sow farrowed in each treatment group, revealed mean weaning weight of piglets among the treatment groups that Group 1 sows were typically the first sows that farrowed (11). Based on historic herd records, the average weaning in each batch and all sows within this group farrowed in the weight of a pig in the control group was presumed to be 5.5 kg least number of subsequent days compared to sows in Groups 2 [standard deviation (SD) = 1.0 kg] and in the FTAI groups it and 3. The time from the first until the last sow farrowing was was estimated to be 6.0 kg (SD = 0.9 kg). Therefore, in order to on average 3.15 d, 3.75 d, and 4.50 d for sows in Groups 1, 2, detect such differences with 80% power and 95% confidence, and 3, respectively. Among batches, the percentages of pigs that

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were small (, 4.5 kg) at weaning were 9%, 15%, and 12% for Table 1. Production performance, represented by means 6 standard deviation, of sows receiving single fixed-time artificial Groups 1, 2, and 3, respectively. insemination (Groups 1 and 2) versus conventional double-mating during a natural estrus (Group 3) on Farm 1 and Farm 2. Farm 2 Farm 1 (300-sow farm with 4-week batch farrowing and historically good The numbers of sows assigned to each treatment group were 62, performance) 55, and 53 for Groups 1, 2, and 3, respectively. Descriptive sta- aGroup 1 bGroup 2 cGroup 3 tistics for performance parameters are presented in Table 1. The (n = 61) (n = 61) (n = 66) ARTICLE ranges, from the time the first sow farrowed in the batch until Farrowing rate (%) 80.3 75.4 88.7 the time the last sow farrowed in each treatment group, revealed Litter size (total born) 13.8 6 4.1 13.2 6 3.7 14.6 6 3.9 that Group 1 sows were typically the first sows that farrowed in Birth weight (kg) 1.6 6 0.4 1.5 6 0.4 1.6 6 0.4 6 6 6 each batch and all sows within this group farrowed in the least Weaning weight (kg) 6.4 1.3 6.2 1.5 6.2 1.4 Age at weaning (days) 18.0 6 1.4 17.7 6 1.7 17.5 6 1.4 number of subsequent days compared to sows in Groups 2 and 3. The times from the first until the last sow farrowing were on Farm 2 (700-sow farm with weekly farrowing and historically low ­farrowing rate) average 3.25 d, 4.0 d, and 4.25 d for sows in Groups 1, 2, and 3, respectively. The regression models indicated that the treatments Group 1 Group 2 Group 3 (n = 62) (n = 55) (n = 53) had no association with the likelihood of farrowing, litter size, or weaning weights on Farm 2. Among batches, the percentages Farrowing rate (%) 74.2 76.4 77.4 Litter size (total born) 12.7 6 3.7 12.4 6 4.1 12.6 6 2.7 of pigs that were small (, 4.5 kg) at weaning were 12%, 10%, Birth weight (kg) 1.6 6 0.4 1.7 6 0.4 1.7 6 0.4 and 12%, for Groups 1, 2 and 3, respectively. Weaning weight (kg) 6.3 6 1.6 6.2 6 1.4 6.2 6 1.5 6 6 6 The ultrasound assessment on Farm 2 showed that 6 of Age at weaning (days) 19.0 1.3 18.0 1.5 17.9 1.4 10 sows in Group 3 did not ovulate until 24 to 30 h after the a Group 1: IM injection of 600 IU eCG at weaning followed by 5 mg pLH given IM 84 h later, then single breeding 36 h later. first breeding, whereas the FTAI sows ovulated between 6 h and b Group 2: A 2-mL intra-vaginal dose of triptorelin acetate 4 d after weaning and 24 h post-breeding. then a single insemination 24 h later. c Group 3: Weaning is followed by boar exposure and daily heat checks, bred when Discussion sow first observed in heat and 24 h later if still in heat. In the present study, there is evidence that FTAI resulted in poorer reproductive performance than conventional breeding on treatment (Group 2), the litter size was reduced compared with Farm 1, with Group 3 sows (controls) tending to have a higher controls. The eCG-pLH treatment did not have a significant farrowing rate compared to sows in Groups 1 and 2. The FTAI effect on litter size at either farm, which is consistent with previ- farrowing rates appear to be low for most modern farms but ous literature (4,5,15). this is not a consistent finding in the literature. There are stud- Ultrasound imaging on a subset of sows on Farm 2 revealed ies which found that farrowing rates were either similar among that the timing of insemination for sows in Groups 1 and 2 was FTAI and control groups, as found on Farm 2, or higher for within 24 h before ovulation, with ovulation occurring within FTAI groups. For instance, a study by Cassar et al (4) reported 12 h of insemination for sows in Group 1, as expected based that farrowing rates were notably higher in eCG-pLH treated on previous studies (8). Sows in Group 2 finished ovulating sows inseminated once at a fixed-time compared to control sows between 6 to 24 h after breeding, making it appropriate to use that were inseminated at least twice. A study by Zak et al (13) a single insemination. This is consistent with the findings of a found that an IM injection of pLH at the onset of estrus in study by Knox et al (8), in which they evaluated the use of a weaned sows followed by a double FTAI produced a farrowing single intrauterine insemination using 1.5 or 2.5 billion sperm rate comparable to controls. It has been reported that farrowing administered at 22, 26, or 30 h following triptorelin treatment, rates are much lower if sows are not in standing heat when bred given 96 h post-weaning in sows. The average interval from using a FTAI protocol (14). Unfortunately, the quality of the administration of triptorelin to ovulation was 42.2 6 0.4 h and estrous behavior at the time of the breeding was not recorded ovulation occurred within a 24-hour period in 88% of sows. The in this trial, but if some of the sows were not in good standing sows in Group 3 completed ovulating 24 to 30 h after the first heat at the time of the FTAI, this might partly explain why the breeding, or up to 6 h after the second breeding. This range of farrowing rates in the FTAI groups were low on both farms. On ovulation times in Group 3 confirmed why at least 2 insemina- Farm 2, in which the control sows recorded a farrowing rate of tions are typically required to achieve desired conception rates. , 80%, similar to the FTAI groups, the explanation for the This also highlights the ability of the hormonal treatments to low performance may be the same, in that the herdsman may narrow the window of ovulation times within a group of sows, have bred some control and FTAI sows that were not in strong allowing for FTAI. Although these results indicate that the tim- standing heat and at the optimum time for insemination. One ing was reasonable, ultrasonography was performed on Farm 2 of the potential advantages of FTAI programs is that breeding only. Future studies should examine whether these results vary would become less reliant on the stockman’s experience and from farm to farm. ability to determine signs of estrus. An objective of using FTAI is to reduce labor by tighten- In addition to farrowing rate, litter size is an important aspect ing the breeding window so that instead of breeding sows of reproductive performance and sow productivity. On Farm 1, over a period of several days they are bred in a single day. A there was evidence that at least in the case of triptorelin acetate consequence should be that all sows farrow close together,

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­improving the efficiency of labor in the farrowing room by mak- Significant benefits of FTAI are the labor savings related to ing cross-fostering, scheduling supervision of farrowing, and the heat checking and double mating. It also enables producers to processing of litters easier. Commonly, due to the variation in eliminate weekend inseminations and plan how much semen the wean-to-estrus interval and gestation length, the farrowing to have available on a particular day, so semen storage time and period in a batch of sows occurs over the span of 10 d (10). In semen wastage can be reduced (10). This study demonstrated the present study, the first sow in the batch to farrow on both that there is a farm to farm variation as to whether FTAI pro- Farm 1 and Farm 2 was generally in Group 1, the same group duces reproductive performance comparable to conventional that required the least number of subsequent farrowing days. double mating or lower farrowing rates and litter size. Therefore, Compared to Group 3, Group 1 sows finished farrowing 1 d ear- caution needs to be used when contemplating a change to FTAI

ARTICLE lier. Due to the controlled breeding, it was predicted that sows because results may vary depending on herd characteristics and in Groups 1 and 2 would farrow closely together and this would management factors. contrast with a wider range of farrowing dates for Group 3 sows. Surprisingly Group 3 sows farrowed over a relatively narrow Acknowledgments range of days as well. Perhaps FTAI protocols would prove to This research was funded in part by Ontario Pork and the be better suited for herds with greater variation in the weaning Ontario Ministry of Agriculture, Food and Rural Affairs- to breeding interval. University of Guelph Research Partnership. OvuGel was donated When sows farrow close together, the lactation length will by Elanco Animal Health. CVJ be similar among them as well as the age and size of their piglets at weaning (10). On both farms, the FTAI groups had References slightly older pigs at weaning compared to Group 3. In addi- . 1 Kauffold J, Beckjunker J, Kanora A, Zaremba W. Synchronization of tion to increased age at weaning, the weaning weights of pigs estrus and ovulation in sows not conceiving in a scheduled fixed-time in Groups 1 and 2 were slightly heavier than those of pigs in insemination program. Anim Reprod Sci 2007;97:84–93. 2. Degenstein KL, O’Donoghue R, Patterson JL, et al. Synchronization of Group 3 on Farm 1 based on models that controlled for vari- ovulation in cyclic gilts with porcine luteinizing hormone (pLH) and its ous factors including birth weight. A previous study found no effects on reproductive function. Theriogenology 2008;70:1075–1085. difference between the weaning weights of pigs in control and 3. Knox RV, Taibl JN, Breen SM, Swanson ME, Webel SK. Effects of altering the dose and timing of triptorelin when given as an intravaginal triptorelin acetate groups (14). Presumably, on farms with gel for advancing and synchronizing ovulation in weaned sows. Therio­ consistently short weaning to breeding intervals there would be genology 2014;82:379–386. very little difference between FTAI and natural breeding with 4. Cassar G, Kirkwood RN, Poljak Z, Bennett-Steward K, Friendship RM. Effect of single or double insemination on fertility of sows bred at an respect to weaning age and weight. An increased weight at wean- induced estrus and ovulation. J Swine Health Prod 2005;13:254–258. ing has been shown to better prepare pigs for more successful 5. Ulguim RR, Fontana DL, Bernardi ML, Wentz I, Bortolozzo FP. performance in the later stages of production (15). In particular, Single fixed-time artificial insemination in gilts and weaned sows using pLH at estrus onset administered through vulvar submucosal route. heavier weights at weaning have been shown to result in more Theriogenology 2016;86:1072–1080. rapid growth post-weaning (15). Uniform age and size at wean- 6. Castagna CD, Peixoto CH, Bortolozzo FP, Wentz I, Ruschel F, Neto G. ing is desired because it reduces the likelihood of pigs that are The effect of post-ovulatory artificial insemination on sow reproductive performance. Reprod Domest Anim 2003;38:373–376. too young and small being moved into the nursery and mixed 7. Rozeboom KJ, Troedsson MHT, Shurson GC, Hawton JD, Crabo with older and larger animals. The results of this trial, which BG. Late estrus or metestrus insemination after estrual inseminations was conducted on 2 farms, show that farm differences do exist decreases farrowing rate and litter size in swine. J Anim Sci 1997;75: 2323–2327. and are important to consider when applying FTAI protocols. 8. Knox RV, Esparza-Harris KC, Johnston ME, Webel SK. Effect of Perhaps the use of FTAI provides more benefit when the herd numbers of sperm and timing of a single, post-cervical insemination ® reproductive performance is below average, particularly if the on the fertility of weaned sows treated with OvuGel . Theriogenology 2017;92:197–203. timing of insemination and observing heat signs are problems 9. De Rensis F, Kirkwood RN. Control of estrus and ovulation: Fertility for the herdsman. Fixed-time artificial insemination protocols to timed insemination of gilts and sows. Theriogenology 2016;86: allow the reproductive performance to be less dependent on the 1460–1466. 10. Kraeling RR, Webel SK. Current strategies for reproductive management stockperson’s ability to detect estrus and to determine the best of gilts and sows in North America. J Anim Sci Biotechnol 2015;6:1–14. time to inseminate because timing is dictated by the FTAI pro- 11. Snedecor GW, Cochran WG. Statistical Methods. 8th ed. Ames, Iowa: tocol. Since FTAI protocols create a tight group which farrows Iowa State University Press, 1989:52–53. 12. Belstra BA, Flowers WL, See MT. Factors affecting temporal relation- together, the monthly batch farrowing farm was expected to ships between estrus and ovulation in commercial sow farms. Anim benefit the most from either protocol. However, in this study the Repro Sci 2004;84:377–394. farm using batch farrowing recorded that control sows were bred 13. Zak LJ, Patterson J, Hancock J, Hockley D, Rogan D, Foxcroft GR. Benefits of synchronizing ovulation with porcine luteinizing hormone within a narrow time frame and reproductive performance was (pLH) in a fixed-time insemination protocol in weaned multiparous excellent in this group as well. Based on the ultrasound results sows. J Swine Health Prod 2010;18:125–131. on Farm 2, it was presumed that the timing of inseminations 14. Francisco C, Johnston M, Webel SK, Swanson ME, Kraeling R. Evalu­ ation of reproductive performance using OvuGel® with a single fixed- was not an issue, but it is possible that the hormone treatments time artificial insemination protocol in six commercial swine farms. resulted in the recruitment of immature follicles causing the Proc Am Assoc Swine Veterinarians 2015:231–236. lower farrowing rates and smaller litters observed on Farm 1. 15. Cabrera RA, Boyd RD, Jungst SB, et al. Impact of lactation length and piglet weaning weight on long-term growth and viability of progeny. Future studies need to investigate the cause of the farm to farm J Anim Sci 2010;88:2265–2276. differences observed in this trial.

56 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Article

Concentrations and deficiencies of minerals in cattle submitted to a diagnostic laboratory in Saskatchewan from 2003–2012: A retrospective study

Ursula Perdrizet, Barry Blakley, Ahmad Al Dissi

Abstract — Trace mineral analyses of samples submitted to Prairie Diagnostic Services laboratory from Saskatchewan cattle between 2003 and 2012 were examined, with the objective of describing trends and reporting concentrations and deficiencies of minerals. Deficiencies were observed with copper, iron, manganese, magnesium, zinc, and cobalt. Deficiency was most commonly seen in copper, followed by iron, manganese, and magnesium accounting for 47.2%, 15.1%, 13.0%, and 10.8% of deficiencies, respectively. Deficiency in cobalt was least common followed by zinc accounting for 4.2% and 9.7% of deficiencies, respectively. The following minerals were also analyzed: barium, beryllium, bismuth, cadmium, chromium, antimony, tin, molybdenum, strontium, thallium, and vanadium. Submissions from 1434 animals were reviewed and a diagnosis of mineral deficiency was made for 509 animals with 92 of these having multiple deficiencies. There were significant differences in the number of deficient animals by year (P = 0.001), age group (P = 0.01), but not month (P = 0.109) or soil type (P = 0.172).

Résumé — Concentrations et déficiences en minéraux dans des échantillons bovins soumis à un laboratoire de diagnostic en Saskatchewan entre 2003-2012 : une étude rétrospective. Les résultats d’analyse pour les oligo-éléments dans des échantillons provenant de bovins en Saskatchewan soumis au laboratoire de Prairie Diagnostic Services entre 2003 et 2012 furent examinés, avec comme objectif de décrire les tendances et rapporter les concentrations et déficiences en minéraux. Des déficiences furent observées pour le cuivre, le fer, le manganèse, le magnésium, le zinc, et le cobalt. Les déficiences étaient les plus fréquemment rencontrées avec le cuivre, suivi du fer, manganèse, et magnésium représentant 47,2 %, 15,1 %, 13,0 %, et 10,8 % des déficiences, respectivement. La déficience en cobalt était moins fréquente suivie par le zinc et représentant 4,2 % et 9,7 % des déficiences, respectivement. Les minéraux suivants furent également analysés : barium, béryllium, bismuth, cadmium, chromium, antimoine, étain, molybdène, strontium, thallium, et vanadium. Les soumissions provenant de 1434 animaux furent revues et un diagnostic de déficience en minéraux fut posé chez 509 animaux, avec 92 de ceux-ci ayant des déficiences multiples. Il y avait des différences significatives dans le nombre d’animaux déficients par année (P = 0,001), les groupes d’âge (P = 0,01), mais pas pour les mois (P = 0,109) ou le type de sol (P = 0,172). (Traduit par Dr Serge Messier) Can Vet J 2020;61:57–62

Introduction minerals and lack of mineral or concentrate supplementation are associated with increased pathologies at the herd level compared ineral deficiencies are a pervasive challenge for livestock with healthy dairy and beef herds (1). Subclinical deficiencies producers and veterinarians. The non-specific or vague M impair reproductive and immune system function and are often clinical manifestations often allow these problems to go undiag- manifested as infertility or a predisposition to disease (2–5). nosed until losses are encountered. Lower concentrations of trace Barriers to a diagnosis are related to not only the subtle nature of clinical signs but also to the cost and invasiveness of sampling Department of Veterinary Pathology (Perdrizet, Al Dissi), for certain minerals. For example, the liver is the preferred sam- Department of Veterinary Biomedical Sciences (Blakley), ple for diagnosis of copper (Cu) deficiency because in the blood University of Saskatchewan, 52 Campus Drive, Saskatoon, it is maintained at a constant concentration through depletion Saskatchewan S7N 5B4. of the liver stores (6). Published reference ranges are scarce, or Address all correspondence to Dr. Ahmad Al Dissi; e-mail: often inconsistent, and frequently have overlapping values for [email protected] what is considered deficient, marginal, normal, or toxic (6,7). Use of this article is limited to a single copy for personal study. Essential elements are those which can reliably produce clini- Anyone interested in obtaining reprints should contact the cal symptoms when they are deficient. Non-essential elements CVMA office ([email protected]) for additional play important biological roles often as cofactors; however, copies or permission to use this material elsewhere. when they are deficient other elements can substitute for them.

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Few non-essential elements with no identifiable roles are found Table 1. Reason for sample submission for trace mineral analysis. in tissues (8,9). Understanding the variation in non-essential N Submissions trace minerals is still important in providing a comparison to Abortion 260 198 real world exposure, and with new and better understanding Deaths 145 138 of the biological roles of some elements, their classification as Downer 79 65 non-essential trace minerals may change (10). In Saskatchewan, Neonatal losses 62 55 Calf scours 61 43 the following trace minerals have been evaluated: Cu, iron Weak calves 55 43 (Fe), manganese (Mn), selenium (Se), and zinc (Zn) with Cu Pneumonia/cough 57 39 deficiency being recognized since the 1950s and in 1989 the Neurological 46 38 Loss of body condition 55 35 ARTICLE magnitude of hypocuprosis was described as extensive (11–13). Stillbirth 23 23 The objectives of this study were to characterize the trends Non-specific 27 19 in trace mineral deficiencies in Saskatchewan cattle samples Herd survey/healthy 91 18 Lameness 19 14 submitted to Prairie Diagnostic Services from 2003 to 2012 Diarrhea 18 12 and to report the ranges of non-essential trace minerals in these Open cows 47 10 a samples. Toxicity 16 10 Premature calves 10 8 Vaccine reaction 40 7 Materials and methods Coat 13 7 The trace mineral analyses used in the study were obtained Loss of production (milk) 9 5 Recheck 16 4 from submissions to Prairie Diagnostic Services, Saskatoon, “Poor doer” calf 6 4 Saskatchewan, from 2003 to 2012. A computer search for all Hind-end weakness 4 4 submitted samples identified 1434 animals that were tested. Anestrus 25 3 Pica 8 1 A submission occasionally contained multiple samples each LDA/metritis/mastitis 7 1 belonging to a different animal. For each submission, the Miscellaneous (each , 3 cases) 37 35 clinical history was reviewed, and the purpose of the submis- Unknown 198 sion was reported. Mineral concentrations were evaluated on N — refers to the number of individual clinical histories evaluated (a submission may have samples from different animals in the same herd). a wet-weight basis for serum, plasma, liver, and kidney using a Causes of toxicity include lead, monensin, mycotoxin, nitrate, copper, and mineral inductively coupled plasma mass spectrometry (14). Published mix. reference ranges for the trace minerals were used to designate deficient and normal concentrations for cobalt (Co), Cu, Fe, postpartum, calf 7 to 364 d, and adult $ 365 d. Copper was Mn, magnesium (Mg), nickel (Ni), and Zn (7). Selenium was the only element for which there was a deficiency category for not included in the study as this major biologically significant fetal liver, and therefore was the only element with a different and economically important element will be considered in deficiency designation based on age (7). Liver concentrations association with vitamin E in a subsequent manuscript. Tissue for the following elements were also reported: barium (Ba), reference ranges for liver and kidney were used for Co, Cu, Fe, beryllium (Be), bismuth (Bi), cadmium (Cd), chromium (Cr), Mg, and Zn but limited to kidney for Ni and to liver for Mn. molybdenum (Mo), antimony (Sb), tin (Sn), strontium (Sr), Reference values were also available for serum for Cu, Fe, Mg, titanium (Ti), and vanadium (V). and Zn. Each mineral status was classified as either deficient IBM SPSS Statistics (version 24.0; IBM, Armonk, New York, or normal. Occasionally, reported reference ranges for “defi- USA) was used to perform Pearson’s Chi-square test for inde- cient” and “normal” overlapped and a mineral was classified as pendence to determine if there were any significant associations deficient if its concentration was lower than the lowest value between the binomial outcome of deficiency and year, month, reported in the reference range. When a marginal range was also age, and soil type of submissions. The contribution of cat- reported for a mineral and its concentration overlapped with egorical variables from significant Chi-square tests was further the reported deficient range, deficiency was assigned when the evaluated by a Z-test of column proportion with Bonferroni mineral concentration was lower than or equal to the highest correction for multiple comparisons. value reported in the deficient range. The limits of detection for Co, Cu, Fe, Mn, Mg, Ni, and Zn were 1.35, 36.0, 0.90, 3.00, Results 2.65, 17.0, and 360 ng/kg on a wet matter basis, respectively. From the 1434 cases submitted for trace mineral analyses there The geometric mean and range of Mn concentrations in fetal were 509 cases considered deficient with 92 cases containing livers were reported with other elements (see below) as they are multiple deficiencies (range: 2 to 5 minerals), resulting in a total usually 60% to 80% of maternal values, and no reference ranges of 638 deficiencies. The purpose for the submissions is listed in have been established for this age group (15). Table 1, with abortions, deaths, downer cows, neonatal losses, The clinical history, location, age, date, and year of submis- calf scours, weak calves, and pneumonia or cough comprising sion were considered. Locations were assigned soil types based about 50% of the submissions. The most common deficiency on the chernozemic soil classification of the rural municipality was Cu (47.2%), followed by Fe (15.1%), Mn (13.0%), and (16). If more than one soil type was present in a rural munici- Mg (10.8%). Zinc and Co deficiencies represented 13.9% of pality, which occurred infrequently, the predominant soil clas- the total with no deficiencies reported for Ni. Most submissions sification was assigned. The ages included fetal, newborn , 7 d having a deficient status were received between February and

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Table 2. Mineral deficiencies by month of submission of samples from Saskatchewan cattle between 2003 and 2012 from the Prairie Diagnostic Services database. Mineral Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total Copper 24 40 49 58 31 20 14 8 14 7 15 21 301 Iron 7 6 27 14 7 11 2 1 5 2 5 9 96 Manganese 3 14 20 25 8 2 5 1 — — — 5 83 Magnesium 8 14 21 10 3 4 — 1 — — — 8 69 Zinc 4 10 12 10 5 7 3 1 1 3 — 6 62 ARTICLE Cobalt 3 15 5 2 — 1 1 — — — — — 27 Nickel — — — — — — — — — — — — 0 Total number of 49 99 134 119 54 45 25 12 20 12 20 49 638 mineral deficiencies N 127 182 292 261 158 73 50 26 62 45 64 94 1434 Number of animals 38 78 117 96 46 29 18 9 17 12 20 29 509 deficient Percentage of animals 29.9a 42.8 40.1 36.8 29.1 39.7 36.0 34.6 27.4 26.7 31.3 30.9 35.5 deficient

N — total number of samples tested. Only 1 sample was tested from each animal. Reference values for deficiencies adapted from (7) are: copper , 3, 10, 20, and 0.5 mg/kg for kidney, liver, fetal liver, and plasma or serum, respectively; iron , 20, 30, and 1.3 mg/kg for kidney, liver, and plasma or serum, respectively; manganese liver values , 1 mg/kg; zinc , 18, 25, and 0.5 mg/kg for kidney, liver and serum, respectively; magnesium , 50, 100, and 11 mg/kg for kidney, liver, and serum or plasma respectively; cobalt , 0.014 and 0.005 mg/kg for kidney and liver, respectively; nickel , 0.01 mg/kg for kidney (wet weight). Pearson’s Chi-square test for the number of deficiencies by month was P = 0.109. a Percentage of deficient animals = number of animals deficient/N.

Table 3. Mineral deficiencies by year identified in Saskatchewan cattle between 2003 and 2012 from the Prairie Diagnostic Services database. Mineral 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Copper 4 9 6 32 15 37 53 43 73 29 301 Iron 4 5 2 3 4 15 8 18 32 5 96 Manganese 1 2 1 8 8 13 26 7 12 5 83 Magnesium — 6 — 2 2 4 24 2 15 14 69 Zinc 5 5 1 4 3 10 12 8 6 8 62 Cobalt — — — 1 — 2 19 1 1 3 27 Nickel — — — — — — — — — — 0 Total number of 14 27 10 50 32 81 142 79 139 64 638 mineral deficiencies N 56 47 29 148 85 148 334 136 293 158 1434 Number of animals 12 10 9 42 28 62 112 64 119 51 509 deficient Percentage of animals 21.4 21.3 31.0 28.4 32.9 41.9 33.5 47.1 40.6 32.3 35.5 deficient

N — total number of samples tested. Only 1 sample was tested from each animal. Reference values for deficiencies adapted from (7) are: copper , 3, 10, 20, and 0.5 mg/kg for kidney, liver, fetal liver, and plasma or serum, respectively; iron , 20, 30, and 1.3 mg/kg for kidney, liver, and plasma or serum, respectively; manganese liver values , 1 mg/kg; zinc , 18, 25, and 0.5 mg/kg for kidney, liver and serum, respectively; magnesium , 50, 100, and 11 mg/kg for kidney, liver, and serum or plasma, respectively; cobalt , 0.014 and 0.005 mg/kg for kidney and liver, respectively; nickel , 0.01 mg/kg for kidney (wet weight). Pearson’s Chi-square test for the occurrence of deficiencies by year P = 0.001 and P = 0.002 for the Z-test of column proportions for 2003 when compared to 2010, with Bonferroni correction.

April (Table 2). The largest number of deficiencies occurred of submissions, Table 4). The number of deficiencies for adult in March, but the highest percentage was in February, during cattle was significantly greater than for calves (P = 0.01) using which 42.8% of the submissions had a mineral deficiency. The a Z-test with Bonferroni correction. observed cases of deficiencies recorded each month were not The highest proportion of mineral deficiencies by soil type significantly different from expected values (P = 0.109). occurred in dark gray soil zones, 42.9%, with the greatest The greatest number of deficiencies occurred in 2009, number of deficiencies from the dark brown soil zone (Table 5). 142 cases, but the highest proportion of diagnosed deficien- The observed values were not significantly different from cies was in 2010 with 47.1% of cases considered deficient the expected values based on the soil zone of the submission (Table 3). The difference in deficiencies by year was significant (P = 0.17). There was also no significant difference in the (P = 0.001); with 2003 having a significantly lower number of number of Cu deficiencies in relation to soil type (P = 0.53). deficiencies (P = 0.002) than 2010. There were no significant Geometric mean, 95% confidence interval (CI), standard differences among the other years. There was a significant deviation (SD), and range of liver values for antimony, barium, difference from the expected values for deficiencies based on beryllium, bismuth, cadmium, chromium, fetal manganese, the age of the animal (P = 0.01). Adult cattle had the greatest molybdenum, strontium, tin, thallium, and vanadium are sum- number and percentage of deficiencies (247 cases and 42.0% marized in Table 6.

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Table 4. Mineral deficiencies by age group identified in Table 5. Mineral deficiencies by chernozemic soil zone identified Saskatchewan cattle between 2003 and 2012 from the Prairie in Saskatchewan cattle between 2003–2012 from the Prairie Diagnostic Services database. Diagnostic Services database. Mineral Fetusa Newborn Calf Adult Total Dark Dark Mineral gray Black brown Brown Gray Total Copper 42 8 62 135 247 Manganese — 37 23 20 80 Copper 21 93 103 61 23 301 Iron 7 7 14 47 75 Iron 9 26 43 10 8 96 Magnesium 46 2 4 15 67 Manganese 9 27 19 25 3 83 Zinc 12 5 11 28 56 Magnesium 9 16 20 18 6 69 Cobalt 21 1 3 2 27 Zinc 9 17 13 19 4 62 Nickel — — — — 0 Cobalt 2 9 6 8 2 27 ARTICLE Total number of 128 60 117 247 552 Nickel — — — — — 0 mineral deficiencies Total number of 59 188 204 141 46 638 N 270 140 325 448 1181 mineral deficiencies Number of animal 95 53 98 188 437 N 77 413 449 378 117 1434 deficiencies Number of animals 33 151 169 120 36 509 Percentage of animal 35.2 37.9 30.2 42.0 37.0 deficient deficiencies Percentage of animal 42.9 36.6 37.6 31.7 30.8 35.5 deficiencies N — total number of samples tested. Only 1 sample was tested from each animal. Reference values for deficiencies adapted from (7) are: copper , 3, 10, 20, and N — total number of samples tested. Only 1 sample was tested from each animal. 0.5 mg/kg for kidney, liver, fetal liver, and plasma or serum, respectively; iron , 20, Reference values for deficiencies adapted from (7) are: copper , 3, 10, 20, and 30, and 1.3 mg/kg for kidney, liver, and plasma or serum, respectively; manganese 0.5 mg/kg for kidney, liver, fetal liver, and plasma or serum, respectively; iron , 20, liver values , 1 mg/kg; zinc , 18, 25, and 0.5 mg/kg for kidney, liver and serum, 30, and 1.3 mg/kg for kidney, liver, and plasma or serum, respectively; manganese respectively; magnesium , 50, 100, and 11 mg/kg for kidney, liver, and serum liver values , 1 mg/kg; zinc , 18, 25, and 0.5 mg/kg for kidney, liver and serum, or plasma, respectively; cobalt , 0.014 and 0.005 mg/kg for kidney and liver, respectively; magnesium , 50, 100, and 11 mg/kg for kidney, liver, and serum or respectively; nickel , 0.01 mg/kg for kidney (wet weight). Pearson’s Chi-square test plasma, respectively; cobalt , 0.014 and 0.005 mg/kg for kidney and liver, for the number of deficiencies by age group P = 0.01, Z-test of column proportions respectively; nickel , 0.01 mg/kg for kidney (wet weight). Pearson’s Chi-square test indicate that adults are significantly different from calves, P = 0.009 with Bonferroni for the occurrence of deficiencies by soil type was not significant, P = 0.172 and correction. P = 0.053 for Cu deficiencies. a Fetus ,0 days, newborn , 7 days, calf 7 to 364 days, adult . 364 days.

encephalopathy was first diagnosed in Canada and may have had a negative impact on diagnostic submissions (22). The diagnos- Discussion tic submissions were low in the following years and increased The observed monthly differences in mineral deficiencies likely after 2005, when the United States lifted the trade ban (22), reflect the seasonal changes in the beef industry and most com- but there were no significant differences between these years. mon clinical manifestations of deficiency, such as abortion given The highest number of submissions occurred in 2009 with 336 the observed trends. Submissions are highest in March and April followed by 2011 with 293. Economic factors over this period with 134 and 119 cases, respectively, and the greatest proportion that may have influenced the submission of diagnostic samples of deficiencies occur in February, March, and June. Late-term include an economic recession, country of origin labelling, abortions or weaker calves likely prompt testing within the herd strong Canadian dollar, and increasing feed prices (23). A limita- during February and March. Whereas early-term abortions or tion of the study was in dichotomizing the outcome as normal increased number of open cows would be overlooked between or deficient instead of treating each element separately. There November and January. An alternative to increased recognition could be interactions amongst these minerals that could affect is increased manifestation of deficiencies due to the quality of the significance of the association. This method was chosen to stored feeds or increased energy demands, such as inclement prevent repeated statistical testing on the data set, which would weather or advanced gestation during these months (17). The inflate the type 1 error. Chi-square analysis was chosen over greater percentage in June likely reflects individual testing of logistic regression as the purpose of this study was to describe animals showing distinct clinical disease. trends and not to predict deficiency. Logistic regression may For wild deer, the severity of winters, specifically the tempera- offer more complexity but essentially showed similar results ture in early winter, is associated with poorer conditions and when it was performed. increased mortalities (18). Despite this association between body The relationship of soil type and mineral content has been condition, physiologic adaptations, and ambient temperature, demonstrated in Saskatchewan for Cu and Mo but not Fe, Zn, there is no published information on the effects of ambient or Mn (12,24). This is inconsistent with our findings, in which temperature on trace mineral status (19). A summary of the there is no significant difference in Cu deficiencies associated severity of Saskatchewan winters was reviewed, but increased with the soil types. The greatest percentage of deficiencies deficiencies did not coincide with severe winters (20). The occurred in the dark gray soil zone which also had the largest significantly greater number of deficiencies in 2010 compared percentage of Cu deficiencies. These dark gray and muskeg soil to 2003 could also not be explained by crop quality, which was zones have lower concentrations of Cu and higher concentra- poor in 2002 to 2003 coincident with a smaller proportion of tions of Mo, which antagonizes Cu absorption, and may explain deficiencies; whereas, in 2010 the crop quality was high with this difference, although it was not significant (24). Reported a higher proportion of deficiencies (21). Our data set did not liver values from Saskatchewan cattle from the dark gray and include the source of feedstuffs and therefore limited conclu- muskeg soil zones were higher in Fe and lower in Cu content sions can be made. Year 2003 was the year bovine spongiform (13,24). This is explained by Fe accumulation in the liver with

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Table 6. Reported trace liver mineral values for Ba, Be, Bi, Cd, Cr, Mn, Mo, Sb, Sn, Sr, Tl, and V measured in mg/kg wet weight in Saskatchewan cattle identified between 2003 and 2012 from the Prairie Diagnostic Services database. Range Geometric Standard Mineral mean deviation min max 95% CI N Barium 42.1 122 0.82 1046 32.4 54.6 78

Beryllium 1.03 13.65 0.02 60 0.645 1.64 54 ARTICLE Bismuth 0.418 2.22 0.001 10.7 0.214 0.818 26 Cadmium 20.2 94.4 0.14 490 13.7 29.7 88 Chromium 76.8 121 9.72 747 64.1 92 90 Manganesea 709 416 70 2100 656 766 237 Molybdenum 427 442 6 3470 403 452 774 Antimony 2.25 33.3 0.06 268 1.57 3.23 73 Tin 7.92 17.7 0.27 106 6.18 10.1 71 Strontium 82.3 77.9 4.9 454 71.1 95.2 89 Thallium 0.36 1.25 0.058 8.09 0.281 0.472 69 Vanadium 44.1 116 0.26 600 30.5 63.8 71

a Fetal liver concentrations.

decreased Cu concentrations, which are low in the aforemen- below toxic levels (7). Vanadium accumulates in the liver and tioned soil zones (24). These soil classifications are chernozemic signs of toxicity include diarrhea, inappetence, dehydration, and are based on the organic content of the surface horizon and emaciation, dry hair coat, and inability to rise (7). Tolerance the mineral content in the organic layer which is released from can develop to greater exposure and these increased values may the clay components (25–27). The lack of association could be not correlate well with clinical manifestations (7). Mineral con- attributed to the soil classification system used. Alternatively, centrations that are higher than the normal reference range for the type of soil, source of feedstuffs, use of mineral supplements, Ba and V could indicate an increase in exposure, alternatively use of fertilizers, or management strategies may confound our it could reflect elemental interactions, or sampling bias in our results. study. The geometric mean concentrations for Mo, Sn, Sr, Cr, Barium has not been shown to be involved in any biochemi- and Tl 427, 7.92, 82.3, 76.8, and 0.36 mg/kg, were comparable cal pathways in the body and is of toxicological concern. The to the previously reported normal reference ranges of 140 to free ion and barium chloride are highly toxic, whereas the envi- 14 000, , 600, 190, 40 to 3800, and , 50 mg/kg, respectively ronmental forms, barium carbonate and barium sulphate, are (7). The geometric mean concentration for fetal liver Mn was much less so (7). The primary sources for the toxic forms are 709 mg/kg. This is comparable to a previous study in which associated with industrial chemicals (28). Liver concentrations the average liver value of aborted fetuses from Saskatchewan are considered elevated between 10 to 21 400 mg/kg (14). The cattle was 870 mg/kg (14). There were no comparisons in the geometric mean for laboratory samples of Saskatchewan cattle literature or reference ranges listed for cattle for Be, Bi, and Sb. is within this range at 42.1 mg/kg (Table 6). This is unexpected The minerals in Table 6, excluding Mn, exhibited large ranges considering Saskatchewan does not contain any deposits of bar- and standard deviations. This is expected for these minerals as ite which is the primary environmental source of barium (29). they reflect environmental exposure and generally have a log The main industrial chemical sources are insecticides, pesticides, normal distribution (7). This was accounted for in the use of rodent poisons, lubricants, and rubber (29). geometric means, confidence interval, and standard deviation The geometric mean Cd liver concentrations from laboratory (8). It is important to note that the percentage of deficiencies samples of Saskatchewan cattle was 20.2 mg/kg (Table 6), which reported in this study do not represent deficiencies in the actual falls within the normal reference range of 20 to 1000 mg/kg (7). population but are drawn from the cases submitted for mineral Previous reports of Cd liver concentrations in Canadian cattle analysis during the evaluated period. did not indicate a mean as most samples were below the limit The variable reference ranges and inconsistent reporting make of detection, 40 to 300 mg/kg, and our current mean falls below interpretation of mineral concentrations and comparisons chal- this range as well (30). The main sources of Cd as well as V are lenging, limitations that have also been encountered by other industrial contamination with exposure occurring by ingestion researchers (32). For non-essential minerals, there is limited of contaminated food or water (12). The geometric mean and published data and further investigation is warranted, particu- range for V, 44.1 mg/kg (range: 0.26 to 600 mg/kg) in liver, was larly for Ba and V in Saskatchewan cattle. Additionally, a better well above the normal range for liver, 6 to 7 mg/kg (7). The only understanding of the kinetics of mineral distribution and use, published comparison is from a test herd in South Africa that particularly in relation to weather extremes, would be beneficial. was divided into high and low environmental exposure groups, Further investigation of the trends in mineral deficiencies and median of 1340 mg/kg (range: 330 to 11 500 mg/kg) (31). The their economic impact should include consideration of breed, geometric mean would, from our study, be above normal but mineral supplementation, feedstuff, and use of fertilizers.

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Acknowledgments 16. Geomatic Services, Ministry of Agriculture. Soil Zones in Southern Saskatchewan. Government of Saskatchewan 2009. The authors thank Prairie Diagnostic Services for access to 17. Corah L. Trace mineral requirements of grazing cattle. Anim Feed Sci their database, Al Rung for his technical support, and Dr. Sarah Technol 1996;5:61–70. 18. Putman RJ, Staines BW. Supplementary winter feeding of wild red deer Parker for her help with statistical analysis. CVJ Cervus elaphus in Europe and North America: Justifications, feeding practice and effectiveness. Mamm Rev 2004;34:285–306. References 19. Young BA. Ruminant cold stress: Effect on production. J Anim Sci . 1 Guyot H, Saegerman C, Lebreton P, Sandersen C, Rollin F. Epidemiol­ 1983;57:1601–1607. ogy of trace elements deficiencies in Belgian beef and dairy cattle herds. 20. Saskatchewan Wildlife Management Report, 2013–2014. Ministry of J Trace Elem Med Biol 2009;23:116–123. Environment, Fish and Wildlife Branch, Wildlife Branch 2015:17–19. 2. Graham TW. Trace element deficiencies in cattle. Vet Clin North Am 21. Annual Report: 2003–2004, 2004–2005, 2005–2006, 2006–2007, ARTICLE Food Anim Pract 1991;7:153–215. 2007–2008, 2008–2009, 2009–2010, 2010–2011. Canadian Wheat 3. Swecker WS. Trace mineral feeding and assessment. Vet Clin North Am Board. Available from: http://www.publications.gc.ca/site/eng/432469/ Food Anim Pract 2014;30:671–688. publication.html Last accessed October 17, 2019. 4. Mohebbi-Fani M, Nazifi S, Ansari-Lari M, Namazi F. Mixed mineral 22. O’Neill K. How two cows make a crisis: US–Canada trade relations and deficiencies in a dairy herd with subclinical production disorders. Comp mad cow disease. Am Rev Can Stud 2005;35:295–319. Clin Path 2010;19:37–41. 23. Twine E, Rude J. Effects of market and policy shocks on the Canadian 5. Orr C, Hutcheson D, Grainger R, Cummins J, Mock R. Serum cop- and US cattle and beef industries. Agricultural and Applied Economics per, zinc, calcium and phosphorus concentrations of calves stressed by Association 2012. Available from: https://ageconsearch.umn.edu/ bovine respiratory disease and infectious bovine rhinotracheitis. J Anim record/123565/files/AAEA2012_TWINE_RUDE_.pdf Last accessed Sci 1990;68:2893–2900. October 17, 2019. 6. Herdt TH, Hoff B. The use of blood analysis to evaluate trace mineral 24. Gooneratne S, Christensen D. A survey of maternal and fetal tissue zinc, status in ruminant livestock. Vet Clin North Am Food Anim Pract 2011; iron, manganese and selenium concentrations in bovine. Can J Anim 27:255–283. Sci 1989;69:151–159. 7. Puls R. Mineral Levels in Animal Health. Diagnostic Data. Clearbrook, 25. Kruger G, Karamanos R, Singh J. The copper fertility of Saskatchewan British Columbia: Sherpa International, 1994:30–32, 39–40, 72, 75–77, soils. Can J Soil Sci 1985;65:89–99. 83–88, 135–137, 192–193, 199, 263, 278, 283–283. 26. Tom-Petersen A, Hansen HCB, Nybroe O. Time and moisture effects 8. Suttle NF. Mineral Nutrition of Livestock. 4th ed. Wallingford, on total and bioavailable copper in soil water extracts. J Environ Qual UK: CABI Publishing, 2010:92–121, 223–305, 334–458, 462–476, 2004;33:505–512. 479–488, 494–501. 27. Mermut A, Jain J, Song L, Kerrich R, Kozak L, Jana S. Trace element 9. World Health Organizaiton. Trace elements in Human Nutrition concentrations of selected soils and fertilizers in Saskatchewan, Canada. and Health. Geneva Switzerland: World Health Organization, 1996: J Environ Qual 1996;25:845–853. 161–228. 28. Johnson CH, VanTassell VJ. Acute barium poisoning with respiratory 10. Nielsen SP. The biological role of strontium. Bone 2004;35:583–588. failure and rhabdomyolysis. Ann Emerg Med 1991;20:1138–1142. 11. Smart ME, Gudmundson J, Christensen DA. Trace mineral deficiencies 29. Canadian Councils of Ministers and the Environment. Canadian soil in cattle: A review. Can Vet J 1981:22:372. quality guideline for the protection of environmental and human health: 12. Smart ME, Cymbaluk NF, Christensen DA. A review of copper status Barium. Canadian environmental quality guideline, Canadian Council of cattle in Canada and recommendations for supplementation. Can of Ministers of the Environment, Winnipeg 2013. Vet J 1992;33:163–170. 30. Korsrud GO, Meldrum JB, Salisbury CD, Houlahan BJ, Saschenbrecker 13. Gooneratne S, Christensen D. A survey of maternal copper status and PW, Tittiger F. Trace element levels in liver and kidney from cattle, fetal tissue copper concentrations in Saskatchewan bovine. Can J Anim swine and poultry slaughtered in Canada. Can J Comp Med 1985;49: Sci 1989;69:141–150. 159–163. 14. Waldner CL, Blakley B. Evaluating micronutrient concentrations in liver 31. Gummow B, Botha C, Noordhuizen J, Heesterbeek J. The public health samples from abortions, stillbirths, and neonatal and postnatal losses in implications of farming cattle in areas with high background concentra- beef calves. J Vet Diagn Invest 2014;26:376–389. tions of vanadium. Prev Vet Med 2005;72:281–290. 15. Kirchgessner M, Neesse K. Copper, manganese, and zinc contents 32. Dermauw V, Alonso ML, Duchateau L, et al. Trace element distribu- in the whole body and in individual parts of veal calves at different tion in selected edible tissues of zebu (Bos indicus) cattle slaughtered at weights (author’s transl). Zeitschrift fur Lebensmittel-Untersuchung Jimma, SW Ethiopia. PloS One 2014 Jan 21;9:e85300. und-Forschung 1975;161:1–6.

62 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Article

Pilot study of the effectiveness of a xylitol-based drinking water additive to reduce plaque and calculus accumulation in dogs

Candace Lowe, James Anthony

Abstract — Over a period of 208 days a randomized, double-blind clinical trial was conducted to assess plaque and calculus accumulation in dogs provided with a xylitol-based drinking water additive. A crossover design was utilized allowing each dog to participate in each 90-day treatment and control phase. Inclusion of a xylitol drinking water additive resulted in a 5.1% decrease in mean tooth plaque score and a 14.9% decrease in mean calculus score. Daily administration of a palatable, xylitol drinking water additive that required little time and effort reduced plaque and calculus accumulation in dogs.

Résumé — Étude pilote sur l’efficacité d’un additif à base de xylitol à l’eau de boisson a pour réduire la plaque et l’accumulation de tartre chez les chiens. Pendant une période de 208 jours, un essai clinique randomisé à double-insu a été mené pour évaluer l’accumulation de plaque et de tartre chez des chiens supplémentés avec un additif à base de xylitol à l’eau de boisson. Une étude croisée fut utilisée permettant ainsi à chaque chien de participer dans chaque période de 90 jours au groupe traité et au groupe témoin. L’inclusion d’un additif à base de xylitol à l’eau de boisson a résulté en une diminution de 5,1 % du pointage de plaque dentaire et de 14,9 % du pointage moyen de tartre dentaire. L’administration quotidienne d’un additif palatable à base de xylitol dans l’eau de boisson ne requérant que peu de temps et d’efforts a permis de réduire l’accumulation de plaque et de tartre. (Traduit par Dr Serge Messier) Can Vet J 2020;61:63–68

Introduction and systemic disease has been reported in the literature (7–10). Within the periodontal tissues, bacteria, bacterial by-products, eriodontal disease is the most frequently diagnosed disease and inflammatory mediators may be released, resulting in the in dogs in all age groups (1). Periodontitis is the inflam- P development of systemic disease. mation of the periodontium which includes the periodontal Plaque is the collection of bacteria, glycoproteins, epithelial ligament, alveolar bone, cementum, and gingiva. Bacterial and inflammatory cells, and extracellular polysaccharides that by-products and host response to plaque accumulation cause adhere to the tooth surface (2,11). Within seconds of a routine inflammation resulting in gingival recession, alveolar bone dental prophylaxis a thin pellicle accumulates on the tooth sur- resorption, and periodontal pocket formation. Untreated peri- faces. Bacterial recolonization is reported to occur within 3 min odontal disease may eventually progress to tooth mobility, loss, following the placement of sterile enamel into the oral cavity. As and/or endodontic disease (2). Oral pain is difficult to assess in the oral bacteria become firmly attached to the tooth surface, the veterinary patients and clients often do not recognize problems plaque matures, and an organized structure or biofilm develops. until periodontal disease has progressed to moderate or severe The biofilm is composed of organic and inorganic materials that stages (3). The initial development and severity of periodontal function to distribute nutrients throughout the plaque matrix disease are dependent on factors such as health status, breed, age, (11). The bacteria that accumulate within the gingival sulcus are and diet (3–6). As well as causing significant oral pain, bone and responsible for the development of gingivitis. Untreated gingivi- tooth loss in dogs, an association between periodontal disease tis may progress to periodontitis. Within 2 to12 d following its development plaque mineralizes resulting in calculus formation Small Animal Clinical Sciences, Western College of Veterinary on the tooth surfaces. Dental calculus is primarily composed of Medicine, University of Saskatchewan, 52 Campus Drive, non-viable plaque microorganisms and calcium phosphate min- Saskatoon, Saskatchewan S7N 5B4. eral salts provided by salivary and gingival crevicular fluids. A Address all correspondence to Dr. Candace Lowe; e-mail: non-mineralized layer of dental plaque containing viable bacteria [email protected] adheres to the surface of calculus deposits (11). Use of this article is limited to a single copy for personal study. Plaque accumulation must be controlled in order to prevent Anyone interested in obtaining reprints should contact the the development or progression of periodontal disease (11). CVMA office ([email protected]) for additional Mechanical or chemical anti-plaque agents can control the copies or permission to use this material elsewhere. development of plaque and its progression to calculus. Multiple

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products have been developed in each category to decrease kibble (Pro Plan Adult Chicken and Rice; Purina, St. Louis, plaque accumulation (12). Frequent brushing is the most effec- Missouri, USA) for the first 14 d of the trial. During this period tive method of mechanically removing plaque in humans and no mechanical or chemical anti-plaque products were given. dogs (13). In a recent study that compared brushing, daily den- On day 15 each patient was anesthetized for an oral examina- tal chew and dental diet, dogs in the daily tooth brushing group tion and dental prophylaxis procedure in order to provide each had a statistically significant lower mean mouth score (14). participant with a mean mouth plaque and calculus score of The goal of routine oral home care is to improve a patient’s zero before initiation of the study. Each participant was fasted general oral health in order to minimize the need for more inva- 12 h before the commencement of general anesthesia. General sive treatments. Decreased client compliance has been reported anesthesia was performed for all scoring and dental prophy-

ARTICLE with respect to mechanical anti-plaque and anti-calculus meth- laxis procedures using the following protocols; placement of ods (i.e., tooth brushing). Research by Miller and Harvey (15) a cephalic IV catheter, induction with propofol (Rapinovet; revealed that 6 mo after periodontal treatment and home care Schering-Plough, Pointe Claire, Quebec), 6 mg/kg body weight education, only 53% of clients complied with homecare recom- (BW), IV, thiopental (Thiotal; Vétoquinol, Lavaltrie, Quebec), mendations by brushing their dogs’ teeth several times a week. 10 mg/kg BW, IV, or ketamine (Vetalar; Bioniche, Belleville, This lack of compliance is thought to primarily be due to the Ontario), 5 mg/kg BW, IV, and diazepam (Diazepam; Sandoz, amount of time required and patient tolerance. Increased client Boucherville, Quebec), 0.5 mg/kg BW, IV, to effect, intuba- compliance may be seen with chemical anti-plaque, anti-calculus tion (Rusch Endotracheal Tube Murphy Eye High Volume agents due to the ease of administration and decreased time Low Pressure Cuff; Teleflex Medical, Triangle Park, North requirement. Xylitol is utilized for its plaque-reducing effect in Carolina, USA) and maintenance of general anesthesia via a humans and animals (16,17). The purpose of this randomized, rebreathing circle system with 1.5% to 2.0% isoflurane (IsoFlo; double-blind clinical trial was to assess plaque and calculus accu- Abbott, Saint-Laurent, Quebec) in 3 L/min of oxygen. Fluid mulation in dogs following the use of a commercially available support (Normosol-R; Hospira, Montreal, Quebec) at a rate xylitol containing water additive. of 10 mL/kg BW per hour and body temperature were main- tained using a warm fluid-circulating mat (T/Pump; Gaymar Materials and methods Industries, Orchard Park, New York, USA) during general A clinical trial was conducted at the University of Saskatchewan anesthesia. Throughout the procedure the heart rate, respira- in accordance with the requirements of the Animal Research tory rate, peripheral oxygen saturation, and indirect systolic Ethics Board. Informed written consent was provided by the cli- blood pressure were measured and recorded every 5 min. Dental ents of study participants. Patients were admitted into the clini- prophylaxis included supra- and sub-gingival scaling using the cal trial based on the following criteria; age 2 to 6 y, medium same sterilized piezoelectric and hand-scaling instruments for to large breed dogs, mesaticephalic head type, and availability each patient. The teeth were polished using a low speed hand on the scheduled dates. Dogs were excluded from the trial for piece and single use rubber prophy cup (Prophylaxis polishing any of the following reasons: concurrent medications, systemic cups; Dentamerica, Industry, California, USA) and fine non- diseases, malocclusion, missing dentition required for scoring fluorinated prophy paste (Glitter professional prophylaxis paste; purposes, and periodontal disease. No form of compensation Premier, Philadelphia, Pennsylvania, USA). No chlorhexidine, was given, but all participants were provided with the same diet fluoride or antibiotic treatments (anti-plaque agents) were throughout the entire trial period. No additional chemical or administered. All dental prophylaxis procedures for the entire mechanical anti-plaque or anti-calculus agents were permitted study were performed by the same second-year dental resident. during the trial period. The study was divided into 2 phases allowing each participant Eight client-owned dogs were entered into the clinical trial to function as its own control. The investigator, second-year based on the inclusion and exclusion criteria. This pilot study resident, and clients were blinded to which treatment the partici- sample size was chosen based on the early recommendations pant was receiving. To ensure blinding, the placebo was prepared of the Veterinary Oral Health Council’s to include at least to have similar physical characteristics as the treatment solution. 5 subjects for a crossover clinical trial design. Oral examina- The placebo included the following components; distilled water tions were performed on staff and faculty members’ dogs until (500 mL), a coloring agent [F.D. & C Powder (Brilliant Blue); the 8 patients were identified. Three male and five female dogs Professional Compounding Centers of America, Houston, Texas, were studied with ages and weights ranging from 2 to 6 y (mean: USA] (0.05 mL) and an emulsifier (Tween 80 NF; Wiler Fine 3.75 y) and 8.2 to 40.1 kg (mean: 28.9 kg), respectively. Two Chemicals Ltd., London, Ontario) (0.05 mL). The treatment and of the three male participants were neutered. Each participant placebo solution were placed in similar containers and marked had mild to moderate plaque and calculus accumulation prior to A and B, and the contents were not revealed to the investiga- entering the study. Physical examination and laboratory testing tors until completion of the study. In phase 1 each participant including complete blood (cell) count (CBC), serum chemistry, was blindly randomized using a computerized randomization and urinalysis performed before commencement of the study program by the same pharmacist who prepared the placebo confirmed participants were healthy. to receive either the treatment or control. Treatment group Participants were housed in their regular environment and participants were offered the xylitol-treated water (Breathalyser received ad libitum untreated tap water and Association of Plus; ImRex, St. Joseph, Missouri, USA) at the concentration American Feed Control Officials (AAFCO) approved adult recommended by the manufacturer (10 mL of water additive

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109 ARTICLE

Figure 1. Evaluation of plaque on right maxillary 103, 104, 107, Figure 2. Evaluation of calculus on right maxillary 103, 104, 107, 108, 109, and right mandibular 404, 407, 408, and 409 target 108, 109, and right mandibular 404, 407, 408, and 409 target teeth. Application of plaque disclosing solution to the buccal teeth. Deposition of calculus before application of plaque and labial surfaces of the crown of the target teeth. disclosing agent. per liter of untreated water) every 24 h for 90 d. Control group toothbrush and the teeth were air dried before scoring. Each participants were given the placebo at the same concentration target tooth was divided vertically into mesial, buccal, and distal for the same time period. thirds and each third was assigned a numerical score. Scores Following phase 1 (90 d) the participants were placed under were given based on percentage of calculus coverage. Grading general anesthesia as previously described for their first plaque criteria for calculus coverage: 0 = no calculus detected, 1 = 1% and calculus assessment. All plaque and calculus evaluations to 24%, 2 = 25% to 49%, 3 = 50% to 74%, 4 = 75% to 100% throughout phases 1 and 2 of the study period were per- (Figure 2). The numerical scores for the mesial, buccal, and formed by the same blinded, second-year dental resident. distal aspect of the tooth were added to provide a total tooth Each participant’s plaque deposition was visually assessed and score. The mean mouth score was calculated by averaging the evaluated using a modified Quigley and Hein (Turesky) plaque 18 total tooth scores for each participant. index reported by Logan and Boyce (18). The following target After completion of phase 1, a 14-day rest period was given teeth were scored in each participant: maxillary third incisors during which participants received ad libitum AAFCO approved (103/203), maxillary canines (104/204), maxillary third and adult kibble, untreated tap water, and no mechanical or chemical fourth premolars (107/207 and 108/208), maxillary first molars anti-plaque products. Prior to initiating phase 2 a mean mouth (109/209), mandibular canines (304/404), mandibular third score of zero was achieved before the second phase of the study and fourth premolars (307/407 and 308/408), and mandibular using the previously described dental prophylaxis procedure first molar (309/409). A 2% eosin plaque disclosing solution under general anesthesia performed by the same second-year (Trace disclosing solution; JorVet, Loveland, Colorado, USA) dental resident. In phase 2 each participant was provided with was applied to the buccal and labial surface of the crown of the the opposite treatment that they received in phase 1, xylitol target teeth. The solution was immediately rinsed from teeth treated water or placebo treated water, at a concentration of using an air water syringe held 15 cm from the tooth surface. 0.05 mg/mL every 24 h for 90 d. Plaque and calculus evalua- Each tooth was divided horizontally into gingival and coronal tions were performed by the same examiner upon completion halves and each half was assigned a numerical score. Scores were of the second, 90-day test phase. given for percentage of plaque coverage and thickness of plaque Participant #8 was eliminated from the study during the first deposition based on intensity of staining of the plaque. Grading test phase as gastrointestinal irritation following ingestion of criteria for plaque coverage: 0 = no plaque detected, 1 = 1% to compost necessitated systemic antibiotic therapy and diet change. 24%, 2 = 25% to 49%, 3 = 50% to 74%, 4 = 75% to 100%. The statistical comparisons do not include data from this partici- Grading criteria for plaque thickness: 1 = Light (pink to light pant. The mean mouth dental plaque and calculus scores for the red), 2 = Medium (red) (Figure 1). Each half of tooth (gingival remaining 7 study participants were utilized. A statistical software and occlusal) received a score by multiplying the coverage and program (Stata SE 10; Stata Corp, College Station, Texas, USA) thickness numerical scores and the gingival and occlusal scores was used to perform statistical analyses. Comparisons between were added to provide a total tooth score. Participants mean participants mean mouth dental plaque and calculus scores with mouth plaque scores were calculated by averaging the 18 total and without the xylitol drinking water additive were made using tooth scores. a 2-tailed Wilcoxon signed-rank test and paired Student’s t-test, Calculus deposition was visually assessed and evaluated using respectively. A P-value , 0.05 was considered significant. a modified Schiff calculus index reported by Logan and Boyce (18). Eighteen target teeth; maxillary third incisors (103/203), Results maxillary canines (104/204), maxillary third and fourth premo- No adverse effects related to the diet or water additive were lars (107/207 and 108/208), maxillary first molars (109/209), reported throughout the study period. The water additive was mandibular canines (304/404), mandibular third and fourth considered palatable as there were no reports of partial or com- premolars (307/407 and 308/408), and mandibular first molar plete refusal to accept the treated drinking water. (309/409) were scored in each participant. The plaque was The crossover study design allowed for the comparison of removed by brushing the teeth with a standard soft bristle each participant’s mean mouth plaque and calculus scores with

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Table 1. Individual participants mean tooth plaque scores with and Table 2. Total mean tooth plaque scores with and without water without water additive treatment. additive treatment. Mean tooth plaque scores Plaque Participant Total mean tooth number No water additive Water additive Treatment score 1/2 SD Percent reduction Significance

1 10.11 7.50 No water additive 8.06 1/2 1.33 5.1% P = 0.2367 2 8.50 7.67 Water additive 7.65 1/2 0.57 3 7.72 7.39 4 7.33 7.22 5 8.28 7.61

ARTICLE 6 8.67 7.28 adhesiveness. A reduced synthesis of insoluble polysaccharides 7 5.78 8.89 was observed in S. mutans when exposed to xylitol in vitro 8 ND ND (20). Since insoluble polysaccharides are required for proper ND — no data. plaque adhesion to the tooth surface it has been proposed that xylitol may affect the adhesiveness of plaque in vivo. Extensive and without the xylitol drinking water additive. All participants research on xylitol metabolism has been performed on S. mutans except dog #7 had a decreased mean mouth plaque score dur- because it constitutes a large proportion of the microbes found ing the xylitol drinking water additive phase of the study. The in human dental plaque. S. mutans is also one of the most sig- participants’ averaged total mean mouth plaque scores were nificant contributors to the development of caries in humans. 8.06 [standard deviation (SD): 1/2 1.33] without the xylitol The anti-bacterial mechanism of xylitol on pathogenic oral drinking water additive and 7.65 (SD: 1/2 0.57) with the bacteria involves cellular competition with sucrose as well as xylitol drinking water additive (Table 1). A 5.1% decrease in the direct toxic effects of xylitol metabolites. Although xylitol is plaque accumulation was noted in participants treated with the readily absorbed by S. mutans, metabolism through fermentation xylitol drinking water additive (Table 2); however, the results does not occur. The inability to produce energy results in a net were not statistically significant (P = 0.2367). An outlier in the energy loss by the pathogenic oral bacteria known as a “futile dataset resulted in an abnormal distribution and because of cycle” and decreased bacterial growth. In addition, a metabolite this, nonparametric evaluation (Wilcoxon signed-rank test) was of xylitol metabolism, xylitol-5-phosphate, is produced. Xylitol performed. In addition, the abnormal distribution resulted in a toxicity and death of pathogenic oral bacteria ensue following large standard deviation resulting in a study power of , 10%. metabolism of xylitol-5-phosphate (21). A decreased mean mouth calculus score was observed dur- This clinical trial detected a significant decrease (14.9%) in ing the xylitol drinking water additive phase in all participants calculus accumulation during the xylitol drinking water addi- except dog #4. The participants averaged total mean mouth tive treatment phase. Greater decreases in calculus deposition calculus scores were 4.84 (1/2 0.89) without the xylitol drink- (53.5%) were found in a similar study performed in 29 cats ing water additive and 4.12 (1/2 0.95) with the xylitol drinking­ (17). The study designs were similar, however, species differ- water additive (Table 3). A 14.9% statistically significant ences, number of participants, and blinding of the examiner decrease in calculus accumulation was observed in participants may account for the differences in calculus accumulation seen during the xylitol drinking water additive treatment phase between the 2 studies. Blinded, randomized, controlled clini- (P = 0.0469, Table 4). A normal distribution was observed in the cal trials are required with a greater number of participants in calculus dataset; therefore, parametric testing (paired Student’s order to establish the effectiveness of xylitol in dogs. Though t-test) was used. not statistically significant, a decrease (5.1%) in plaque accu- mulation was detected in participants when provided with Discussion xylitol drinking water additive compared to untreated water. Numerous successful plaque control methods have been docu- This is quite different from Clarke’s study in cats in which a mented in the literature, but client compliance is often unsat- 52.3% statistically significant decrease in plaque deposition was isfactory (15). A plaque-reducing drinking water additive may observed (17). Proposed hypotheses for the findings include; increase client compliance due to its ease of administration and species differences, insufficient sample size, inadequate plaque palatability. The present study used xylitol as a drinking water scoring system, disruption of plaque deposition prior to scoring, additive to decrease the plaque and calculus accumulation in the and xylitol ineffectiveness. study population. Xylitol is a natural polyalcohol that is com- Numerous plaque and calculus grading systems have been monly used as a low-calorie sugar substitute. Xylitol has been developed for humans and modified for veterinary patients. The proposed to reduce the quantity of plaque, decrease the adhe- precision, accuracy, and clinical relevance of these systems have sion of plaque flora, be non-fermentable by plaque organisms, been questioned in the literature (22–24). The method to index reduce Streptococcus mutans, participate in a futile metabolic plaque and calculus for the current study was chosen based on cycle and result in an accumulation of xylitol-5-phosphate in research by Logan and Boyce (18). Recent plaque and calculus some plaque streptococcal species (19). As discussed earlier, quantification methods state greater accuracy and reproducibil- plaque is the collection of bacteria, salivary glycoproteins, and ity. A novel plaque quantification method proposed by Scherl extracellular polysaccharides that adhere to the tooth surface. et al (22) has been evaluated and accepted by the Veterinary Plaque quantity is thought to be reduced by decreasing plaque Oral Health Council. A specialized instrument measures the

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Table 3. Individual participant mean tooth calculus scores with Table 4. Total mean tooth calculus scores with and without water and without water additive treatment. additive treatment. Mean tooth calculus scores Calculus Participant Total mean tooth number No water additive Water additive Treatment score 1/2 SD Percent reduction Significance

1 5.94 4.39 No water additive 4.84 1/2 0.89 14.9% P = 0.0469

2 4.22 3.72 Water additive 4.12 1/2 0.95 ARTICLE 3 5.44 5.22 4 3.94 4.22 5 5.78 4.39 6 4.83 4.72 a dose-related release of insulin and resultant hypoglycemia 7 3.78 2.22 (32,33). Hypoglycemia following xylitol administration in dogs 8 ND ND is thought to result from hypersecretion of endogenous insulin ND — no data. from the pancreas. A toxicity trial performed by Xia et al (33) showed that orally administered doses of 100 and 400 mg/kg lengths of the gingival margins and compares this measure- BW of xylitol resulted in hyperinsulinemia and hypoglycemia as ment to the length of plaque on the gingival margin. Hennet well as changes such as hypokalemia, hypophosphatemia, hyper- et al (25) increased the accuracy and reproducibility of plaque bilirubinemia, and increased serum aspartate aminotransferase quantification using shade scales and anatomic landmarks for and alanine aminotransferase concentrations. Clinical signs in division of the tooth. Perhaps utilizing these methods would all dogs following xylitol administration included inactivity and have allowed the collection of data with greater accuracy and depression. One dog exhibited mild to moderate dystaxia and precision, resulting in greater difference between the treatment mild tremors. All dogs recovered without treatment and blood and control groups. glucose values returned to reference interval within 3 to 4 h The mean mouth plaque score (5.78) for participant #7 was following xylitol administration. The ASPCA Animal Poison significantly decreased in comparison to the averaged mean Control Center considers that dogs that ingest . 100 mg/kg mouth plaque score (8.06 1/2 1.33). There are many potential BW and 500 mg/kg BW of xylitol are at risk for developing explanations for this outlier, our main concern was disruption hypoglycemia and hepatotoxicity, respectively. Gastrointestinal of plaque deposition before scoring. Plaque disruption while decontamination and blood glucose monitoring are recom- unsupervised or during anesthesia may have affected the results, mended for toxicities . 50 mg/kg BW (29). The vast difference leading to our insignificant findings. Use of one of the previ- in outcomes following oral ingestion of xylitol is thought to be ously discussed less invasive plaque evaluation techniques or by caused by the complete and rapid absorption of xylitol in dogs performing the research in a 24-hour controlled environment in comparison to humans (32). may have allowed collection of more accurate data (22). Xylitol toxicity research in dogs is ongoing. A retrospective A substantial amount of microbiological research and clinical study of 199 dogs that ingested 3 to 3640 mg/kg BW of xylitol trials on the effects of xylitol have been performed in humans. found that the clinical signs ranged from none to vomiting, leth- Streptococcus mutans has been the primary focus of microbiologic argy, diarrhea, or seizures. This study showed that if veterinary studies because it constitutes a large proportion of the microbes care is sought following ingestion of xylitol-containing products, found in dental plaque and is a significant contributor to the a good prognosis for full recovery is expected (34). A prospective development of caries in humans. In comparison to human study in which dogs received the xylitol drinking water additive microbiological flora, Streptococcus species are reportedly infre- at the dose recommended by the manufacturer and at 5 times quent components of healthy subgingival flora in dogs (26). the recommended dosage resulted in no clinical signs or statisti- Thirty-eight to seventy-six percent of the microorganisms found cally significant alterations in CBC or serum chemistry values in human plaque are comprised of Streptococcus species, whereas (35). If prepared according to package instructions (0.05 mg/mL only 2.6% and 5.6% were reported in dogs (27). Further concentration), a 15-kg dog with an average daily water intake research into the effects of xylitol on common oral pathogenic (60 mL/kg BW) of 900 mL of treated water would result in a bacteria in dogs is necessary. total xylitol dose of 45 mg. The same 15 kg dog would need Extensive research into the safety of xylitol in humans to ingest 1500 mg or 30 L of appropriately treated water/day resulted in classification of the additive as generally recog- in order to receive the reported toxic dose (100 mg/kg BW). nized as safe (GRAS) and approval by the Food and Drug Regardless of size the maximum daily dose recommended by the Administration. Toxic effects (i.e., osmotic diarrhea) are docu- manufacturer is 50 mg; therefore, even a 2-kg dog would receive mented in humans at doses of 130 g/day (28). Toxicity, includ- well under the reported toxic dose. If adequate instructions are ing acute liver necrosis, coagulopathies, and hypoglycemia have given and client compliance is good, the product used in this been reported in dogs receiving doses . 100 mg/kg body weight clinical trial poses minimal acute health risk to patients. Despite (BW) (29,30). Early research in dogs performed by Kuzuya et al this, there are no studies reporting the health risks of chronic, (31) revealed a 2.5 times increase in insulin concentration fol- low dose administration of xylitol in dogs. lowing IV administration of 400 mg/kg BW of xylitol in com- Clinical trials similar to those performed in humans are parison to IV administration of 400 mg/kg BW of glucose (31). required in dogs in order to determine therapeutic doses of Following oral xylitol administration 2 studies also observed xylitol in dogs. If the therapeutic dose is extrapolated from data

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performed in humans, the therapeutic dose must be expressed 9. DeBowes LJ, Mosier D, Logan E, Harvey CE, Lowry S, Richardson as a dose per unit of body weight (mg/kg BW) due to the wide DC. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996;13:57–60. difference in average weight from humans to dogs. In order to 10. Rawlinson JE, Goldstein RE, Reiter AM, Attwater DZ, Harvey CE. reach therapeutic (anti-plaque) effects, the required daily dose Association of periodontal disease with systemic health indices in dogs of xylitol in humans is 5000 to 10 000 mg divided into 3 doses and the systemic response to treatment of periodontal disease. J Am Vet Med Assoc 2011;238:601–609. (16). An average human weight of 70 kg results in a recommen- 11. Quirynen M, Teughels W, Jakubovics N. Periodontal microbiology. In: dation of 71 to 143 mg/kg BW per day to reach plaque-reducing Carranza’s Clinical Periodontology. St. Louis, Missouri: WB Saunders therapeutic levels of xylitol. As discussed earlier, the toxic effects 2012:232–270. 12. Roudebush P, Logan E, Hale FA. A systematic review of homecare reported in dogs are seen with doses . 100 mg/kg BW. At the for prevention of periodontal disease in dogs and cats. J Vet Dent

ARTICLE maximum dose recommended by the manufacturer (50 mg) 2005;22:6–14. the maximum daily dose of xylitol for a 15-kg dog would be 13. Harvey C, Serfilippi L, Barnvos D. Effect of frequency of brushing teeth on plaque and calculus accumulation, and gingivitis in dogs. J Vet Dent 3 mg/kg BW. Although this is well below the reported toxic 2015;32:16–21. dose, it is also well below the therapeutic range recommended 14. Allan RM, Adams VJ, Johnston NW. Prospective randomised blinded for humans (71 to 143 mg/kg BW per day). Following micro- clinical trial assessing effectiveness of three dental plaque control meth- ods in dogs. J Small Anim Pract 2019;60:212–217. biological and further safety trials, therapeutic levels of xylitol 15. Miller BR, Harvey CE. Compliance with oral hygiene recommenda- need to be determined in dogs. tions following periodontal treatment of client owned dogs. J Vet Dent A product offering high client compliance with plaque and 1994;11:18–19. 16. Ly KA, Milgrom P, Rothen M. The potential of dental-protective calculus reducing properties is ideal. Previous reports in cats chewing gum in oral health interventions. J Am Dent Assoc 2008; have documented great success in the reduction of plaque 139:553–563. (52.3%) and calculus (53.5%) using a xylitol drinking water 17. Clarke DE. Drinking water additive decreases plaque and calculus accumulation in cats. J Vet Dent 2006;23:79–82. additive (21). This study did not find similar results, although 18. Logan EI, Boyce EN. Oral health assessment in dogs: Parameters and a 14.9% and 5.1% decrease in calculus and plaque accumula- methods. J Vet Dent 1994;11:58–63. tion was reported. While an overall decrease was seen in plaque 19. Maguire A, Rugg-Gunn AJ. Xylitol and caries prevention — Is it a magic bullet? Br Dent J 194:429–436. and calculus development with use of a xylitol drinking water 20. Söderling E, Alaräisänen L, Scheinin A, Mäkinen KK. Effect of xylitol additive, in order to achieve an optimal oral health status it and sorbitol on polysaccharide production by and adhesive properties should be used in conjunction with additional anti-plaque of Streptococcus mutans. Caries Res 1987;21:109–116. 21. Trahan L, Bareil M, Gauthier L, Vadeboncoeur C. Transport and and anti-calculus agents such as dental diets, treats, oral gels phosphorylation of xylitol by a fructose phosphotransferase system in and rinses, tooth brushing, and routine oral examinations by a Streptococcus mutans. Caries Res 1985;19:53–63. veterinarian. The current study shows potential results into the 22. Scherl DS, Coffman L, Van Cleave M, Lowry S. Validation of a new dental plaque quantification method in dogs. J Vet Dent 2007; plaque and calculus reducing effects of xylitol in dogs. Because 24:14–20. of this, further research is warranted to evaluate the effect of 23. Hennet P. Review of studies assessing plaque accumulation and gingival xylitol drinking water additives on plaque and calculus accumu- inflammation in dogs. J Vet Dent 1999;16:23–29. 24. Harvey CE. Shape and size of teeth of dogs and cats–Relevance to stud- lation in dogs. Potential research may involve microbiological ies of plaque and calculus accumulation. J Vet Dent 2002;19:186–95. effects of xylitol on common subgingival plaque in dogs. Larger 25. Hennet P, Servet E, Salesse H, Soulard Y. Evaluation of the Logan & clinical trials using less invasive scoring methods are required to Boyce plaque index for the study of dental plaque accumulation in dogs. Res Vet Sci 2006;80:175–180. investigate the therapeutic levels of xylitol. CVJ 26. Loret J. Etude de l’efficacité in vivo in vitro de l’association spiramycine- metronidazole sur la flore paradontale après induction experimentale References d’une paradontite chez le chien. These d’edoctorate en pharmacie, Université Paul Sabatier, Toulouse, France, December, 1990. . 1 Lund EM, Armstrong PJ, Kirk CA, Kolar LM, Klausner JS. Health sta- 27. Wunder JA, Briner WW, Calkins GP. Identification of the cultivable tus and population characteristics of dogs and cats examined at private bacteria in dental plaque from the beagle dog. J Dent Res 1976;55: veterinary practices in the United States. J Am Vet Med Assoc 1999; 1097–1102. 214:1336–4131. 28. Forster H, Quadbeck R, Gottstein U. Metabolic tolerance to high doses 2. Wiggs RB, Lobprise HB. Periodontology. In: Veterinary Dentistry, of oral xylitol in human volunteers not previously adapted to xylitol. Principles and Practice. Philadelphia, Pennsylvania: Lippincott Raven Int J Vitam Nutr Res Suppl 1982;22:67–88. 1997:186–231. 29. Dunayer EK. New findings on the effects of xylitol ingestion in dogs. 3. Harvey CE, Shofer SS, Laster L. Association of age and body weight Vet Med 2006;12:791–796. with periodontal disease in North American Dogs. J Vet Dent 1994;11: 30. Dunayer EK, Qwaltney-Brant SM. Acute hepatic failure and coagu- 94–105. lopathy associated with xylitol ingestion in eight dogs. J Am Vet Med 4. Logan EI. Dietary influences on periodontal health in dogs and cats. Assoc 2006;229:1113–1117. Vet Clin North Am Small Anim Pract 2006;36:1385–1401. 31. Kuzuya T, Kanazawa Y, Kosaka K. Plasma insulin response to intrave- 5. Jensen L, Logan EI, Finney O, et al. Reduction in accumulation of nously administered xylitol in dogs. Metabolism 1966;15:1149–1152. plaque, stain, and calculus in dogs by dietary means. J Vet Dent 1995; 32. Kuzuya T, Kanazawa Y, Kosaka K. Stimulation of insulin secretion by 12:161–163. xylitol in dogs. Endocrinology 1969;84:200–207. 6. Hennet P, Servet E, Soulard Y, Biourge V. Effect of pellet food size and 33. Xia Z, He Y, Yu J. Experimental acute toxicity of xylitol in dogs. J Vet polyphosphates in preventing calculus accumulation in dogs. J Vet Dent Pharmacol Therap 2009;32:465–469. 2007;24:236–239. 34. DuHadway MR, Sharp CR, Meyers KE, Koenigshof AM. Retrospective 7. Pavlica Z, Petelin M, Juntes P, Erzen D, Crossley DA, Skaleric U. evaluation of xylitol ingestion in dogs: 192 cases (2007–2012). J Vet Periodontal disease burden and pathological changes in organs of dogs. Emerg Crit Care 2015;25:646–654. J Vet Dent 2008;25:97–105. 35. Anthony JM, Weber LP, Alkemade S. Blood glucose and liver function 8. Glickman LT, Glickman NW, Moore GE, Goldstein GS, Lewis HB. in dogs administered a xylitol drinking water additive at zero, one and Evaluation of the risk of endocarditis and other cardiovascular events on five times dosage rates. Vet Sci Develop 2011;2:7–9. the basis of the severity of periodontal disease in dogs. J Am Vet Med Assoc 2009;234:486–494.

68 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Article

The comparative efficacy of disinfectant wipes on common-use computer keyboards in a veterinary teaching hospital

Eileen K. Wong, Brandy A. Burgess, Ben M. Brainard, Craig E. Greene, David J. Hurley, Amie Koenig

Abstract — The efficacies of 3 disinfectant wipes at reducing bacterial contamination on keyboards in a veterinary teaching hospital were studied. Thirty common-use keyboards were randomized into “dirty” and “clean” halves. Cultures were obtained from the “dirty” halves. The “clean” halves were disinfected with a randomly assigned wipe [peroxygen (AHP)-, alcohol-, quaternary ammonium (QAC)-based] or untreated (NT) and cultured. Colony- forming units (CFU) were enumerated after 48 hours. Mean reduction in CFU was 91.5%, 65.3%, 94.9%, and 78.8% for the AHP, alcohol, QAC, and NT groups, respectively. There was a significant reduction in CFUs between the dirty and clean keyboard halves within each group but no statistically significant differences were noted between groups. The reduction in CFUs in the NT group was attributed to the mechanical action of wiping the keyboard surface for culture. The use of disinfectant wipes reduced CFUs on keyboards and may be a useful component of veterinary infection control programs.

Résumé — Efficacité comparative de lingettes désinfectantes sur des claviers d’ordinateurs en usage commun dans un hôpital d’enseignement vétérinaire. L’efficacité de trois lingettes désinfectantes à réduire la contamination bactérienne sur des claviers dans un hôpital d’enseignement vétérinaire fut étudiée. Trente claviers en usage commun furent séparés de manière aléatoire en moitié « sale » et « propre ». Des cultures furent obtenues de la moitié « sale ». La moitié « propre » fut désinfectée avec une lingette assignée de manière aléatoire [à base de peroxygène (AHP), alcool, ou ammonium quaternaire (QAC)] ou non traitée (NT) et échantillonnée pour culture. Le nombre d’unités formatrices de colonies (CFU) fut énuméré après 48 heures. La réduction moyenne de CFU était de 91,5 %, 65,3 %, 94,9 %, et 78,8 % pour les groupes AHP, alcool, QAC, et NT, respectivement. Il y avait une réduction significative dans les CFUs entre les claviers des moitiés sale et propre dans chaque groupe mais aucune différence statistiquement significative ne fut notée entre les groupes. La réduction en CFU dans le groupe NT fut attribuée à l’action mécanique de frottage de la surface des claviers. L’utilisation de lingettes désinfectantes a réduit le nombre d’UFC sur les claviers et pourrait être une composante utile des programmes de surveillance des infections vétérinaires. (Traduit par Dr Serge Messier) Can Vet J 2020;61:69–74

Introduction cine, a single study using syndromic surveillance in veterinary ospital-associated infections (HAIs) are infections acquired teaching hospital ICUs found that HAIs may occur in up to H by patients during the course of hospitalization (1). With 16% of canine and 12% of feline critical care patients, and that a prevalence of approximately 4.5 infections per 100 hospital increased duration of hospitalization was a significant risk factor admissions, HAIs in human hospitals throughout the United for the development of HAIs (4). Infections acquired during States result in up to 99 000 deaths and an estimated $28 to hospitalization are more likely to be caused by organisms that 45 billion in direct costs annually (1,2). Hospital-associated are resistant to many antimicrobial drugs and therefore may be infections result in increased duration of hospitalization, cost more difficult to treat (5,6). of care, and morbidity and mortality among human patients Environmental surfaces can play an important role in the (3). While there are limited data available in veterinary medi- transmission of infectious agents in the hospital environment

Departments of Small Animal Medicine and Surgery (Wong, Brainard, Greene, Koenig), Population Health (Burgess), and Large Animal Medicine (Hurley), College of Veterinary Medicine, University of Georgia, Athens, Georgia 30602, USA. Address all correspondence to Dr. Amie Koenig; e-mail: [email protected] This study was funded in part by a grant from the University of Georgia Department of Small Animal Medicine and Surgery Internal Research Program. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

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ARTICLE Figure 1. The keyboards were divided into halves delineated by the middle of the numeral 7. Each half was randomly assigned to be “dirty” or “clean.”

(7). Of particular concern are user interfaces such as common- testing, ordering medications from the pharmacy, submitting use computer keyboards in patient care areas. Studies performed requests for advanced procedures (e.g., surgery, endoscopy, in human intensive care and burn units have shown that anesthesia, diagnostic imaging), and typing discharge notes. ­computer keyboards are commonly contaminated with potential pathogens and may serve as a fomite for pathogens that may Part 1: Efficacy of keyboard cleaning agents cause HAIs (8–11). More recently, researchers in Scotland found A total of 30 common-use QWERTY keyboards (Dell Keyboard similar results in veterinary practices (12). KB212-B; Dell, Round Rock, Texas, USA) from 14 differ- Computer keyboards present a cleaning and disinfection ent patient care areas throughout the University of Georgia challenge as they are commonly used in patient care areas, have Veterinary Teaching Hospital were tested. Each keyboard was many cracks and crevices, and are not amenable to the use of studied in a randomized crossover design of peroxygen-based standard disinfection procedures (e.g., spraying with a liquid (AHP) (Preempt Wipes; Virox Technologies, Oakville, Ontario), chemical disinfectant). Disinfectant wipes have been shown to 70% isopropyl alcohol-based (Premoistened Clean-Wipes; VWR have varying efficacy for reducing bacterial contamination of International, Radnor, Pennsylvania, USA), and quaternary keyboards in the human healthcare setting, and several studies ammonium-based compound (QAC) (Lysol Disinfecting Wipes; report sustained reduction of keyboard contamination when Reckitt Benckiser, Parsippany, New Jersey, USA) disinfectant using various disinfectants (11,13,14). Disinfectant wipes may wipes with a minimum 2-week washout period between treat- thus be a viable option for reducing bacterial contamination on ments. Treatment order was randomized using a random num- keyboards located in patient care areas of a veterinary teaching ber generator (Microsoft Excel for Mac 2011 Version 14.5.2; hospital, but only a few studies have been performed in the Microsoft Corporation, Redmond, Washington, USA). Five veterinary environment in which patient populations and their additional keyboards were used as a no treatment (NT) group. microbiota differ from those in human hospitals. Bender et al Keyboards were sampled on a day of the week that the service (15) demonstrated that routine cleaning of computer keyboards area had scheduled patient appointments. in a veterinary environment decreased recovery of Staphylococcus The keyboards were divided into right and left halves (the left spp. from their surfaces, but they did not compare the efficacy half delineated by all keys located to the left of middle of the of different disinfectant products (15). numeral 7 key and the right half delineated by all keys located The primary objective of this study was to determine the effi- to the right of the middle of the numeral 7 key) (Figure 1), with cacy of 3 commonly used disinfectant wipes (peroxygen-based, the surface area of each half measuring 126 cm2. Each half was 70% isopropyl alcohol-based, and quaternary ammonium- randomly designated as the untreated “dirty” side or the disin- based) for reducing bacterial contamination of keyboards. It fected “clean” side with a coin toss performed at each sampling was hypothesized that the 3 different disinfectant wipes would time. The surface of the “clean” half of the keyboard was wiped be equally effective in significantly reducing the bacterial load with its assigned disinfectant for 5 s in an S-shaped pattern to found on common-use keyboards in patient care areas of a cover that half of the keyboard. Following disinfection, the veterinary teaching hospital. keyboard was allowed to dry before sample collection (below). Samples were collected separately from each side using sterile, Materials and methods pre-moistened sponges (Solar Biologicals Sterile Sponge with Common-use keyboards located in specialty service patient care Neutralizing Buffer; Weber Scientific, Hamilton, New Jersey, areas throughout the University of Georgia Veterinary Teaching USA) that were wrung out to remove excess buffer. The sponges Hospital were used to assess the efficacy of 3 disinfecting agents were wiped across half of the keyboard in an “S”-shaped pat- in reducing the number of colony-forming units (CFUs) of tern with a gloved hand and new gloves were donned before bacteria cultured from the keyboard surfaces. The time it took each culture. The sponges were then placed in individual ster- for each of the disinfectants to dry following cleansing was also ile bags (Nasco Whirl-Pak Write-On Bags — 24 oz.; Nasco, quantified. The teaching hospital has an electronic medical Fort Atkinson, Wisconsin, USA) with 25 mL of Dey-Engley record system, and computers are used by faculty, house officers, disinfectant-neutralizing broth (Difco D/E Neutralizing Broth; students, and technicians for reviewing patient files, submitting Becton, Dickinson and Company, Sparks, Maryland, USA), agi- requests for diagnostic imaging, viewing the results of laboratory tated, and allowed to sit at room temperature for 10 min. After

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Table 1. Numbers of CFU after 48 hours of incubation, before and after cleaning with a disinfectant wipe. Least squares Mean N means 95% CI Median IQR CFU/cm2 AHP Dirty 30 14.40 6.67, 22.19 12.00 9, 21 28.57 Clean 30 1.31 25.72, 8.35 0.50 0, 2 2.60 ARTICLE Alcohol Dirty 30 23.90 16.20, 31.72 14.50 8, 26 47.42 Clean 30 8.58 1.54, 15.62 1.00 0, 3 17.02 QAC Dirty 30 19.99 12.24, 27.75 10.00 7, 26 39.66 Clean 30 3.18 23.86, 10.22 1.00 0, 4 6.31 NT Pre 10 20.39 4.85, 35.93 15.5 10, 23 40.46 Post 10 6.51 27.58, 20.60 2.5 1, 9 12.92

AHP — accelerated hydrogen peroxygen; CFU — colony-forming unit; CI — confidence interval; IQR — interquartile range; NT — no treatment; QAC — quaternary ammonium compound.

10 min, the sponge and solution were kneaded, and 100 mL boards were studied in a randomized crossover design of the aliquots of this solution were plated onto tryptic soy blood 3 disinfectant wipes: AHP-, alcohol-, and QAC-based wipes. agar plates (TSBA) (BBL TSA II 5% SB Agar Plates; Becton, The keyboards were randomized using a random number gen- Dickinson and Company) using a sterile 30-mm bacterial erator to order the disinfectants used and were wiped with their spreader (Bio Plas 30 mm Bacti Cell Spreader; Blue, Bio Plas, respective disinfectant agent for approximately 5 s until the San Rafael, California, USA). All plates were incubated for 48 h entire surface of the keyboard was wet. All drying time studies at 35°C and CFUs on each plate were enumerated by hand after were performed in a small draft-free room at room temperature 24 and 48 h of incubation. (21°C to 23°C). The time it took to completely visibly dry after Dirty (pre) culture samples from 5 NT keyboards were cleaning was measured to the nearest second using a stopwatch. obtained as described. After each half keyboard had dried from Subjective characteristics, including formation of suds and resi- the initial sampling, a second pre-moistened sterile sponge due, were also noted for each disinfectant wipe. was wrung out and used to collect a post-culture sample from the same half of the keyboard in the same manner. Following Data analysis incubation for 24 and 48 h at 35°C, CFUs on each plate were Data were entered into a spreadsheet, validated, and descriptive enumerated as described. statistics were calculated using commercially available statistics The average number of CFUs/cm2 on each keyboard half was software (PROC GEN MOD, SAS 9.4; SAS, Cary, North calculated using the following method. The number of CFUs Carolina, USA). Bacterial counts (CFUs) were log-transformed counted on each plate represented the number of CFUs per to facilitate parametric analyses. A paired t-test was used to com- 100 mL aliquot of broth solution that was cultured. This was pare log-transformed CFUs on dirty versus clean halves within used to estimate the number of CFUs within the entire 25 mL each group. Multivariable linear regression was used to assess (25 000 mL) of broth, which represented the total number of the dependent variable of bacterial reduction following 48 h of CFUs obtained from the keyboard half. An estimated CFU/cm2 incubation. Variables included in the model were determined was calculated for each keyboard half using a measured surface a priori as factors of interest or potential confounding variables area of 126 cm2. The percent reduction in CFU between cul- and were therefore included in the model regardless of P-value. tures obtained from the dirty half of the keyboard and the clean The independent variables evaluated included the keyboard half of the keyboard was calculated using the following equation: location [categorized as emergency room, medicine, surgery, or other (cardiology, dermatology, oncology, ophthalmology, and % reduction = [(dirty CFU/cm2 2 clean CFU/cm2)/ radiology)], sample period (1, 2, or 3), and disinfectant type dirty CFU/cm2] 3 100. (AHP, Alcohol, QAC, or NT). Least squares means bacterial reduction and 95% confidence intervals (CI) were derived from The percent reductions were then averaged for each treatment linear regression models. Disinfectant wipe drying times were group. evaluated for normality and paired t-tests were used to make Cultures and CFU enumeration were performed for the 5 NT comparisons. A critical a of 0.05 was used for all statistical keyboards and all disinfectant wipes on all keyboards with a comparisons. minimum 2-week washout between sampling periods. Results Part 2: Drying time Part 1: Efficacy of keyboard cleaning agents The time it took for the keyboards to dry after cleaning with In this study, the dirty keyboards averaged 28.57 to 47.42 each disinfectant wipe was also quantified. A total of 6 key- CFU/cm2 for each of the disinfectant wipe study groups

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Table 2. Multivariable model Least Squares Means reduction in log10 CFUs at 48 hours of incubation (controlling for keyboard location). Least squares Least squares means baseline means

count in log10 reduction in Percent Disinfectant CFUs 95% CI log10 CFUs 95% CI reduction* AHP 1.09 0.95, 1.23 0.97 0.73, 1.20 91.5% Alcohol 1.18 1.04, 1.32 0.99 0.76, 1.20 65.3% QAC 1.10 0.96, 1.24 0.86 0.63, 1.10 94.9% NT 1.06 0.78, 1.34 0.75 0.28, 1.23 78.8%

ARTICLE AHP — accelerated hydrogen peroxygen; CFU — colony-forming unit; CI — confidence interval; NT — no treatment; QAC — quaternary ammonium compound; *percent difference between least squares means for “dirty” and “clean” samples where positive values represent reduced growth.

Table 3. Drying times for disinfectant wipes in seconds. Disinfectant N Mean SD Minimum Maximum 95% LCL 95% UCL AHP 6 483.17 275.36 147.00 905.00 194.19 772.14 Alcohol 6 96.83 16.17 68.00 108.00 79.87 113.8 QAC 6 422.17 157.87 273.00 613.00 256.50 587.84

AHP — accelerated hydrogen peroxygen; QAC — quaternary ammonium compound; SD — standard deviation; LCL — lower confidence limit; UCL — upper confidence limit.

(Table 1). While controlling for keyboard location, reductions in sponges moistened with a neutralizing buffer, suggesting that average CFUs were detected in each of the 3 treatment groups; bacterial contamination can be reduced by the mechanical use of the AHP product resulted in a 91.5% reduction in CFUs, action of wiping. Ultimately, this study did not find statistically use of the alcohol product resulted in a 65.3% reduction, and significant differences in CFU reductions between any of the use of the QAC product resulted in a 94.9% reduction. The NT 3 treatment groups or the NT group. group also demonstrated a reduction in average CFUs, with a In human hospitals, the assessment of surface hygiene relies 78.8% reduction (Table 2). There was a statistically significant on either the identification of an indicator organism of potential difference between CFUs enumerated on dirty and clean halves high-risk to patients in any amount (including methicillin- within each treatment group (P , 0.001 for each disinfectant resistant Staphylococcus aureus, Clostridium difficile, or multi- wipe and P = 0.006 for the NT group). No statistically signifi- drug resistant Gram-negative bacilli) or the quantitative assess- cant differences in percent reduction were noted between any ment of the total number of aerobic colonies found within a of the 3 treatment groups or the NT group (P-values ranged specified area (16). An appropriately cleaned and disinfected from 0.36 to 0.84). Residual contamination of the keyboards surface in a clinical environment should have , 1 CFU/cm2 of following disinfection was 2.60 CFU/cm2, 17.02 CFU/cm2, an indicator organism or , 2.5 CFU/cm2 total aerobic colony 6.31 CFU/cm2, and 12.92 CFU/cm2 for the AHP, alcohol, count (16). We chose to use the aerobic colony count pre- and QAC, and NT groups, respectively (Table 1). Neither location post-disinfection as an indicator of efficacy of the disinfectant of the keyboard nor sample period was associated with percent wipe. In this study, dirty keyboard contamination ranged reduction (P = 0.15). from 28.57 to 47.42 CFU/cm2 for each test group, indicating considerable contamination; this is not surprising given the Part 2: Drying time proximity of these keyboards to areas of routine patient care Alcohol-based wipes had a faster drying time than QAC- or and frequency of use. Interestingly, however, all treatments, AHP-based wipes (P = 0.005 and 0.016, respectively) (Table 3). including no treatment, resulted in reductions in the aver- No significant difference in drying time was noted between age number of CFUs. Because disinfectants are expected to QAC- and AHP-based wipes (P = 0.66). While the alcohol and eliminate most types of pathogenic bacteria (except bacterial AHP products did not create foam or leave behind any visible spores) on inanimate objects, one would anticipate that any of or tactile residue, cleaning with the QAC product produced a the 3 disinfectant wipes would better help to reduce keyboard moderate amount of foam and left a visible thin white film. contamination than simply wiping them down with a moistened sponge. Furthermore, both AHP and QAC contain detergents, Discussion which can greatly reduce bacterial counts on surfaces (17). This study documents substantial bacterial contamination of Nevertheless, mechanical action is known to reduce bacterial common-use keyboards throughout the University of Georgia contamination and biofilms, even without the use of soaps and Veterinary Teaching Hospital and demonstrates reductions in detergents (18). It is possible that wiping with the sponge pro- average CFUs following cleaning with AHP-, alcohol-, and vided more mechanical cleaning than the smooth-surfaced wipes QAC-based wipes. Interestingly, similar reductions in average and that this contributed to the comparable CFU reduction in CFUs were noted when the keyboards were simply wiped with the NT group. Additional studies using wipes moistened with

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saline or water as a control group, instead of a no treatment to reduction in keyboard bacterial load, we cannot definitively group, would better delineate the difference in CFU reduction recommend that this product be used for routine keyboard between disinfection and cleaning with wipes. disinfection without considering the possibility that the other While percent reductions in CFUs were documented for disinfectants may have residual antimicrobial effects that alcohol all disinfectant wipes evaluated, none of the treatments suc- does not. Due to its rapid drying time, alcohol is not considered cessfully decreased the mean total aerobic colony count to less to have any residual effects; however, quaternary ammonium 2 than 2.5 CFU/cm . This is an unanticipated finding, as Rutala products have residual antimicrobial activity even after drying ARTICLE et al (11) found that several disinfectant wipes (including those (13). Although there was no statistically significant difference containing QAC and 70% isopropyl alcohol) were effective between the treatments, the difference between a 94.9% and at decreasing CFU growth on keyboards by 95% to 100%. a 65.3% reduction in CFUs may still be biologically relevant However, this group did not evaluate the final CFU/cm2, so and of clinical importance. It is also known that some of the making direct comparisons is difficult. This group also only disinfectants (QAC) have residual effects following application tested the efficacy of disinfectants on 5 individual test keys and that may extend their effects. Additional studies are warranted not on a complete keyboard. It is possible that the entire key- to investigate whether these residual effects would result in board poses a greater cleaning challenge, as the crevices between clinically relevant differences in duration of disinfectant efficacy. the keys may be harder to reach with the wipes. The configura- There are several limitations to this study. Because only tion of the keyboard itself may also significantly affect the ability decreases in standard aerobic colony counts were quantified to adequately disinfect it, as keyboards with higher profile keys, after disinfection with each respective wipe, it is unknown like the ones used in this study, may be more difficult to clean whether the wipes equally reduced numbers of pathogenic bac- by physical wiping than those with lower profile keys or touch teria, non-pathogenic bacteria, or both. The AHP-, alcohol-, screen keys. If a single wipe, as applied to the keyboards in and QAC-based disinfectants are labeled as being efficacious this study, is insufficient to attain the desired level of keyboard for a wide range of pathogens and should be effective against disinfection, additional protocols (e.g., using multiple wiping these organisms (20); however, further studies identifying cycles, longer wiping duration, or more detailed wiping) or use specific organisms cultured before and after cleaning would of keyboard covers should be tested to see if they can achieve help determine if some wipes are superior for specific bacterial superior disinfection. Keyboards may accumulate visible biofilms or viral reduction. Furthermore, each disinfectant agent has a from skin oils that may be difficult to remove with a single wipe, different antimicrobial spectrum, and choice of product may and multiple wiping cycles or a regular wiping regimen may be also depend on the types of organisms anticipated to be present more effective than the protocol tested here. This study did not in the keyboard environment. Although we demonstrated a address the level of visible contamination of these keyboards, decrease in bacterial load for all tested protocols, re-colonization and additional studies to investigate if gross contamination is dynamics were not assessed. Thus, the optimal frequency of a confounding factor in the ability of a single wipe to achieve disinfection (daily, twice daily, etc.) was not determined, and appropriate CFU reduction are warranted. The 3 disinfectant we were unable to verify residual antimicrobial activity for any wipes used in this study were chosen based on products cur- disinfectant wipes. Additional studies investigating the time to rently in use in this hospital, and a different product not tested re-colonization are indicated in order to determine what clean- here may be more efficacious. For example, Jones et al (13) ing protocol would best minimize keyboard contamination. noted sustained and significant reduction in CFUs of bacteria Lastly, while it was not the goal of this paper, characterization cultured from common-use hospital keyboards with use of a 2% of the bacterial population of these keyboards would be valuable chlorhexidine in 70% isopropyl alcohol spray. in determining if there are significant numbers of pathogenic The choice of disinfectant to be used may also depend on or multi-drug resistant organisms that may pose greater risk for other factors including drying time, formation of suds, product patients and staff. These organisms can then be compared to scent, residue left on the keyboards, preservation of keyboard the organisms cultured from HAIs occurring around the same function, and cost. We thus evaluated drying time with each of time to see if keyboard contamination has any correlation to the the disinfectant wipes and found that the keyboards dried sig- development of HAIs. nificantly faster when alcohol wipes were used to disinfect them This study demonstrates that common use keyboards in ani- and that no visible residue was left behind. While the faster mal care areas of a veterinary teaching hospital are likely to be drying time and lack of residue may increase user compliance, it highly contaminated and suggests that they should be routinely is also important to consider the fact that its rapid evaporation cleaned and disinfected. Although the optimal disinfection may limit contact time of the alcohol with any pathogens. A protocol is yet to be determined, this study demonstrates that contaminated surface may not be adequately disinfected if the use of any of 3 commercially available wipes reduced overall alcohol evaporates before an appropriate contact time is reached, aerobic counts on keyboards and may be a useful component and general recommendations for alcohol-based disinfectants is of an infection control program. a contact time greater than 1 min (19). In this study, the visible drying time for the entire surface of each alcohol-disinfected Acknowledgments keyboard was longer than 1 min. This study was funded in part by a grant from the University Although alcohol wipes had a faster drying time and did not of Georgia Department of Small Animal Medicine and Surgery statistically differ from the other treatment groups with regard Internal Research Program. Preliminary results were presented

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as an oral abstract at IVECCS 2018, New Orleans, Louisiana, contact increases with environmental contamination. Crit Care Med USA. 2012;40:1045–1051. 9. Al-Hamad A, Maxwell S. How clean is clean? Proposed methods for The authors declare that there were no conflicts of interest. hospital cleaning assessment. J Hosp Infect 2008;70:328–334. The authors thank Barbara Artelt, Department of Small 10. Hartmann B, Benson M, Junger A, et al. Computer keyboard and Animal Medicine and Surgery at the University of Georgia mouse as a reservoir of pathogens in an intensive care unit. J Clin Monit Comput 2004;1:7–12. College of Veterinary Medicine, for her assistance with labora- 11. Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial contamination tory work. CVJ of keyboards: Efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol 2006;27:372–377. References 12. Fraser MA, Girling SJ. Bacterial carriage of computer keyboards in veterinary practices in Scotland. Vet Rec 2009;165:26–27.

ARTICLE 1. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care- 13. Jones R, Hutton A, Mariyaselvam M, et al. Keyboard cleanliness: associated infections and deaths in U.S. hospitals, 2002. Public Health A controlled study of the residual effect of chlorhexidine gluconate. Rep 2007;122:160–166. Am J Infect Control 2015;43:289–291. 2. Scott R, II. The direct medical costs of healthcare-associated infections 14. Ide N, Frogner BK, LeRouge CM, Vigil P, Thompson M. What’s on in US hospitals and the benefits of prevention [monograph on the your keyboard? A systematic review of contamination of peripheral Internet]. London, UK: Economist c2009. Available from: https://www. computer devices in healthcare settings. BMJ Open 2019;9:e026437. cdc.gov/hai/pdfs/hai/scott_costpaper.pdf Last accessed November 11, 15. Bender JB, Schiffman E, Hiber L, Gerads L, Olsen K. Recovery of 2019. staphylococci from computer keyboards in a veterinary medical centre 3. Calfee DP. Crisis in hospital-acquired, healthcare-associated infections. and the effect of routine cleaning. Vet Rec 2012;170:414. Annu Rev Med 2012;63:359–371. 16. Mulvey D, Redding P, Robertson C, et al. Finding a benchmark for 4. Ruple-Czerniak A, Aceto HW, Bender JB, et al. Using syndromic sur- monitoring hospital cleanliness. J Hosp Infect 2011;77:25–30. veillance to estimate baseline rates for healthcare-associated infections 17. Walters A. Hard surface disinfection and its evaluation. J Appl Microbiol in critical care units of small animal referral hospitals. J Vet Intern Med 1967;30:56–65. 2013;27:1392–1399. 18. Assanta MA, Massicotte R, Pichette G, Ahmad D. Importance of 5. Weiner LM, Webb AK, Limbago B, et al. Antimicrobial-resistant mechanical action in a terminal disinfection process for decontamina- pathogens associated with healthcare-associated infections: Summary of tion of Clostridium difficile spores on hospital inert contact surfaces. Int data reported to the national healthcare safety network at the Centers J Infect Control 2014;11:1–9. for Disease Control and Prevention, 2011–2014. Infect Control Hosp 19. Rutala WA, Weber DJ. Guideline for disinfection and sterilization Epidemiol 2016;37:1288–1301. in healthcare facilities, 2008 [monograph on the Internet]. Atlanta, 6. Ogeer-Gyles JS, Mathews KA, Boerlin P. Nosocomial infections and Georgia: Centers for Disease Control and Prevention c. 2008. Available antimicrobial resistance in critical care medicine. J Vet Emerg Crit from: www.cdc.gov/infectioncontrol/guidelines/disinfection/ Last Care 2006;16:1–18. accessed November 11, 2019. 7. Weber DJ, Anderson D, Rutala WA. The role of the surface envi- 20. Quinn PJ, Markey BK. Disinfection and Disease Prevention in ronment in healthcare-associated infections. Curr Opin Infect Dis Veterinary Medicine. In: Block SS, ed. Disinfection, Sterilization, and 2013;26:338–344. Preservation. 5th ed. Philadelphia, Pennsylvania: Lippincott, Williams 8. Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug- & Wilkins, 2001:1069–1103. resistant bacteria to healthcare workers’ gloves and gowns after patient

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74 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Brief Communication Communication brève

Update on demographics of the Canadian Dairy Industry for the period 2011 to 2016

Christopher D. Luby, Cheryl Waldner, Murray D. Jelinski

Abstract — Between 2011 and 2016, the number of dairy operations in Canada decreased by 13.3%. Mean herd size increased from 65 to 73 animals per farm. The ratio of older (. 60 years old) to younger (, 31 years old) producers also increased. The age structure of the industry suggests that consolidation will continue for the next decade, which has implications for the provision of veterinary services to dairy operations.

Résumé — Actualisation des données démographiques des exploitations laitières pendant la période de 2011 à 2016. De 2011 à 2016, le nombre d’exploitations laitières au Canada a diminué de 13,3 %. La taille moyenne des exploitations a augmenté de 65 à 73 animaux par ferme. Le ratio d’éleveurs plus âges (. 60 ans) de ceux plus jeunes (, 31 ans) a augmenté aussi. La structure par âge suggère que cette consolidation doive se poursuivra pendant la prochaine décennie et devrait toucher l’offre des services vétérinaires aux exploitations laitières. (Traduit par les auteurs) Can Vet J 2020;61:75–78

he Canadian dairy and cow-calf sectors have experienced All source data were derived from Statistics Canada’s Census T significant consolidation since 1991. Jelinski et al (1) previ- of Agriculture. Statistics Canada was contracted to perform ously reported that the number of Canadian dairy producers and a custom data extraction using parameters identical to those farms decreased by 49% and 62%, respectively, between 1991 of the previous study (1). In brief, data were provided on the and 2011. Furthermore, as of 2011, 46% of dairy producers number of dairy operators stratified by gender (male, female), were . 50 y old, but more significantly there were 2 producers age (, 26 y, 26 to 30 y, 31 to 35 y, 36 to 40 y, 41 to 45 y, 46 to . 60 y old for every producer , 31 y old. This age structure 50 y, 51 to 55 y, 56 to 60 y, and . 60 y), herd size (, 51, 51 to strongly suggested that the dairy industry would continue to 100, 101 to 200, 201 to 300, 301 to 500, and . 500 dairy consolidate in the coming years. The rapidly changing demo- cows and replacement heifers . 1 y old) and region (Canada, graphics of the dairy sector reflects Canada’s underlying age Atlantic Canada, Quebec, Ontario, western Canada). Census structure. That is, a very large cohort of “baby boomers” began of Agriculture reports were also accessed in order to obtain to retire around the time of the 2011 census and this trend is data on the number of dairies and dairy cows (females which expected to continue until the 2026 census (2,3). have produced a calf) by province (4). Dairies were defined as The purpose of this update is to describe the changes to the an agricultural operation that produced milk intended for sale. demographics of the Canadian dairy industry from 2011 to Farm operators were defined as those persons responsible for the 2016 and discuss their potential implications with respect to the management decisions in operating the farm including owners, need for veterinary services. Furthermore, the Canada-European tenants, and hired managers (5). The datasets were subject to Union Comprehensive Economic and Trade Agreement (CETA) random rounding in that data cells with , 5 producers were entered into force provisionally on September 21, 2017 and the randomly rounded so that data could not be associated with a Canada-United States-Mexico Agreement (CUSMA) was ten- specific dairy operation. tatively agreed to on November 30, 2018. The Canadian dairy The dairy industry has continued to consolidate with industry has posited that these agreements will have deleterious the number of dairy operations in Canada decreasing by effects on the industry, thus this update provides an opportu- 13.3% from 2011 (14 883 dairies) to 2016 (12 895 dairies). nity to capture demographic data regarding the Canadian dairy Concurrently the number of dairy cows in Canada decreased industry before these agreements come fully into effect. by 2.3% (961 726 to 939 071). Mean herd size increased from

Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5B4. Address all correspondence to Dr. Christopher D. Luby; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

CVJ / VOL 61 / JANUARY 2020 75 FOR PERSONAL USE ONLY COMMUNICATIONBRÈVE

Figure 1. Average number of dairy cows (excluding heifers) per herd by region and census year. Average herd size was calculated from the number of herds (n = 12 895) and dairy cows (n = 939 071) reported by Statistics Canada on national and regional levels. Data from years before 2011 were originally reported in the study which this article updates (1).

65 to 73 cows per herd (Figure 1). This represents a 13% otherwise known as the P5 provinces, and the western provinces. increase in herd size and this increase was similar across all The price of quota is capped in the P5 provinces. Given the regions. The largest average herd size was in western Canada similar magnitude in herd size increase, regulations regarding (101 animals per herd) and the smallest average herd size was sale and purchase of quota do not appear to have affected the in Quebec (62 animals per herd). rate of consolidation. Arguably, consolidation towards fewer but larger operations Increased dairy size results in a need for either increased num- is driven by both demographics and economics. With respect bers of employees per farm or increased technology use. Skilled to demographics, approximately half (52.7%) of dairy operators farm labor is often in short supply and dairies may hire immi- were . 50 y old, with 20.4% being . 60 y old (Figure 2). The grant workers to address this labor shortfall. Previous work has ratio of older (. 60 y) to younger (, 31 y) producers was 2.4:1, indicated that a reliance on immigrant labor and any associated an increase from 2.0:1 in 2011 (6). The ratio of older to younger language barriers can lead to communication challenges result- producers was highest (3.2:1) on dairies with less than 51 cows. ing in errors in animal management including impaired disease The ratio was similar for farm sizes ranging from 1.8:1 (51 to detection and treatment (8). These errors may lead to increased 100 cows) to 2.2:1 (101 to 200 cows). The age demographics antimicrobial use, impaired animal care, and reduced biosecu- strongly suggest that a significant proportion of older operators rity. To ensure the successful implementation of farm-specific with smaller dairies will retire in the upcoming years and, given protocols for disease detection and treatment, animal care and the comparative lack of younger operators, the trend towards biosecurity, veterinarians may need to be aware of communica- fewer larger dairies will increase. tion challenges associated with immigrant labor and strategies Despite the trend in consolidation, total Canadian milk to overcome these. This will allow veterinarians to respond to quota increased by 8.9% between May 2011 (26 043 573 kg the needs of producers and continue to support improvements butterfat) and May 2016 (28 367 836 kg butterfat), and from in animal health, welfare, and dairy production (9). May 2016 to November 2018 it increased by a further 21% to Recent years have seen improvements in the detection of mas- 34 309 488 kg butterfat (7). While the rapid increase in quota titis, fertility, locomotion, and metabolism using automated sys- between 2016 and 2018 is unlikely to be sustained, the long- tems (10). For example, several companies market technologies term trend of the industry since 2011 has been for a gradual for pregnancy testing using either blood or milk (10). Despite increase in quota. We anticipate that this increase in production these improvements, most Canadian dairies identify pregnancies alongside decreased dairy numbers will result in a continued using either ultrasonography or rectal palpation (11) and most increase in the number of cows per farm. The magnitude of the dairy veterinarians perform pregnancy diagnosis at least once increase in herd size (13%) did not differ between herds that per month (12). Reasons for the slow uptake of these technolo- are in the eastern provinces that make up the “All Milk Pool,” gies may include a lack of training of dairy operators and their

76 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY BRIEF COMMUNICATION

Figure 2. Age distribution (%) of Canadian dairy operators for the census years 1991 to 2016. Age distribution was calculated from the number of dairy operators (n = 26 935) reported by Statistics Canada. The number at the top of each bar represents the ratio of older operators (. 60 years of age) to younger operators (, 31 years of age). Data from years before 2011 were originally reported in the study which this article updates (1). advisors and the need for further refinement of the technologies provide dairies with a value proposition. Veterinarians will have themselves (8). As dairies increase in size, dairy operators may to provide more consultative services in which they implement opt to become better trained in automated dairy management. and oversee farm-specific protocols. In their minimal form, these As a result, pregnancy detection by blood or milk assay may protocols should address areas in which most veterinarians are become more common. This has potentially significant implica- currently involved, including identification and treatment of tions for veterinarians given the frequency at which veterinarians sick animals, animal care, antimicrobial use, and biosecurity. perform pregnancy diagnosis. Opportunities also exist to further veterinary involvement in Despite the demographic changes observed, Canadian dairy which veterinarians can work as part of an advisory team for producers remain younger than cow-calf producers (13,6). The dairy operators alongside other professionals including those existence of supply-management has been hypothesized to result from financial services, agrology, and nutrition. Potential services in stability of milk prices, increasing the attractiveness of this offered by veterinarians could include providing training and industry to younger producers (1). Each provincial dairy board support for automated dairy technologies, fertility, nutrition, has invested in new entrant or dairy farm start-up programs and genetics. For example, the veterinarian may play the role that assist farm operators in overcoming the cost of purchasing of an independent advisor to the dairy operator. This role may quota. These programs may, in part, be responsible for the dif- involve evaluating evidence regarding adoption of novel tech- ference in age between dairy and cow-calf producers. nologies and procedures in the light of the particular operation, Future change in the dairy industry may occur as a result incorporation of these technologies and procedures into farm of free trade agreements. The provisions of CETA allow for protocols, and monitoring their impact. CVJ tariff-free import of up to 17 700 tonnes of cheese from the European Union to Canada annually (14). This represents 4% References of the Canadian cheese market. The provisions of CUSMA . 1 Jelinski MD, LeBlanc S, Kennedy R. Demographics of the Canadian dairy industry from 1991 to 2011. Can Vet J 2015;56:701–708. mandate changes in pricing of non-fat milk solids which may 2. Statistics Canada. Generations in Canada. Available from: http:// increase imports of these to Canada from the United States (15). www12.statcan.ca/census-recensement/2011/as-sa/98-311-x/98-311- These changes may result in decreased milk prices in Canada. x2011003_2-eng.cfm Last accessed November 11, 2019. 3. Statistics Canada. The Daily 2011 May 29, 2012, Census: Age and Decreased milk prices may result in increased herd sizes to sex. Available from: http://www.statcan.gc.ca/daily-quotidien/120529/ maintain cash flow (9). Increased herd sizes may also result in dq120529a-eng.htm Last accessed November 11, 2019. 4. Table 32-10-0424-01, Census of Agriculture, cattle and calves on cen- attempts by dairy operators to reduce costs including a reduction sus day [database on the Internet]: Statistics Canada. Available from: in financial resources allocated to each cow and reduced use of https://www150.statcan.gc.ca/n1/en/type/data?text=40221 Last accessed veterinary and herd monitoring services (8). November 11, 2019. 5. Dictionary, Census of Population, 2016 [database on the Internet]: These changes in the industry represent both a challenge and Statistics Canada. Available from: https://www12.statcan.gc.ca/census- an opportunity for the veterinary profession. It is likely that vet- recensement/2016/ref/dict/pop032-eng.cfm Last accessed November 11, erinary involvement with individual animals will decrease. Given 2019. 6. Jelinski MD, Waldner C. Changing demographics of the Canadian that dairy veterinarians continue to perform individual animal cow-calf industry for the period 2011 to 2016. Can Vet J 2018;59: work (12), veterinary service delivery must evolve to order to 1001–1004.

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. 7 Total Quota [database on the Internet]: Canadian Dairy Commission. 12. Luby CD, McIntyre K, Jelinski MD. Skills required of dairy veterinar- Available from: http://www.cdc-ccl.gc.ca/CDC/index-eng.php?id=4421 ians in western Canada: A survey of practicing veterinarians. Can Vet J Last accessed November 11, 2019. 2013;54:267–270. 8. Barkema HW, von Keyserlingk MA, Kastelic JP, et al. Invited review: 13. Jelinski MD, Kennedy R, Campbell JR. Demographics of the Canadian Changes in the dairy industry affecting dairy cattle health and welfare. cow-calf industry for the period 1991 to 2011. Can Vet J 2015;56: J Dairy Sci 2015;98:7426–7445. 163–168. 9. proAction®, On-Farm Excellence [database on the Internet]: Dairy 14. Canada-European Union Comprehensive Economic and Trade Farmers of Canada. Available from: https://www.dairyfarmers.ca/ Agreement (CETA) [database on the Internet]: Government of Canada. proaction Last accessed November 11, 2019. Available from: https://www.international.gc.ca/trade-commerce/trade- 10. Rutten CJ, Velthuis AGJ, Steenveld W, Hogeveen H. Invited review: agreements-accords-commerciaux/agr-acc/ceta-aecg/index.aspx?lang=eng Sensors to support health management on dairy farms. J Dairy Sci 2013; Last accessed November 11, 2019. 96:1928–1952. 15. Canada-United States-Mexico Agreement Chapter 3 Agriculture [data- 11. Van Schyndel SJ, Bauman CA, Pascottini OB, Renaud DL, Dubuc J, base on the Internet]: Government of Canada. Available from: https:// Kelton DF. Reproductive management practices on dairy farms: international.gc.ca/trade-commerce/assets/pdfs/agreements-accords/ The Canadian National Dairy Study 2015. J Dairy Sci 2019;102: cusma-aceum/cusma-03.pdf Last accessed November 11, 2019. 1822–1831. COMMUNICATIONBRÈVE

Answers to Quiz Corner Les réponses du test éclair

1. D) A reason for this common finding is unknown. 5. A) Cattle infected with a noncytopathic strain of BVD virus early D) La raison de ce phénomène n’est pas connue. in life (even in utero) become “PI” or persistently infected animals. If these animals are later exposed to a cytopathic 2. B) In cats, struvite stones form in sterile urine greater than 95% strain of the virus, they can develop “mucosal disease,” which of the time. The opposite is true for dogs. 2-MPG is the drug is characterized primarily by erosions and ulcers over Peyer’s that increases cystine solubility in urine. It has no effect on patches, as well as on the tongue, gingiva, palate, esophagus, calcium oxalate. rumen, and abomasum. B) Chez le chat, les calculs de struvite se forment dans de l’urine A) Les bovins infectés par une souche non cytopathogène du stérile dans plus de 95 % des cas. L’opposé est vrai chez le virus de la diarrhée virale bovine tôt dans la vie (même dans chien. L’administration de 2-MPG augmente la solubilité de la l’utérus) deviennent des animaux infectés de façon persis- cystine dans l’urine; ce produit n’a pas d’effet sur les calculs tante. Si ces animaux sont plus tard exposés à une souche d’oxalate de calcium. cytopathogène du virus, ils peuvent développer la maladie 3. C) PDA, subaortic stenosis, and pulmonic stenosis are the most des muqueuses qui est caractérisée principalement par des commonly diagnosed congenital heart defects in dogs. érosions et des ulcères sur les plaques de Peyer, ainsi que C) La persistance du canal artériel, la sténose subaortique et la sur la langue, les gencives, le palais, l’œsophage, le rumen et sténose pulmonaire sont les cardiopathies congénitales les l’abomasum. plus communes chez le chien. 4. A) Inability to concentrate urine following exogenous adminis- tration of ADH (vasopressin) supports nephrogenic diabetes insipidus. A) L’incapacité à concentrer l’urine à la suite de l’administration exogène d’hormone antidiurétique plasmatique (vasopres- sine) appuie un diagnostic de diabète insipide néphrogène.

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78 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Student Paper Communication étudiante

A peculiar case of soft tissue sarcoma in a cat

Werdah Iqbal

Abstract — A 13-year-old cat was presented to a clinic in Texas with an open draining lesion and severe swelling of the left foreleg. Initial diagnosis was a brown recluse spider bite and treatment was undertaken accordingly. A few weeks later, the cat was returned to the clinic with further swelling of the left foreleg. A diagnosis of a high- grade soft tissue sarcoma with an increased risk of metastasis was made based on a histopathology report. The cat was euthanized following the diagnosis as the cat had a fair to poor prognosis.

Résumé — Un cas particulier de sarcome des tissus mous chez un chat. Un chat âgé de 13 ans fut présenté dans une clinique du Texas avec une plaie ouverte drainante et œdème sévère de la patte arrière gauche. Le diagnostic initial était la morsure d’une araignée marron recluse et un traitement en conséquence débuté. Quelques semaines plus tard le chat revint à la clinique avec plus d’enflure de la patte arrière gauche. Un diagnostic de sarcome des tissus mous de grade élevé avec risques augmentés de métastases fut posé sur la base du rapport d’histopathologie. Le chat fut euthanasié à la suite du diagnostic étant donné le pronostic passable à pauvre. (Traduit par Dr Serge Messier) Can Vet J 2020;61:79–81

n early May 2019, a 13-year-old spayed British shorthair specifically a brown recluse spider bite. In light of this differ- I cat was presented to the Gray County Veterinary Clinic ential, the cat was given cefovecin sodium (Convenia; Zoetis, in Pampa, Texas for severe swelling of the medial left foreleg. Kalamazoo, Michigan, USA), 8 mg/kg BW, SQ, and was sent There was a draining lesion on the left foreleg, just distal to the home. A few weeks later, on May 20, 2019, the patient returned elbow, and the leg was edematous. The patient was unable to to the clinic as the lesion had grown substantially since the bear weight on the leg. The cat was eating and drinking well, last visit and a probe of the lesion revealed purulent material and all remaining components of the physical examination were (Figure 2). The lesion was approximately 5 mm in height and within normal limits. A radiograph was taken to identify if a 5 cm wide and there was a small abscess cranial to the mass. An fracture was present, which could be causing the edema. The additional fine-needle aspirate was obtained, but there were no radiograph revealed no fracture, but soft tissue swelling could significant cytologic findings. Due to non-diagnostic cytology, be seen surrounding the radius and ulna (Figure 1). Further the lesion was biopsied and submitted for histopathology. For diagnostic tests included a probe of the lesion and a fine-needle sedation, the patient was given dexmedetomidine hydrochloride aspirate. The cat was given dexmedetomidine hydrochloride (Dechra), 30 mg/kg BW, IM and butorphanol tartrate (Merck (Dexmedesed; Dechra, Leawood, Kansas, USA), 35 mg/kg body Animal Health), 0.17 mg/kg BW, IM. An incisional biopsy was weight (BW), IM and butorphanol tartrate (Dolorex; Merck completed, followed by a wide excisional biopsy to remove the Animal Health, Madison, New Jersey, USA), 0.17 mg/kg BW, mass completely. There was not enough skin to close the site IM. The lesion was probed, and massive edema was identified, so a bandage was applied and the cat was given dexamethasone but there was no purulent material present. A fine-needle aspi- (Phoenix, Saint Joseph, Missouri, USA), 0.09 mg/kg BW, SQ. rate was also obtained but there were no significant cytologic The patient was hospitalized at the clinic so that the foreleg changes. At this time, the appearance and characteristics of could be monitored, and treatment could be continued. During the lesion resulted in the top differential being a spider bite, the patient’s stay of 4 d, she was given clindamycin phos- phate (Clindamycin; Alvogen, Pine Brook, New Jersey, USA), 40 mg/kg BW, IM, q24h, ceftiofur sodium (Ceftilex; Aspen, Ontario Veterinary College, University of Guelph, Guelph, Liberty, Missouri, USA), 10 mg/kg BW, SQ, q24h, and her Ontario N1G 2W1. bandage was changed daily. Over the next 3 d, the patient made Address all correspondence to Werdah Iqbal; e-mail: good progress — eating and drinking normally, and cardiorespi- [email protected] ratory parameters and temperature were within normal limits. Use of this article is limited to a single copy for personal study. However, within 2 d, a mass reappeared at the site of the original Anyone interested in obtaining reprints should contact the mass and was approximately the same size as it had been before CVMA office ([email protected]) for additional removal. The mass was now more purulent and began draining copies or permission to use this material elsewhere. as it became larger (Figure 2). On May 24, the histopathology

CVJ / VOL 61 / JANUARY 2020 79 FOR PERSONAL USE ONLY

and urinalysis will detect changes such as anemia, thrombocy- topenia, and hemoglobinuria but these are uncommon and do not provide a definitive diagnosis. Treatment ideally includes an antivenom; however, antivenoms for spider bites are not currently available. Supportive therapy can be administered, which includes a cool compress, immobilization of the affected area, and in some cases with severe necrosis, surgical manage- ment (4). Because of the prevalence of brown recluse spiders in Texas, the acute onset, the appearance of the lesion initially, and the lack of significant cytologic findings, the most likely differential diagnosis initially was a brown recluse spider bite. Accordingly, supportive treatment was carried out to hopefully slow the necrosis and allow the bite to heal. However, after a COMMUNICATIONÉTUDIANTE few days it was clear that the treatment was not effective, and so other differential diagnoses were investigated. Another differential diagnosis was an aggressive neoplasia, Figure 1. A lateral radiograph of the left foreleg. There was as the lesion was growing rapidly. Differentiating a brown soft tissue swelling around the radius and ulna. No fracture was present. recluse spider bite from a neoplasia requires histopathology. Consequently, a biopsy of the lesion was taken and submitted for histopathology — the report indicated a soft tissue sarcoma. Soft tissue sarcoma is a generalized term for common tumors results identified a high-grade soft tissue sarcoma. Specifically, such as histiocytoma, nerve sheath tumor, liposarcoma, fibrosar- the report indicated that there was extensive coagulation necrosis coma, and lymphangiosarcoma (5). A fine-needle aspirate can with purulent inflammatory cells and neoplastic spindle-shaped help identify a tumor to be of soft tissue origin. However, soft fibroblastic cells. There were also tumor cells with a collagenous tissue sarcomas often exfoliate poorly, particularly in effusions, stroma present and the mitotic index was 26. The prognosis was which results in a non-diagnostic sample. In general, cytologic fair to poor as this high-grade soft tissue sarcoma was locally diagnosis is difficult; however, malignant sarcomas exfoli- infiltrative and had an increased risk of metastasis. The owners ate better and are accordingly more evident on cytology (6). were given the diagnosis, prognosis, and treatment options and Special stains can help differentiate between the various types they elected to have the patient euthanized. The cat was given of tumors (4). Soft tissue sarcomas account for approximately dexmedetomidine hydrochloride (Dechra), 50 mg/kg BW, IM, 7% of skin and subcutaneous tumors in cats (7). Most soft butorphanol tartrate (Merck Animal Health), 0.17 mg/kg BW, tissue sarcomas are heterogenous and are solitary tumors that IM, and pentobarbital (Euthanasia-III Solution; Med-Pharmex have no breed or sex predilection. They often occur in middle- Incorporated, Pomona, California, USA), 0.22 mg/kg BW, IV. to older-aged animals, which is consistent with the signalment of this case (4). In terms of appearance, soft tissue sarcomas Discussion often present as pseudoencapsulated tumors that feel soft to The primary differential diagnosis for this case was a brown firm (3). The tumors are locally invasive, often on limbs, and recluse spider bite. The brown recluse spider (Loxosceles reclusa) are poorly marginated (5). An incisional or marginal excisional is a nocturnal spider found in the southern regions of the United biopsy can be completed to provide a histological diagnosis. A States (i.e., Texas, Georgia). The primary active ingredient in the marginal excisional biopsy should be completed if the mass is spider venom is sphingomyelinase, which results in local necrosis small (, 1 cm) and not on a limb, otherwise a wide excisional as well as systemic effects. Initially, a brown recluse spider bite biopsy is needed (6). In this case, an incisional biopsy was com- results in local signs of pain, redness shortly after being bitten, pleted for a histological diagnosis and was then followed with a and necrosis around the bite (1). The bite becomes a blister, wide excisional biopsy. If surgical excision is completed, there resembling a “bull’s eye,” which then expands and becomes a is a high chance of recurrence, particularly if the margins are necrotizing wound (2). Although there was no “bull’s eye” or not clean. A clean margin would be one in which there are no “target-like” lesion for this cat, the assumption was that the tumor cells in contact with the margins. There is up to a 20% spider bite was several days old and so, the classic appearance chance of metastasis and the histological grade can indicate the had been missed. After a few days, the bite becomes a necrotic likelihood of metastasis (7). The histopathological diagnosis in dermal lesion which can range in diameter from 1 to 25 cm. A the present case was a high-grade soft tissue sarcoma, which had typical case of a brown recluse spider bite is described for a cat an increased risk of metastasis. in Tennessee which had a necrotic lesion on the flank. The lesion Due to financial constraints and the fair to poor prognosis, had sloughing of tissue over time (3). Systemic signs can also further diagnostic tests were not completed. An appropriate develop, including hemolysis, fever, hematuria, and arthralgia. next-step diagnostic could have been thoracic radiographs to A definitive diagnosis can be made by an assay that identifies determine whether there was pulmonary metastasis. Without circulating antibodies to the spider venom; however, this test is any identified metastasis, amputation of the affected limb not available in the United States. A complete blood cell count could have been a treatment option. Amputation would be

80 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY STUDENT PAPER STUDENT

Figure 2. On the left is the appearance of the lesion when the patient returned to the clinic on May 20th, 2019. The lesion had some necrosis and little to no purulent material. On the right, is the left forearm as seen on May 22nd following biopsy. The original mass had been debrided down to the skin and this re-growth resulted a few days later.

considered a radical resection as it would completely remove made my externship experience one I’ll never forget. I appreciate cancerous cells as well as surrounding tissue. Removing the the endless support and encouragement; you’ve all become like limb leaves no chance for local recurrence on the affected limb. family to me. CVJ It also decreases the chance of hematogenous spread and thus, metastasis. Another local treatment would be radiation of the References affected limb. If metastasis has occurred then systemic therapy is 1. Pace LB, Vetter RS. Brown recluse spider (Loxosceles reclusa) envenom- ation in small animals. J Vet Emerg Crit Care 2009;19:329–336. needed, which includes the options of chemotherapy, radiation, 2. Peterson ME. Brown spider envenomation. Clin Tech Small Anim Pract and immunotherapy. The grade of the tumor dictates whether 2006;21:191–193. chemotherapy is appropriate. Further studies on useful diag- 3. Brown Recluse Spider Bite — Case Studies: Pet Stories. Available from: http://www.highway60.com/mark/brs/casestudy_petstories.asp?Msg=1786 nostic tests for detecting brown recluse spider bites may help Last accessed November 6, 2019. to quicken identification of a spider bite. In this case, it would 4. Tilley LP, Smith FWK. Blackwell’s Five-Minute Veterinary Consult: have been less expensive and more timely if there was a way Canine and Feline. 6th ed. Ames, Iowa: Blackwell, 2007:1245–1246. 5. Wilson DA. Clinical Veterinary Advisor. St. Louis, Missouri: Elsevier to rule out a spider bite from the list of differential diagnoses. Saunders, 2012:1395–1397. 6. Woods P, Oblak M. “Oncology.” Ontario Veterinary College lecture. Acknowledgments Guelph, Ontario. September 2018. 7. Withrow SJ, Vail DM. Withrow & MacEwen’s Small Animal Clinical I am grateful to Dr. Brian Gordzelik for his commitment to Oncology. 4th ed. St. Louis, Missouri: Saunders Elsevier, 2007:425–429. teaching me and treating me like a colleague. I also offer my thanks to all the staff at Gray County Veterinary Clinic who

CVJ / VOL 61 / JANUARY 2020 81 FOR PERSONAL USE ONLY Veterinary Dermatology Dermatologie vétérinaire

Atopic dermatitis in humans and dogs

Martín A. Arcique, Jangi Bajwa

he term atopy was introduced by Coca and Cooke (1) in From an immunological standpoint, atopy in humans is T 1923, to describe a disease in humans with ongoing respi- defined by the European Task Force on Atopic Dermatitis as a ratory signs that affected subjects at a certain time of the year, familial (genetic) tendency to develop a response by cooperative mainly in spring. The condition, generally called “hay fever,” T-lymphocytes (Th2) against common environmental antigens was associated with a reaginic antibody, which was thermostable (3). Some of the characteristics encoded by genes in atopic and could be transferred to normal individuals by the Prausnitz- individuals include abnormal expression of the gene encoding Kustner test (1). In 1966, Ishizaka et al (2) determined that interleukin (IL)-4, mutations in the receptor for IL-12, poly- the reaginic antibody belonged to an undescribed class, which morphism in the beta subunit of the high affinity receptor for these authors called immunoglobulin E (IgE). By describing the IgE, and genetic variations in mast cell enzymes. unique immunoglobulin (IgE), further work in development These examples can help us understand that all mutations of techniques for identification and research in related diseases described in humans converge at the point of improving polar- was possible (2). ization towards the presentation of allergens by dendritic cells, polarization towards the Th2 immune response, increase of IgE and its binding to mast cells, and an exaggeration of the inflam- Dr. Arcique is a Specialist in Veterinary Internal Medicine, matory response mediated by type 1 hypersensitivity. Clinical Practice limited to Veterinary Dermatology, Consultorio In 1941, the human allergist, F.W. Whittich (4), diagnosed Veterinario de referencia en dermatologia e immunologia, and treated a dog suffering from hay fever. This was the first Mexico; Dr. Bajwa is a Board-certified Veterinary Dermatologist, documentation of atopy in dogs. Interestingly, the dog exhib- Veterinary Dermatology & Ear Referral Medical Clinic, Surrey, ited a similarity with the presentation described in humans; British Columbia. however, dermatological signs were not mentioned in this first Address all correspondence to Dr. Jangi Bajwa; e-mail: case. Initial identification and description of canine IgE was [email protected] reported in 1973, with characteristics similar to those reported The Canadian Academy of Veterinary Dermatology (CAVD) is in humans (5). a not-for-profit organization that promotes veterinary dermatol- ogy in Canada and provides continuing education for veterinar- Atopic dermatitis in humans and dogs ians, animal health technicians/technologists, and veterinary Atopic dermatitis (AD), atopic eczema, and eczema are syn- students. The CAVD welcomes applications for membership onyms in human medicine, referring to chronic inflammatory (www.cavd.ca). disease of the skin that presents intense itching, with patterns of Use of this article is limited to a single copy for personal study. distribution and configuration of characteristic lesions, which is Anyone interested in obtaining reprints should contact the genetically predisposed, and occurs frequently in families with CVMA office ([email protected]) for additional atopic conditions such as atopic bronchial asthma, rhinitis, copies or permission to use this material elsewhere. and/or atopic conjunctivitis (3).

the dermatology feature is generously sponsored by royal canin. la rubrique sur la dermatologie est généreusement commanditée par royal canin.

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In humans, the term inhalant allergic dermatitis was com- they serve as receptors, and upon being stimulated by binding monly used in the 1980s, implying that the path of allergen with allergens, they favor the inflammatory process in skin. exposure in atopic patients is respiratory. It was similarly With this brief introduction to a small but important part of VETERINARY DERMATOLOGYVETERINARY believed that in dogs with respiratory and dermatological the causes for presentations and exacerbation of clinical signs manifestations compatible with AD, the same thing happened. in a human AD patient, it becomes apparent that control of However, with the advancement of knowledge in human AD this clinical picture should be multimodal and based on the patients with dermatological manifestations, it was found that knowledge of its various mechanisms. they present damage to the skin barrier, which allows exogenous proteins to penetrate their epidermis. Evidence in favor of the Immunologic mechanisms in canine percutaneous route as an allergen entry route in dogs was dem- atopic dermatitis onstrated in the skin of atopic dogs due to a focal proliferation In canine AD, various mechanisms for activation of clinical of Langerhans cells, which were coated with IgE antibodies signs have also been reported. Recent studies in dogs indicate (6). More recently, Marsella et al (7) provided direct evidence that activation of toll like receptors and PAR-2 in keratinocytes that the primary route of allergen exposure in AD beagles is induces the production of cytokines and chemokines neces- percutaneous. Although oral and respiratory exposures are sary for initiating and maintaining symptoms associated with also important, these routes mainly participate in exacerbating AD (9). In acute lesions, allergic inflammation triggers the clinical signs (7). Thus, over time, the reason for the primar- release of cytokines such as IL-4 and IL-13, which induce a ily dermatological presentation of the atopic dog was better T-helper 2 (T2) response (10). understood, and involvement of the cutaneous immune system In chronic skin lesions, CD8 cells predominate in the epider- was studied. mis of an AD dog, while CD4 cells predominate in the dermis. Greater numbers of both cell types are present in lesional and Immunologic mechanisms in humans non-lesional atopic epidermis as well as in lesional dermis com- with atopic dermatitis pared to healthy skin. In contrast, non-lesional dermis exhibit In humans, allergens suspended in air (mites, pollen, animal an increase in CD8 cells only. dander) can deposit on the skin of the AD patient, penetrate Interleukin-31 is a recently described cytokine thought to play the epidermis and trigger the disease through 3 mechanisms: an important role in AD and pruritus. Interleukin-31 was detected 1. Inherent proteolytic activity. in more than 50% of serum samples from atopic dogs, but not in 2. Activation of proteinase activated receptor-2 (PAR-2). dogs with other inflammatory skin diseases or in healthy dogs (11). 3. Binding to IgE antibodies. Development of canine AD is associated with changes in These 3 mechanisms cause cutaneous inflammation in the both cutaneous and circulating lymphocyte populations. These AD patient (8). lymphocyte responses are characterized by the production of a Inherent proteolytic activity. Aerial allergens produced complex variety of cytokines, including not only T-helper 2 but by dust mites and cockroaches have proteolytic activity on also T-helper 1, T-helper 17, and regulatory T-cell responses. the skin that can contribute to delayed cutaneous recovery of In addition, microarray gene expression analysis has enabled AD patients. Dust mite proteins include serine cysteine p​​ rote- the identification of several non-cytokine factors that appear ases which alter epithelial junctions, degrade eosinophils, and to be associated with atopic inflammation. These include the activate keratinocytes, causing an increased production of IL-6, calcium-binding protein S100A8, serum amyloid A, and vari- IL-8 and macrophage colony stimulating factor (GM-CSF). ous protease inhibitors, as well as genes involved in epidermal These exogenous proteases alter the natural balance of the skin barrier formation, innate immunity receptors, cell cycle proteins between endogenous proteases and endogenous protease inhibi- and apoptosis (12). tors, leading to delayed recovery of the stratum corneum. These Such a variety of immunological mechanisms being at play in effects contribute to alterations in the skin barrier and increased canine AD demonstrates the complex nature of the disease from local inflammation. This allows aerial proteins, microbes, and an immunological point of view. Understanding the immuno- other irritants to have easy access to the epidermis where they logical complexity of the disease is valuable clinically as it helps can interact with the cutaneous immune system and trigger in planning a multimodal treatment approach for canine AD type I and type II hypersensitivity reactions commonly seen in patients. A single therapeutic strategy is usually inadequate in AD patients. the long-term; thus the treatment goals should include long- Activation of PAR-2. Aeroallergens exacerbate AD by direct term modification of the patient’s immune response while activation of PAR-2, belonging to a subfamily of G protein- minimizing therapy related long-term adverse effects. coupled 7-transmembrane domain receptors. PAR-2 r​​eceptor is located in epidermal keratinocytes and demyelinated nerve fibers Diagnosis of AD and allergen of the dermis. It i​​s crucial for neural transmission of the itch identification in humans and dogs sensation, maintenance of calcium gradient ion, and recovery Diagnosis of AD in humans is clinical, since there is currently of the skin barrier, although the exact mechanism is not known. no test that can diagnose AD. There are standardized criteria Binding to IgE antibodies. In the classic IgE-mediated based on clinical signs that an atopic patient may manifest; the mechanism, allergens bind to specific IgE antibodies. These anti- major and minor criteria described by Hanifin and Rajka are bodies are deposited in Langerhans cells and mast cells, where the most utilized (13).

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As in humans, the diagnosis of canine AD is also clinical, inoculation of grass pollen in hay fever patients in 1911 (16). based on age of onset, breed, and clinical signs. No single test Administration of ASIT in human and canine AD patients exists that can differentiate the atopic dog from a non-atopic can reduce symptoms and medication scores, alter the natural dog. A sub-group of the International Committee for Allergic course of allergic diseases, prevent disease progression, and can Diseases in Animals (ICADA) has developed a set of practical help prevent new allergen sensitization (16). Allergen-specific guidelines that can be used to assist in the diagnosis of canine immuno­therapy is the only treatment that can reverse the AD. These guidelines include ruling out other skin conditions immune response dominated by Th2 lymphocytes in atopic with clinical signs that can resemble or overlap with canine AD, people exposed to aeroallergens. The 2 main routes for admin- detailed interpretation of the historical and clinical features of istering ASIT with scientific evidence of its effectiveness are sub- the condition. A new tool to assist with interpretation of these cutaneous and sublingual. While multimodal therapy is desirable findings is the application of clinical criteria known as Favrot’s in all canine AD patients due to the complicated immunological criteria (14). It must be remembered that Favrot’s criteria are basis of the disease, modification of the patient’s altered immune not diagnostic tests, rather they are a tool that helps assess pos- response by utilizing ASIT is encouraged in order to achieve DERMATOLOGIE VÉTÉRINAIRE sible likelihood of AD in a patient, while taking into account long-term success, wherever available. other parameters. Intra-dermal allergy testing and serum allergy testing are References the 2 primary methods used for identification of offending . 1 Coca AF, Cooke RA. On the classification of the phenomena of hyper- sensitiveness. J Immunol 1923;8:163–166. environmental allergens. In humans, knowledge of the age of 2. Ishizaka K, Ishizaka T, Hornbrook MM. Physicochemical properties of onset of AD is considered quite important, with food allergens human reaginic antibody. IV. Presence of a unique immunoglobulin as inducing flares in some infants with moderate-to-severe AD, a carrier of reaginic activity. J Immunol 1966;97:75–85. 3. Wollenberg A, Oranje A, Deleuran M, et al. ETFAD/EADV Eczema whereas environmental allergens such as house dust mite, pollen task force 2015 position paper on diagnosis and treatment of atopic der- or animal fur seem to be more relevant triggers in older children matitis in adult and paediatric patients. J Eur Acad Dermatol Venereol and adults. The spectrum of relevant allergens may change with 2016;30:729–747. 4. Wittich FW. Spontaneous allergy (atopy) in the lower animal. J Allergy the course of disease. Clinical relevance of suspected offending 1941;12:247–257. allergens can be ascertained by the atopy patch test or allergen 5. Halliwell REW, Schwartzman RM, Rockey LH. Antigenic relationship exposure in an environmental challenge chamber (a sealed between human and canine IgE. Clin Exp Immunol 1972;10:399–407. 6. Olivry T, Moore PF, Affolter VK, Naydan DK. Langerhans cell hyper- chamber of aeroallergens). For suspected food allergy the current plasia and IgE expression in canine atopic dermatitis. Arch Dermatol guidelines propose that the suspected food be administered in a Res 1996;288:579–585. blinded provocation test (3,15). 7. Marsella R, Nicklin C, Lopez J. Studies on the route of access of allergen exposure in high IgE-producing beagle dogs sensitized to house dust In dogs, it is not possible to distinguish clinical signs of atopic mites. Vet Dermatol 2006;17:306–312. dermatitis caused by environmental allergens from those caused 8. Hostetler MD, Kaffenberger BS, Hostetler MD, Zirwas J. The role of by food allergy. Elimination diet followed by a provocation airborne proteins in atopic dermatitis. J Clin Aesthet Dermatol 2010; 3:22–31. challenge with the original diet should be performed in any 9. Maeda S, Maeda S, Ohno K, et al. Protease-activated receptor-2 induces dog with a suspicion of AD. Food allergies are considered more proinflammatory cytokine and chemokine gene expression in canine likely based on the presence of perennial pruritus, particularly keratinocytes. Vet Immunol Immunopathol 2013;153:17–25. 10. Schlotter YM, Rutten VP, Riemers FM, Knol EF, Willemse T. Lesional in patients with a long history of pruritus and/or gastrointestinal skin in atopic dogs shows a mixed Type-1 and Type-2 immune respon- signs. A dietary elimination length of 6 to 8 weeks is recom- siveness. Vet Immunol Immunopathol 2011;143:20–26. mended, as 90% of dogs with food allergy show some improve- 11. McCandless EE, Rugg CA, Fici GJ, Messamore JE, Aleo MM, Gonzales AJ. Allergen-induced production of IL-31 by canine Th2 cells and ment during this time period. Intra-dermal testing (IDT) to identification of immune, skin, and neuronal target cells. Vet Immunol identify offending environmental allergens is considered the Immunopathol 2014;157:42–48. preferred diagnostic method among veterinary dermatolo- 12. Pucheu-Haston CM, Bizikova P, Marsella R, Santoro D, Nuttall T, Eisenschenk MN. Lymphocytes, cytokines, chemokines and the gists (14). It is the only technique that can evaluate mast cell T-helper 1–T-helper 2 balance in canine atopic dermatitis. Vet Dermatol degranulation through binding of the specific allergen IgE to 2015;26:124–e32. mast cells. Appropriate selection of allergens to test is fundamen- 13. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh) 1980;92:44–47. tal in obtaining reliable IDT results. It is important to test for 14. Hensel P, Santoro D, Favrot C, Hill P, Griffin C. Canine atopic derma- and identify the allergens present in the patient’s environment. titis: Detailed guidelines for diagnosis and allergen identification. BMC Vet Res 2015;11:196. Allergen-specific immunotherapy in 15. Werfel T, Heratizadeh A, Niebuhr M, et al. Exacerbation of atopic der- matitis on grass pollen exposure in an environmental challenge chamber. humans and dogs J Allergy Clin Immunol 2015;136:96–103.e9. Allergen-specific immunotherapy (ASIT) has been used to treat 16. Noon L. Prophylactic inoculation against hay fever. Int Arch Allergy Appl Immunol 1953;4:285–288. allergic diseases in clinical practice for more than a hundred years, since Leonard Noon reported the effect of prophylactic

84 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Veterinary Practice Management Gestion d’une clinique vétérinaire

The demand for associate veterinarians: Surveying the “shortage” Analyse de la « pénurie » de médecins vétérinaires

Chris Doherty

ver recent years, as the Canadian economy has picked up u cours des dernières années, alors que l’économie cana- O steam, and veterinary hospitals have seen their revenues A dienne reprenait de la vigueur et que les revenus et les and net incomes grow, the demand for associate veterinarians bénéfices nets des établissements vétérinaires augmentaient, la has climbed to new highs. This has resulted in many veterinary demande pour les vétérinaires employés a atteint de nouveaux hospitals having increasing difficulty attracting veterinarians to sommets. Ainsi, de nombreux établissements vétérinaires ont job opportunities, leading some to believe there is a shortage. de plus en plus de difficulté à attirer des professionnels pour Data from the CVMA confirm that the number of hospitals combler des emplois, ce qui fait croire à certains qu’il y a une seeking an associate veterinarian has surged. By measuring pénurie de médecins vétérinaires. the number of help-wanted advertisements placed for associ- Les données de l’ACMV confirment que le nombre d’éta- ate veterinarians in The Canadian Veterinary Journal and on blissements qui cherchent un vétérinaire employé a augmenté. the CVMA’s website, it is possible to estimate demand across En calculant le nombre d’annonces d’offres d’emploi pour des Canada. The number of ads has jumped from a low of 52 at vétérinaires employés publiées dans La Revue vétérinaire cana- the beginning of 2016, to a record high of 115 in March 2019 dienne et sur le site Web de l’ACMV, il est possible d’estimer la (Figure 1). demande dans l’ensemble du Canada. Le nombre d’annonces est One commonly cited hypothesis as to a cause of this increased passé d’un minimum de 52 au début de 2016 à un maximum demand is that associate veterinarians these days don’t want to record de 115 en mars 2019 (figure 1). work as many hours as they used to. Where a practice used to Une hypothèse souvent avancée pour expliquer cette demande only need 1 associate, they now need 2 to work the same total accrue est celle selon laquelle les vétérinaires employés ne veulent number of hours, as more veterinarians focus on work-life plus travailler autant d’heures qu’auparavant. Ainsi, là où une balance. Yet, the data do not seem to support this assertion. pratique n’avait besoin que d’un vétérinaire employé, il en faut Although many associate veterinarians reduce their hours as they maintenant deux pour travailler le même nombre total d’heures, grow in experience, newer graduates continue to work a greater car davantage de médecins vétérinaires recherchent un meil- number of hours. In fact, the national weighted average number leur équilibre entre leur vie professionnelle et leur vie privée. of hours worked annually for full-time associate veterinarians Pourtant, les données ne semblent pas appuyer cette affirmation. has climbed from 1703 in 2009 to 1777 in 2019. As a group, Bien que de nombreux médecins vétérinaires réduisent leurs

Dr. Doherty is a graduate of the Ontario Veterinary College and he works as an economic analyst for the Ontario Veterinary Medical Association. This article is provided as part of the CVMA Business Management Program, which is co-sponsored by IDEXX Laboratories, Petsecure Pet Health Insurance, Merck Animal Health, and Scotiabank. Address all correspondence to the CVMA Business Management Committee; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. Le Dr Doherty est diplômé de l’Ontario Veterinary College et travaille en tant qu’analyste économique pour l’Ontario Veterinary Medical Association. Le présent article est rédigé dans le cadre du Programme de gestion commerciale de l’ACMV, qui est cocommandité par IDEXX Laboratories, Petsecure Insurance, Merck Santé Animale et la Banque Scotia. Veuillez adresser toute correspondance au Comité de la gestion commerciale de l’ACMV ([email protected]). L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des ­réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.

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120

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GESTION D’UNECLINIQUE VÉTÉRINAIRE 0

May/MaiJuly/Juil. Nov/Nov. May/MaiJuly/Juil. Nov/Nov. May/MaiJuly/Juil. Nov/Nov. May/MaiJuly/Juil. Mar/Mars Sept/Sept. Mar/Mars Sept/Sept. Mar/Mars Sept/Sept. Mar/Mars Sept/Sept.

Jan-16/Janv. 2016 Jan-17/Janv. 2017 Jan-18/Janv. 2018 Jan-19/Janv. 2019

Figure 1. Monthly number of help-wanted advertisements for associate veterinarians placed with the CVMA./Nombre mensuel d’annonces d’offres d’emploi pour des vétérinaires employés publiées par l’ACMV.

associate veterinarians are working more today than they were heures de travail à mesure qu’ils acquièrent de l’expérience, les 10 years ago, well before the current talk of a shortage (Table 1). nouveaux diplômés continuent de travailler un nombre d’heures In response to this perceived shortage, some have suggested plus élevé. En fait, le nombre moyen pondéré d’heures travaillées that veterinary colleges be lobbied to add seats, resulting in more par année à l’échelle nationale pour les vétérinaires employés à graduates and thus more veterinarians to satisfy this demand. temps plein est passé de 1703 en 2009 à 1777 en 2019. En tant While this would certainly add to the pool of veterinarians avail- que groupe, les vétérinaires employés travaillent plus aujourd’hui able, this strategy would take, at a minimum, 4 to 5 years to qu’il y a 10 ans, bien avant que l’on parle de pénurie (Tableau 1). bear fruit. Yet it was only a short 5 years ago, in 2015, that the En réponse à cette pénurie perçue, certains ont suggéré de number of help-wanted advertisements for veterinarians was lan- faire pression pour accroître la capacité des écoles vétérinaires, guishing at low levels. In the American veterinary market, jobs afin qu’il y ait plus de diplômés, donc plus de médecins vétéri- were scarce compared to applicants, resulting in the American naires, pour répondre à la demande. Même s’il est vrai que cette Veterinary Medical Association (AVMA) declaring there to be stratégie ferait augmenter le nombre de médecins vétérinaires “excess capacity.” Given how rapidly conditions have changed, disponibles, il s’écoulerait au moins 4 ou 5 ans avant qu’elle caution would be warranted in making plans for 5 years from porte ses fruits. Or, il y a à peine 5 ans, en 2015, le nombre now, based on today’s realities. d’annonces d’offres d’emploi pour des médecins vétérinaires This is especially true as Canada’s population continues to était très faible. Aux États-Unis, l’AVMA (American Veterinary change and age. In 2019, veterinarians are fortunate to have Medical Association) avait même déclaré faire face à une situa- 2 huge generational cohorts currently in some of the prime tion de « capacité excédentaire » étant donné que le nombre pet-owning years of their lives; Baby Boomers and Millennials. d’emplois était inférieur au nombre de candidats. Compte While the average Baby Boomer today is 63.1 years old (per tenu de la rapidité avec laquelle les conditions ont changé, la Statistics Canada), that figure will obviously climb over the prudence est de mise si on élabore des plans pour corriger la coming years. History would suggest that, as people age, they situation dans 5 ans en se basant sur les réalités d’aujourd’hui. begin to own pets less commonly. By 2029, nearly 1 in 4 (24%) Cela est d’autant plus vrai que la population du Canada Canadians will be over 65 years of age, compared to 18% today. continue d’évoluer et de vieillir. En 2019, les médecins vétéri- The impact of these shifting demographics needs to be con- naires ont la chance de travailler à une époque où deux énormes sidered before jumping to change the supply of veterinarians. cohortes générationnelles (les baby-boomers et les millénariaux) In addition, this shortage appears to be regional in nature. en sont aux stades de leur vie où ils sont les plus susceptibles A recent survey in Ontario found that associate veterinarian d’avoir des animaux de compagnie. Le baby-boomer moyen a help wanted advertisements in Toronto received a median of aujourd’hui 63,1 ans (selon Statistique Canada), et ce chiffre 4 respondents, those in the greater Toronto area (GTA) a median va évidemment augmenter au cours des prochaines années. of 3 respondents, and those in areas just outside the GTA a Historiquement, le taux de possession d’un animal de compagnie median of 2 respondents. More rural parts of the province, diminue plus l’âge des gens augmente. D’ici 2029, près d’un

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Table 1/Tableau 1. Median annual hours worked for full-time Table 2/Tableau 2. Median annual compensation for full-time

associate veterinarians, stratified by province, 2009 and 2019. associate veterinarians, stratified by province, 2018 and 2019. PRACTICE MANAGEMENT VETERINARY Nombre médian d’heures travaillées par année chez les Rémunération annuelle médiane des médecins vétérinaires médecins vétérinaires employés à temps plein, par province, employés à temps plein, par province, en 2018 et 2019. en 2009 et 2019. Full-time associate Full-time associate veterinarian median veterinarian median compensation annual hours worked Rémunération médiane des Nombre médian médecins vétérinaires d’heures travaillées par employés à temps plein année des médecins Change vétérinaires employés 2018 2019 Variation à temps plein Change Canada $84 847 $89 980 6.0% 2009 2019 Variation BC/C.-B. $90 000 $100 000 11.1% AB/Alb. $90 000 $95 000 5.6% Canada 1703 1777 4.3% SK/Sask. $81 000 $85 000 4.9% BC/C.-B. 1819 1798 21.2% MB/Man. $87 500 $85 000 22.9% AB/Alb. 1880 1880 0.0% ON/Ont. $85 000 $90 000 5.9% SK/Sask. 1880 1880 0.0% QC/Qc $79 500 $85 000 6.9% MB/Man. 1880 1959 4.2% NB/N.-B. $76 000 $74 500 22.0% ON/Ont. 1692 1792 5.9% NS/N.-É. $80 000 $80 000 0.0% QC/Qc 1504 1632 8.5% PE/Î.-P.-É. $66 000 $75 900 15.0% NB/N.-B. 1880 1792 24.7% NL/T.-N.-L. $106 000 $105 000 20.9% NS/N.-É. 1645 1880 14.3% PE/Î.-P.-É. 1645 1692 2.9% BC — British Columbia; AB — Alberta; SK — Saskatchewan; MB — Manitoba; NL/T.-N.-L. 1734 1800 3.8% ON — Ontario; QC — Quebec; NB — New Brunswick; NS — Nova Scotia; PE — Prince Edward Island; NL — Newfoundland and Labrador. BC — British Columbia; AB — Alberta; SK — Saskatchewan; MB — Manitoba; (C.-B. : Colombie-Britannique; Alb. : Alberta; Sask. : Saskatchewan; ON — Ontario; QC — Quebec; NB — New Brunswick; NS — Nova Scotia; Man. : Manitoba; Ont. : Ontario; Qc : Québec; N.-B. : Nouveau-Brunswick; PE — Prince Edward Island; NL — Newfoundland and Labrador. N.-É. : Nouvelle-Écosse; Î.-P.-É. : Île-du-Prince-Édouard; T.-N.-L. : (C.-B. : Colombie-Britannique; Alb. : Alberta; Sask. : Saskatchewan; Terre-Neuve-et-Labrador). Man. : Manitoba; Ont. : Ontario; Qc : Québec; N.-B. : Nouveau-Brunswick; N.-É. : Nouvelle-Écosse; Î.-P.-É. : Île-du-Prince-Édouard; T.-N.-L. : Terre-Neuve-et-Labrador). Canadien sur quatre (24 %) aura plus de 65 ans, comparati- vement à 18 % maintenant. L’impact de ces données démo- graphiques qui évoluent doit être pris en considération avant such as northern Ontario, received a median of 0 respondents de prendre une décision visant à modifier l’offre de médecins to their help wanted advertisements. These findings are echoed vétérinaires. by the AVMA’s Economics Department, which determined En outre, la pénurie semble être de nature régionale. Un that shortages of veterinarians were area-specific (e.g., a short- récent sondage mené en Ontario a révélé que le nombre médian age of rural food animal veterinarians in the Kent County of de réponses reçues aux annonces d’offres d’emploi pour un Delaware), and that help wanted advertisements in larger cities vétérinaire employé était de 4 pour Toronto, de 3 pour la région (e.g., New York, Los Angeles, Chicago, Seattle) continued to du Grand Toronto (GTA) et de 2 pour les régions situées à attract a greater number of applicants than those in more rural l’extérieur de la région du Grand Toronto. Dans les régions plus parts of the country. rurales de la province, comme le nord de l’Ontario, le nombre All of this is likely little comfort to the individual veterinary médian de réponses reçues était de 0. Ces conclusions semblent practice owner who is struggling to find an associate to help corroborées par le département des affaires économiques de with the caseload they are currently experiencing. In this envi- l’AVMA, qui a déterminé que les pénuries de médecins vétéri- ronment, what can be done to increase the odds of attracting naires étaient spécifiques à des régions données (par exemple, a veterinarian? Most economists would likely suggest that the pénurie de médecins vétérinaires ruraux en pratique des grands rational response is to increase the wages on offer. animaux dans le comté de Kent au Delaware), et que les offres Mr. Neel Kashkari, President of the Federal Reserve Bank of d’emploi dans les grandes villes (comme New York, Los Angeles, Minneapolis has responded to complaints of a shortage of skilled Chicago et Seattle) continuaient d’attirer un plus grand nombre labor by simply stating, “If you pay more, they will come.” This de candidats que celles des régions plus rurales du pays. assertion is supported by one of the basic fundamental ten- Évidemment, ces données n’apportent pas de réconfort aux ants of economics: the supply and demand curve. As demand propriétaires d’établissements vétérinaires qui ont du mal à has climbed, higher pricing is necessary to attract the supply trouver un médecin vétérinaire employé pour les aider à faire required to re-attain equilibrium. Some may argue that the sup- face à la charge de travail qu’ils vivent actuellement. Dans ce ply of veterinarians is limited, so greater pay won’t boost supply; contexte, que peut-on faire pour augmenter les chances d’attirer but this seems unlikely, as higher associate veterinarian wages un médecin vétérinaire? La plupart des économistes diraient would draw in labor from other provinces and countries, entice probablement que la réponse rationnelle à cette question est locums, and those in government, industry, and academia, and d’augmenter les salaires proposés. further incentivize those associates currently working part-time Neel Kashkari, président de la Federal Reserve Bank de to consider taking on more hours (by increasing the compensa- Minneapolis, a répondu aux doléances concernant la pénurie tion they sacrifice in working part-time). de main-d’œuvre qualifiée en déclarant simplement : « Si vous

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The results of the 2019 Provincial Surveys of Compensation Resources and Benefits for Associate Veterinarians suggest that some 1. Statistics Canada [page on Internet], Historical Age Pyramid. Available Canadian veterinary hospitals have indeed begun to respond from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/ to the increased competition for associates with higher wages pyramid/pyramid.cfm?geo1=01&type=1 Last accessed November 6, 2019. 2. The Economist [page on Internet]. Available from: https://www. (Table 2). The national weighted average annual compensation economist.com/united-states/2019/07/20/low-inflation-means-the- for full-time associates climbed by 6%, to $89 980, well above federal-reserve-is-changing-whom-it-listens-to Last accessed November 6, the rate of inflation (Table 2). 2019. 3. National Post [page on Internet], available from: https://nationalpost. As University of British Columbia economics professor com/opinion/columnists/douglas-todd-dramatic-jump-in-guest-workers- Dr. David Green succinctly puts it: “When something is scarce, hurts-canadians-low-wage-earners Last accessed November 6, 2019. ■ the price for it goes up and people and companies adjust. That’s the whole wonder of the capitalist system.”

GESTION D’UNECLINIQUE VÉTÉRINAIRE payez plus, vous aurez des candidats ». Cette affirmation s’appuie pour les vétérinaires employés en offrant des salaires plus élevés sur l’un des fondements de l’économie : la courbe de l’offre (tableau 2). La rémunération annuelle moyenne pondérée des et de la demande. À mesure que la demande augmente, il est médecins vétérinaires employés à temps plein a augmenté de nécessaire de hausser les prix afin d’attirer l’offre nécessaire pour 6 % au pays, à un rythme nettement supérieur à l’inflation, pour retrouver l’équilibre. Certains diront peut-être que le nombre atteindre 89 980 $ (tableau 2). de médecins vétérinaires est limité et qu’un salaire plus élevé ne David Green, professeur d’économie à l’Université de la fera pas augmenter l’offre, mais cela semble peu probable, car Colombie-Britannique, résume ainsi : « Lorsqu’une chose se fait des salaires plus élevés des vétérinaires employés attireraient des rare, son prix augmente et les gens et les entreprises s’adaptent. professionnels d’autres provinces et pays, des remplaçants ainsi C’est l’essence même du capitalisme. » que des professionnels travaillant pour le gouvernement, l’indus- trie ou des établissements d’enseignement, en plus d’inciter les Ressources vétérinaires employés travaillant actuellement à temps partiel à 1. Statistique Canada [page Web], « Historical Age Pyramid ». Disponible au : https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/pyramid/ accepter plus d’heures (en faisant augmenter la rémunération pyramid.cfm?geo1=01&type=1 (dernière consultation le 6 novembre 2019). qu’ils sacrifient en ne travaillant qu’à temps partiel). 2. The Economist [page Web], disponible au : https://www.economist.com/ Les résultats des sondages provinciaux de 2019 sur la rému- united-states/2019/07/20/low-inflation-means-the-federal-reserve-is- changing-whom-it-listens-to (dernière consultation le 6 novembre 2019). nération et les avantages sociaux des vétérinaires employés 3. National Post [page Web], disponible au : https://nationalpost.com/ indiquent que certains établissements vétérinaires canadiens opinion/columnists/douglas-todd-dramatic-jump-in-guest-workers-hurts- ont effectivement commencé à réagir à la concurrence accrue canadians-low-wage-earners (dernière consultation le 6 novembre 2019). ■

Index of Advertisers Index des annonceurs

AlphaVet Science...... 74 Lebalab, Inc...... IBC Atlantic Provinces Veterinary Conference...... 28,29 Nestle Purina...... 2 Borden Ladner Gervais LLP...... 103 NVA...... 4 Canadian Veterinary Medical Association...... 22, 34, 91 Pawpals Pawprint Keepsake – Canada...... 104 Chiron Compounding Pharmacy...... 103 Sensor Health Veterinary Diagnostics, Inc...... 104 Elanco Animal Health...... 1 Simmons & Associates Canada, Inc...... 104 Hill’s Pet Nutrition Canada, Inc...... IFC UXR, Inc...... 104 Invermere Veterinary Hospital...... 102 Vetcare...... 103 Jackson & Associates...... 104 Western Financial Group Insurance Solutions...... OBC

The participation of advertisers in the CVJ is an indication of their com- Le support des annonceurs démontre leur engagement pour mitment to the advancement of veterinary medicine in Canada. We l’avancement de la médecine vétérinaire au Canada. Nous vous encourage our readers to give their products and services appropriate ­encourageons à prendre ­connaissance de leurs services et ­produits. consideration. — Ed. — NDLR

88 CVJ / VOL 61 / JANUARY 2020 FOR PERSONAL USE ONLY Diagnostic Ophthalmology Ophtalmologie diagnostique

Lynne S. Sandmeyer, Marina Leis, Stephanie Osinchuk

History and clinical signs the posterior lens capsule to the optic nerve in the right eye. No abnormalities were detected in the left eye. Photographs of 7-month-old male Yorkshire terrier cross was examined the right eye at presentation are provided for your assessment at the ophthalmology service at the Western College of A (Figure 1). Veterinary Medicine for evaluation of ocular abnormalities in the right eye. The menace responses, palpebral, occulocephalic, and direct and consensual pupillary light reflexes were present What are your clinical diagnosis, bilaterally. Schirmer tear test (Schirmer Tear Test Strips; Alcon differential diagnoses, therapeutic plan, Canada, Mississauga, Ontario) values were 22 and 20 mm/min and prognosis? in the right and left eyes, respectively. The intraocular pressures Discussion were estimated with a rebound tonometer (Tonovet; Tiolat, The clinical diagnosis was persistent, hyperplastic, primary Helsinki, Finland) and were 21 and 14 mmHg in the right and vitreous (PHPV) and incipient cataract of the right eye. PHPV left eyes, respectively. Fluorescein staining (Fluorets; Bausch & is a congenital anomaly resulting from failure of regression of Lomb Canada, Markham, Ontario) was negative bilaterally. the primitive vitreous and hyaloid vascular system, as well as On direct examination a circular opacity was noted in the pos- hyperplasia of the mesodermal elements of these components terior aspect of the right lens. Following application of 0.5% (1,2). PHPV may be unilateral or bilateral. The most common tropicamide (Mydriacyl; Alcon Canada, Mississauga, Ontario), clinical manifestation of PHPV is leukocoria (white pupil) biomicroscopic examination (Osram 64222; Carl Zeiss Canada, resulting from a white plaque of tissue containing blood vessels Don Mills, Ontario) revealed the opacity to involve the posterior attached to the posterior lens capsule (2). lens cortex and lens capsule of the right eye. There was vascu- Dog breeds in which PHPV is inherited include the larization present within the opacity. Indirect ophthalmoscopic Doberman pinscher, Staffordshire bull terrier, Bouvier des (Heine Omega 200; Heine Instruments Canada, Kitchener, Flandres, and miniature schnauzer (2–5). It occurs sporadi- Ontario) examinations were completed bilaterally and a linear cally in other canine breeds and other species (1,6–10). The blood vessel was noted extending from the central aspect of complete pathogenesis of PHPV is unknown. The primitive

Figure 1. Retroilluminated (left) and directly illuminated (right) photographs of the right eye of a 7-month-old Yorkshire terrier cross.

Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

CVJ / VOL 61 / JANUARY 2020 89 FOR PERSONAL USE ONLY

or primary vitreous is located between the developing lens and transection of the hyaloid artery and anterior vitrectomy (1). retina. It consists of blood vessels of the hyaloid system, mesen- Surgical outcomes may be less favorable than standard cataract chymal cells, collagenous fibrillary material, and macrophages surgery due to these added anatomical abnormalities (1,2). No (11). The hyaloid artery (HA) penetrates the primary vitreous treatment was initiated in this dog due to the lack of clinically through the optic fissure and grows toward the posterior pole appreciable vision deficits or ocular complications. However, of the lens where it branches and develops into a vascular net- it was recommended that the dog return for re-evaluation on work around the primitive lens forming the tunica vasculosa a 6-month to yearly basis to monitor the possibility of cataract lentis (TVL). After day 45, the hyaloid vascular system starts progression and complications such as uveitis and intraocular to regress, and regression is usually complete by 2 to 4 wk after hemorrhage. birth. Incomplete regression of the hyaloid system can result in The prognosis for PHPV is variable and depends on the a patent hyaloid artery (PHA), persistent hyperplastic tunica degree of severity. Affected dogs should be monitored through- vasculosa lentis (PHTVL), or PHPV (1,2,12,13). Manifestations out life for development of complications which may be sight of PHA range from a white connective tissue strand attached and globe threatening. Screening ocular examinations are to the posterior lens capsule, to patent blood vessels extending indicated in breeds with inherited forms of the condition but OPHTALMOLOGIE DIAGNOSTIQUE OPHTALMOLOGIE from the posterior lens capsule toward the optic nerve (14). should be completed after 6 wk of age. In these breeds, affected Manifestations of PHTVL include fine white strands or blood dogs should not be bred. vessels attached to the posterior lens capsule with possible exten- sion around the equator of the lens (1). PHPV involves not only References failure of regression of the hyaloid artery system but includes 1. Boeve MH, Stades FC. Diseases and surgery of the canine vitreous. In: Gelatt KN, ed. Veterinary Ophthalmology. 5th ed. Ames, Iowa: Wiley- hyperplasia of the mesenchymal tissue of the primary vitreous. Blackwell, 2013:1287–1302. In addition to a retrolental fibrovascular plaque, PHPV may also 2. Stades FC. Persistent hyperplastic tunica vasculosa lentis and per- manifest with lenticular anomalies such as cataract, microphakia, sistent hyperplastic primary vitreous (PHTVL/PHPV) in 90 closely related Doberman Pinschers: Clinical aspects. J Am Anim Hosp Assoc lens coloboma, posterior lenticonus, and lens capsular disrup- 1983;19:957–964. tion. Additionally, the vascular components may be disrupted 3. Leon A, Curtis R, Barnett KC. Hereditary persistent hyperplastic pri- causing intralenticular hemorrhage (2). mary vitreous in the Staffordshire Bull Terrier. J Am Anim Hosp Assoc 1986;22:765–774. The differential diagnosis for PHPV includes other causes 4. van Rensburg IBJ, Petrick SW, van der Lugt JJ, Smit MME. Multiple of leukocoria such as cataract, retinal detachment, inflamma- inherited eye anomalies including persistent hyperplastic tunica vas- tory infiltrates in the vitreous, and intraocular neoplasia (1,2). culosa lentis in Bouvier Des Flandres. Prog Vet Comp Ophthalmol 1992;2:133–139. Diagnosis of PHPV is based on direct examination and the 5. Grahn BH, Storey ES, McMillan C. Inherited retinal dysplasia and clinical findings of a retrolental plaque of white fibrovascular persistent hyperplastic primary vitreous in Miniature Schnauzer dogs. tissue located against the posterior polar lens capsule. Ocular Vet Ophthalmol 2004;7:151–158. ultrasound is useful if opacification of the cornea, anterior 6. Verbruggen AM, Boroffka SA, Boeve MH, Stades FC. Persistent hyper- plastic tunica vasculosa lentis and persistent hyaloid in a 2-year-old chamber, or lens prevents direct visualization of the posterior basset hound. Vet Q 1999;2:63–65. lens (8). The ultrasonic appearance consists of a hyperechoic 7. Gemensky-Metzler AJ, Wilkie DA. Surgical management and histologic lens and retrolental mass, representing cataract and fibrovascular and immunohistochemical features of a cataract and retrolental plaque secondary to persistent hyperplastic tunica vasculosa lentis/persistent tissue, with or without a hyperechoic strand extending from the hyper plastic primary vitreous (PHTVL/PHPV) in a Bloodhound central retrolental tissue toward the optic disk, representing a puppy. Vet Ophthalmol 2004;7:369–375. persistent hyaloid artery (8). 8. Bayon A, Tovar MC, Frenandez del Palacio MN, Aqut A. Ocular com- plications of persistent hyperplastic primary vitreous in three dogs. Vet Ocular complications arising from PHPV include vision Ophthalmol 2001;4:35–40. loss due to cataract, hyphema, vitreous hemorrhage, uveitis, 9. Boeve MB, Stades FC, van der Linde-Spiman JS, Vrensen GF. Persistent retinal detachment, and secondary glaucoma (7,8). There is hyperplastic tunica vasculosa lentis and primary vitreous in the dog: A comparative review. Prog Vet Comp Ophthalmol 1992;2:163–172. one case report of intraocular sarcoma associated with lens 10. Graham KL, Krockenberger MB, Billson FM. Intraocular sarcoma capsule rupture related to PHPV in a dog (10). Although the associated with lens capsule rupture and persistent hyperplastic primary pathogenesis of the malignancy was not conclusive, there were vitreous in a dog. Vet Ophthalmol 2018;21:188–193. 11. Cook C. Embryogenesis of congenital eye malformations. Vet Comp similarities with post-traumatic ocular sarcomas of cats, which Ophthalmol 1995;5:109–123. are frequently a sequela of lens capsule rupture (14–16). 12. Boeve MH, Lide-Sipman JS, Stades FC. Early morphogenesis of the The treatment of PHPV depends on the severity of the canine lens, hyaloid system and vitreous body. Anat Rec 1988;220: 435–441. condition and presence of concurrent ocular complications. 13. Aguirre GD, Rubin LF, Bistner SI. Development of the canine eye. Am Small plaques not causing vision deficits may be monitored for J Vet Res 1974;44:2399–2414. progression of cataract. Topical anti-inflammatory therapy is 14. Duddy J, Powzaniuk W, Rubin L. Hyaloid artery patency in neonatal beagles. Am J Vet Res 1983;44:2344–2346. indicated if cataract is causing lens-induced uveitis. Vision loss 15. Dubielzig RR, Everitt J, Shadduck JA, Albert DM. Clinical and mor- associated with cataract may be treated with phacoemulsifica- phologic features of post-traumatic ocular sarcomas in cats. Vet Pathol tion; however, this is complicated by the variable retrolental 1990;27:62–65. 16. Dubielzig RR, Hawkins KL, Toy KA. Morphologic features of feline ocu- anomalies. For example, surgery may be complicated by an lar sarcomas in 10 cats: Light microscopy, ultrastructure, and immuno­ incomplete or disrupted posterior lens capsule and may require histochemistry. Vet Comp Ophthalmol 1994;4:7–12.

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