WSAVA Nov 2021 Proceedings

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COME AND LIVE A NEW EXPERIENCE! JOIN US AT THE ROYAL CANIN BOOTH GLOBAL COMMUNITY CONGRESS 13-15 NOVEMBER 2021 VISIT the 3D Royal Canin Booth BIENVENIDA BEM-VINDO WELCOME BIENVENUE WELKOMWILLKOMMEN VELKOMMEN BENVENUTO

13–15 NOVEMBER, 2021 4 WSAVA GLOBAL COMMUNITY CONGRESS

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13–15 NOVEMBER, 2021 AUTHOR INDEX z 149 Farry, T. 38, 40 Abatzidis, M. 88, 90, 268-269 Fischer, M.-C. 240, 242, 261 Appleby, R. 185, 210, 234 Fitzgerald, G. 170, 172 Bacon, N. 248 Fox, P. 186, 303, 305, 335-336, 338-339 Beatty, J. 97, 212 Fredholm, M. 96 Bell, J. 77 Freiche, V. 65, 251 Beltran, E. 314 Friis, H. 96 Bhutia, T. 259, 284 Garosi, L. 28, 30, 58, 60, 62 Boonyarittichaikij, R. 194, 219-220, 326 Gaschen, F. 17 Bowman, D. 99-100, 116 Gilkerson, J. 248 Brashear, M. 76 Giuliano, A. 257 Braun, C. 248 Grubb, T. 188, 211, 319, 321 Bruce, M. 96 Hampson, K. 313 Bruun, C. 18, 143-144 Heath, S. 147 Burley, M. 195-196 Hickey, M. 132, 134, 158-160 Carlson, E. 173 Hochleithner, C. 260 Chandler, M. 286 Hochleithner, M. 260 Churchill, J. 313 Hock, H. 75 Cleaveland, S. 235 Hofmann-Lehmann, R. 273, 275 Clemente-Vicario, P. 21, 23, 47, 49-50, 52 Hohenhaus, A. 182, 208 Coetzer, A. 227 Hur, B. 248 Coghlan, S. 41, 43, 74 Ignatenko, N. 258 Comazzi, S. 248 Irimajiri, M. 137-138, 165-166 Combs, M. 80, 107 Irwin, P. 15 Cousins, M. 280-281 Jekl, V. 237-238 Crawford, C. 296, 299, 327, 329 Kirpensteijn, J. 181, 294 Dear, J. 277 Kouki, M. 81 Del, R. 175 Krekeler, N. 230 De, M. 248 Kutzler, M. 253 Dhand, N. 135, 216-217 Ladlow, J. 31, 92, 270, 272 Dowgray, N. 220, 222 Lambrecht, K. 317 Durham, E. 140-141, 167, 169 Lappin, M. 179, 207 Elliott, D. Larenza, P. 94, 244-245, 265-z 6 WSAVA GLOBAL COMMUNITY CONGRESS

Lim, V. 125 Ratanakorn, P. 259 Liu, N. 31 Reagan, K. 111 Lobetti, R. 102 Reusch, C. 115 Manchester, A. 283 Rinkinen, M. 121 Mansfield, C. 248 Rolph, K. 189 Marcondes, M. 105, 311 Romagnoli, S. 232, 323 Marx, T. 96 Ryan, L. 163 Masters, S. 248 Saint-Erne, N. 192, 218 Mcerlean, B. 123 Schaefer-Somi, S. 255 Mcleod, K. 83 Scorza, V. 180 Mcmichael, M. 118 Scott, T. 21, 23, 47, 49-50, 52 Megens, M. 113 Sharp, C. 24, 26, 53, 55-56 Meijboom, F. 252 Simpson, K. 205 Mellersh, C. 263 Singh, A. 106 Milne, E. 278 Soares, R. 248 Monnet, E. 184, 297, 301, 330, 332-333 Squires, R. 248 Morgenegg, G. 19 Steele, A. 71-72 Nadal, D. 313 Steiner, J. 198, 200, 223, 225-226, 326 Nel, L. 21, 23, 47, 49-50, 52 Sykes, J. 119 Niemiec, B. 108, 215 Tan, C. 127, 152, 154 Noli, C. 129-130, 155, 157, 213, 250 Taylor, S. 136, 162, 191, 217 O’Neill, D. 33, 63, 247 Tepper, J. 87, 111, 219 Ong, B. 45 Thieman, K. 84, 86, 294-295 Palmer, R. 201, 292 Tunhikorn, M. 35-36, 67, 69 Papadimitriou, S. 81 Turnbull, G. 151 Peaston, A. 248 Verton-Shaw, S. 315 Peterson, M. 178, 204 Villaverde, C. 122, 201, 288 Petty, M. 289-290 Wasiatycz, G. 125 Plangsangmas, T. 259 Webb, T. 146 Powell, M. 177 Weeth, L. 203, 324 Quain, A. 229 Wensley, S. 308 Queiroga, F. 104 Whitley, N. 109, 310 Questen, J. 87, 193 Wickramasinghe, C. 44 7

13–15 NOVEMBER, 2021 CONTENTS UPDATE ON CANINE AND FELINE BABESIOSIS 15 PERIODONTAL DISEASE AND THERAPY 44 ACUTE DIARRHEA IN THE DOG - WHY ANTIBIOTICS PAIN MANAGEMENT FOR CANINE AND FELINE 45 ARE ONLY RARELY NEEDED 17 DENTAL PATIENTS DENTAL RADIOLOGY TECHNIQUES 18 THE CRITICAL ROLE OF PRIVATE AND PUBLIC VETERINARIANS IN RABIES ELIMINATION 47 ORAL EXAM AND CHARTING 19 RABIES AND MHEALTH: YOUR ROLE IN RABIES SURVEILLANCE49 THE STATUS QUO OF RABIES: FROM GLOBAL TO LOCAL 21 RABIES: PRACTICAL DELIVERY OF ONE HEALTH 23 E-LEARNING FOR PROFESSIONALS: RABIES 50 CERTIFICATION COURSES ANTICOAGULATION – WHO, WHEN AND HOW? 24 ONE HEALTH IN ACTION: RABIES IN THE SHOES OF A HUMAN HEALTH PROFESSIONAL 20 52 ANTIFIBRINOLYTICS – WHAT IS THE EVIDENCE? 26 EVERYTHING A GENERAL PRACTITIONER NEEDS TO UPDATES ON IMHA DIAGNOSIS AND TREATMENT; 53 KNOW ABOUT CANINE EPILEPSY INCORPORATING NEW GUIDELINES 28 WHAT IS SO SPECIAL ABOUT FELINE EPILEPSY? 30 NOVEL TRANSFUSION PRODUCTS; REFRIGERATED 55 PLASMA, PLATELET TRANSFUSIONS AND MORE BRACHYCEPHALIC OBSTRUCTIVE AIRWAY INTRAVENOUS LIPID EMULSION FOR TOXICITIES IN SYNDROME: PATHO-PHYSIOLOGY AND RECOGNITION 31 DOGS.56 FLAT-FACED LIE OR TRUTH: BRACHYCEPHALICS ARE TIGHT JAW 58 LESS HEALTHY? THE BIG DATA ANSWER 33 DROOPY FACE 60 DIAGNOSTIC APPROACH FOR THE ITCHY DOG AND CAT 35 PAROXYSMAL DYSKINESIA 62 BASIC DIAGNOSTIC TESTS- PUT THE RIGHT TEST TO 36 IS THERE MORE TO THE BRACHYCEPHALIC HEAD THE RIGHT JOB STORY APART FROM BOAS? - THE EVIDENCE 63 THE ANAESTHESIA PLAN 38 CAESAREAN ANAESTHESIA 40 MANAGEMENT OF DIGESTIVE DISEASES IN 65 BRACHYCEPHALIC DOGS: A CRUCIAL STEP FOR A SUCCESSFUL APPROACH HOW CAN LABORATORY ASSIST FOR DIAGNOSIS, HOW TO RECOGNIZE PARASITIC SKIN DISEASES & 67 PROGNOSIS AND MONITORING ONCOLOGIC PATIENTS? 41 TREAT IT PROPERLY BONE MARROW CYTOLOGY: WHY, WHEN AND HOW? 43 8 WSAVA GLOBAL COMMUNITY CONGRESS

STRATEGIES TO SUCCESSFULLY TREAT STAPH BRACHYCEPHALIC OBSTRUCTIVE AIRWAY 92 PYODERMA IN THE ERA OF MULTIDRUG RESISTANCE 69 SYNDROME: SURGICAL APPROACH FIRST IMPRESSIONS COUNT: ASSESSING AND ANESTHESIA CHALLENGES IN BRACHYCEPHALIC DOGS 94 STABILIZING71 TECHNIQUES IN CRITICAL CARE 72 INTERVERTEBRAL DISC DISEASE IN CHONDRODYSTROPIC BREEDS – BACKGROUND, GENETICS AND SCREENING PROGRAMS 96 CLINICAL PATHOLOGIC APPROACH TO CANINE DEGENERATIVE MYELOPATHY - DIAGNOSIS AND LYMPHOMA74 INHERITANCE97 FELINE SPOROTRICHOSIS IN A NUTSHELL 75 CRITICALLY IMPORTANT CRITICAL THINKING SKILLS 99 TIPS AND TRICKS FOR INTUBATION OF THE 76 NURSING CARE FOR THE CRITICAL PATIENT 100 DIFFICULT AIRWAY CLINICAL REASONING IN DOGS WITH ACUTE SPINAL EHRLICHIOSIS - MORE THAN ONE DISEASE 102 CORD INJURY, WHAT SHOULD I KNOW? 77 THE ART OF FELINE PRACTICE 80 IS THIS MASTITIS OR INFLAMMATORY MAMMARY CARCINOMA?104 FELINE CAUDAL STOMATITIS 81 CPV& CDV IMMUNIZATION FAILURES: WHY THEY 105 STILL OCCUR? WELFARE ASPECTS OF UNTREATED AND UNDERTREATED DENTAL DISEASE 83 MINIMALLY INVASIVE SURGERY FOR THE 106 TREATMENT OF HIATAL HERNIA MORE THAN A NIBBLE: THE ESSENTIAL GUIDE TO BITE WOUNDS 84 PERSPECTIVES ON FELINE HEARTWORM DISEASE 107 SURGICAL SAFETY CHECKLISTS 86 EXTRACTIONS MADE EASIER 108 FILTER SYSTEMS - THE INS AND OUTS OF KOI POND 87 DIAGNOSIS AND MANAGEMENT OF IMMUNE- 109 LIFE SUPPORT MEDIATED THROMBOCYTOPENIA AQUATIC CLINICAL CASES IN A MIXED ANIMAL VET CUTANEOUS LESIONS IN KOI - A CLINICAL REVIEW 111 PRACTICE87 ARTIFICIAL INTELLIGENCE FOR CLINICAL DECISION 111 ARTIFICIAL INTELLIGENCE 101 FOR VETERINARIANS 88 MAKING AND EARLY DISEASE DETECTION, APPLICATIONS OF ARTIFICIAL INTELLIGENCE IN BOAS: A CHALLENGE REQUIRING COOPERATION VETERINARY RADIOLOGY 90 BETWEEN VETERINARIANS, BREEDERS AND AUTHORITIES113 9

13–15 NOVEMBER, 2021 SCIENTIFIC ACHIEVEMENT AWARD LECTURE: FELINE DIAGNOSIS AND MANAGEMENT OF COMPULSIVE DISORDERS IN DOGS DIABETES MELLITUS: CHALLENGES IN DIAGNOSIS, 137 THERAPY AND MONITORING 115 THRIVING, NOT JUST SURVIVING IN VETERINARY DIAGNOSIS AND MANAGEMENT OF COMPULSIVE 138 MEDICINE116 DISORDERS IN CATS COMMON BEHAVIOURAL CONDITIONS IN PARROTS 140 ANTI-AGING CONCEPTS FOR GERIATRIC PETS 118 ANAESTHESIA IN BIRDS 141 NEW PRACTICE TOOLS FOR RECOGNITION OF LEPTOSPIROSIS119 THE ABC’S OF COHAT DENTISTRY 143 HOW TO USE NUTRITIONAL ASSESSMENT IN PRACTICE 121 HOMECARE AND GAINING CLIENT COMPLIANCE 144 ALTERNATIVE DIETS (RAW, GRAIN FREE, VEGETARIAN) 122 HOW PSYCHOLOGY CAN IMPROVE CLIENT COMMUNICATIONS146 TRANSITIONING TO PRACTICE - IF ONLY SOMEONE 123 HAD TOLD ME THIS BEFORE I GRADUATED! FEEDING RESPONSIBILITY: WHERE BEHAVIOUR AND NUTRITION MERGE IN THE HUMAN ANIMAL BOND 147 A NEW GRADUATE’S PERSPECTIVE AND 125 TRANSITIONING - WHAT HELPED & WHAT DIDN’T. MEDIAL SHOULDER INSTABILITY: DIAGNOSIS AND SIX FUNDAMENTAL NEEDS - NEW GRADUATE MANAGEMENT125 MENTORSHIP PROGRAM EXTRACT FROM SOUTH AFRICA.149 FRACTURE ASSESSMENT AND DECISION MAKING 127 OVERCOMING THE FEARS & FRUSTRATIONS THAT IMPACT THE RESILIENCE OF VETERINARY PROFESSIONALS151 FOOD ALLERGY IN DOGS AND CATS 360°: THE BEST WAY TO DIAGNOSE 129 IS BIGGER BETTER? CHOOSING THE RIGHT SIZED IMPLANT152 QUALITY OF LIFE IN DERMATOLOGY AND ALLERGIC TIPS AND TRICKS FOR LOCKING PLATES 154 DERMATITIS130 MANAGING RESPIRATORY DISTRESS IN THE 132 THERAPY OF ATOPIC DERMATITIS: DOG 155 EMERGENCY PATIENT THERAPY OF ATOPIC DERMATITIS: CAT 157 HOW TO APPROACH THE TRAUMA PATIENT 158 THE INITIAL APPROACH FOR COLLAPSED PATIENTS 134 HOW TO APPROACH TREMORGENIC TOXINS 159 HOW TO APPROACH PARALYSIS TOXINS 160 CAT FRIENDLY HANDLING TIPS AND TRICKS 135 LIQUID GOLD: TRANSFUSION OF BLOOD AND BLOOD PRODUCTS IN CATS 136 10 WSAVA GLOBAL COMMUNITY CONGRESS

EVERY BREATH YOU TAKE: RESPIRATORY DISEASE 162 BIOPSY BASICS: GETTING THE MOST FROM A 182 IN CATS CYTOLOGY/HISTOLOGY REPORT INTRODUCING INHALERS: TRAINING TO CATS FOR HOW I TREAT LARYNGEAL PARALYSIS: UNILATERAL COMFORT WITH INHALED THERAPY 163 ARYTENOID LATERALISATION 184 MANAGEMENT OF INAPPROPRIATE URINATION IN HOW I TREAT TUMORS OF THE DIGITS IN DOGS 185 CATS165 HOW TO TRAIN CATS TO GO INTO THEIR CARRIER 166 HOW I MANAGE END STAGE CARDIOPULMONARY DISEASES186 IS THIS A BEHAVIOR DISORDER OR NOT - TIPS FOR HOW I TREAT BREAKTHROUGH PAIN 188 DIFFERENTIAL DIAGNOSES 166 EMERGENCY CARE AND TRIAGE OF BIRDS AND INFECTIOUS DISEASE IN KITTENS: PREVENTION AND EXOTIC ANIMALS CURE189 167 MANAGEMENT OF INAPPETANT CATS 191 THE APPROACH TO THE ANOREXIC RABBIT 169 EXOTIC ANIMAL EMERGENCIES 170 A BETTA SOLUTION - EXPLORING SIAMESE 192 FIGHTING FISH MEDICINE EXOTIC ANIMAL ANALGESIA 172 WINTER WOES - COLD WEATHER KOI POND PROBLEMS193 ADVERSE REACTIONS TO FOOD 173 A QUICK GLOBAL REVIEW OF THE MYRIAD OF 194 TREMATODES FOUND IN DOMESTIC CATS NUTRITIONAL SUPPORT IN THE HOSPITALIZED PATIENT175 ADAPTIVE LEADERSHIP FOR A HAPPY, HEALTHY & THE FILARIOID PARASITES, OTHER THAN PRODUCTIVE WORKPLACE. DIROFILARIA IMMITIS, OCCURRING IN THE DOMESTIC CAT194 177 NUTRITIONAL APPROACH TO THE DIABETIC PATIENT 195 VETERINARY STUDENT WELLBEING & 178 TRANSITIONING INTO THE PROFESSION. NUTRITION FOR THE HOSPITALIZED VETERINARY PATIENT196 SARS-COV-2 UPDATE AND ONE HEALTH 179 COMMITTEE REPORT CANINE PANCREATITIS - DO WE FINALLY HAVE A TREATMENT?198 ENTERIC PARASITIC ZOONOSES 180 INTRODUCTION TO THE WOW GLOBAL BIOPSY FELINE PANCREATITIS - ACVIM CONSENSUS 200 GUIDELINES: HOW TO DO A PROPER BIOPSY STATEMENT SUMMARY 181 MEDICAL AND NUTRITIONAL THERAPY FOR OSTEOARTHRITIS201 11

13–15 NOVEMBER, 2021 HOMEMADE VS COMMERCIAL DIETS 203 NURSING OF THE CARDIAC PATIENT 222 TEACHERS ARE STRESSED TOO! TRAINING AND COBALAMIN AND COBALAMIN DEFICIENCY 223 SUPPORT FOR EDUCATORS 204 BACTERIAL GASTROINTESTINAL DISEASES OF PETS DYSBIOSIS AND FECAL MICROBIOTA AND THEIR PEOPLE TRANSPLANTATION225 205 DIAGNOSTIC USE OF BILE ACIDS 226 USE OF PROBIOTICS IN THE MANAGEMENT OF 207 DIARRHEA IN PETS AND THEIR PEOPLE ETHICS AND EMERGING DIGITAL TECHNOLOGIES IN 227 VETERINARY MEDICINE NOT CUSHING’S DISEASE: DIAGNOSIS AND 208 ETHICALLY CHALLENGING SITUATIONS IN MANAGEMENT OF ADRENAL TUMORS IN THE DOG VETERINARY CLINICAL PRACTICE AND CAT 229 SURGICAL APPROACHES TO ADRENAL TUMORS 210 CANINE BREEDING MANAGEMENT VS MISMATING 230 HOW I TREAT POSTOPERATIVE DELIRIUM/DYSPHORIA 211 CLINICAL USE OF REPRODUCTIVE HORMONES 232 HOW I TREAT GENETIC DISEASE BEFORE ONSET 212 SOFT TISSUE SARCOMA & SURGERY, THE IDEAL COMBI?234 HOW I TREAT DERMATOPHYTOSIS 213 EVIDENCE BASED ADJUNCTIVE MANAGEMENT OF 235 CANINE SOFT TISSUE SARCOMAS HOW I TREAT FRACTURED TEETH 215 HOW TO MANAGE DENTAL PROBLEMS IN RABBITS - FELINE HEALTHY AGING 216 DRAFT OF DENTAL GUIDELINES 237 CASE STUDIES IN FELINE MEDICINE 217 HOW TO MANAGE DENTAL PROBLEMS IN CHINCHILLAS - DRAFT OF DENTAL GUIDELINES 238 THE ABC’S OF KOI PRACTICE - GETTING STARTED 218 MASTERING DRY EYE DISEASE- A SYSTEM FOR 240 CLINICAL SUCCESS FEED, FEEDING BEHAVIOR AND BODY CONDITION 219 CORNEAL ULCER- WHAT TO DO WHEN IT WON’T HEAL 242 WHICH ANCYLOSTOMA SPECIES IS WHERE IN THE 219 DOMESTIC CATS OF THE WORLD THREE WORLD-TRAVELERS – FELICOLA WHAT IS NEW IN VETERINARY ANESTHESIA? SUBROSTRATUS, LYNXACARUS RADOVSKYI AND REVIEW OF NEW ANESTHETIC AGENTS AND NOTOEDRES CATI TECHNIQUES244 220 ANESTHESIA FOR PATIENTS WITH CARDIAC DISEASE 245 CARDIOVASCULAR PHYSICAL EXAMINATION 220 12 WSAVA GLOBAL COMMUNITY CONGRESS

USING ANONYMIZED CLINICAL RECORDS AS ANESTHESIA FOR EMERGENCY PATIENTS - CASE BIG DATA TO GENERATE COMPANION ANIMAL SCENARIOS266 EVIDENCE: THE VETCOMPASS UK EXPERIENCE 247 CARDIOVASCULAR RADIOLOGY 268 USING ANONYMIZED CLINICAL RECORDS AS PULMONARY RADIOLOGY 269 BIG DATA TO GENERATE COMPANION ANIMAL EVIDENCE: THE VETCOMPASS AUSTRALIA EXPERIENCE248 ALLERGEN SPECIFIC IMMUNOTHERAPY 250 LUMPS IN TRICKY PLACES 270 FELINE LOW-GRADE INTESTINAL T-CELL GI FOREIGN BODIES 272 LYMPHOMA OR CHRONIC INFLAMMATORY ENTEROPATHY ? A CHALLENGE FOR CLINICIANS 251 ALL YOU NEED TO KNOW ABOUT FELINE LEUKEMIA VIRUS INFECTION DIAGNOSTICS 273 THE END OF ANIMAL LIFE AS THE START FOR AN UPDATE ON FELINE CALICIVIRUS INFECTION 275 ETHICS: ON EUTHANASIA AND THE ROLE OF THE VETERINARIAN252 PET POPULATION CONTROL: ADVANTAGES AND TRAP-NEUTER-VACCINATE-RELEASE: ETHICAL 277 DISADVANTAGES OF SURGICAL VS MEDICAL PERSPECTIVES IN THE PHILIPPINES. STERILIZATION253 THE CANINE PROSTATE: ITS ROLE IN FERTILITY AND THE ETHICS OF BREEDING FOR EXTREME 278 CONFORMATION IN COMPANION ANIMALS MANAGEMENT OF HYPERPLASTIC CONDITIONS 255 PALLIATIVE TREATMENT IN VETERINARY ONCOLOGY 257 VACCINATION OF DOGS IN SHELTERS: WHO, WHAT, 280 WHEN AND WHY DOC, WHAT HAPPENS IF I DON’T TREAT MY PET’S VACCINATION OF CATS IN SHELTERS: WHO, WHAT, 281 TUMOR?258 WHEN AND WHY PAIN MANAGEMENT FOR REPTILE PATIENTS - COMPARATIVE GASTROENTEROLOGY 283 WHAT WE REALLY KNOW! 259 JUVENILE AND SENIOR BIRDS - WHAT’S SPECIAL - SALMONELLA AND OTHER GASTROINTESTINAL 284 WHAT’S DIFFERENT? ZOONOSIS IN EXOTICS 260 CORNEAL COLLAGEN CROSS LINKING- USEFUL IN WHY NUTRITION MATTERS - THE KEY ROLE OF 286 GENERAL PRACTICE? NUTRITION IN HELPING PETS THRIVE 261 SEPARATING FACT FROM FICTION: NAVIGATING THE GENETICS OF PROGRESSIVE RETINAL ATROPHY; INTERNET AND THE PET FOOD AISLE 288 MORE COMPLEX THAN MEETS THE EYE? 263 CONSIDERATIONS FOR YOUR VETERINARY CLINIC TO PERIOPERATIVE PAIN RECOGNITION AND IMPROVE THE COMFORT OF YOUR PATIENTS 289 MANAGEMENT265 13

13–15 NOVEMBER, 2021 EFFECTS OF PAIN ON THE HEALTH, EMOTIONAL HOW NEW DIGITAL TOOLS CAN PROVIDE BETTER WELLBEING & QUALITY-OF-LIFE IN DOGS AND CATS 290 OUTCOMES & PET PARENT ADHERENCE FOR NUTRITION CASES 317 HOW I TREAT FRACTURES IN YOUNG PUPPIES (< 5 292 DEVELOPING ACUTE PAIN PROTOCOLS TO MONTHS OF AGE) MAXIMIZE ANALGESIA AND MINIMIZE PATIENT STRESS319 HOW I TREAT MY CLIENTS ON SOCIAL MEDIA 294 WHAT ARE THEY HIDING? FINDING PAIN IN DOGS 321 AND CAT HOW I PERFORM FULL THICKNESS GI BIOPSIES 294 HOW I TREAT MISMATING IN BITCHES AND QUEENS 323 HOW I PERFORM CYSTOTOMY/UROHYDROPULSION FOR A URETHRAL STONE 295 HOW I TREAT FELINE DIABETES 324 NEW OPTIONS FOR TREATMENT OF FIP 296 HOW I DISCUSS PARASITE TREATMENT WITH 326 VETERINARIANS WHO ASK FOR ADVICE GASTRIC DILATION VOLVULUS 297 HOW I TREAT SUBCLINICAL PANCREATITIS 326 FELINE PNEUMONIA - AN UNDER DIAGNOSED DISEASE?299 SURGERY OF THE LOWER URINARY TRACT 301 CANINE INFECTIOUS RESPIRATORY DISEASE COMPLEX - A REVIEW OF PREVENTION AND TREATMENT327 FELINE HEART DISEASE - HOW TO DIAGNOSE AND WHEN TO TREAT? UTI VS SUBCLINICAL BACTERIURIA MANAGE?303 (CASE BASED) 329 HOW TO DIAGNOSE AND MANAGE CANINE LARYNGEAL PARALYSIS 330 MYXOMATOUS VALVE DISEASE (MMVD) 305 TEMPORARY AND PERMANENT TRACHEOSTOMY 332 WELFARE AND ETHICS IN COMPANION ANIMAL 308 COSMETIC SURGERY SPLENECTOMY333 DOG AND CAT VACCINATION: BOOSTER DILEMMAS 310 HOW TO DIAGNOSE HEART DISEASE WITHOUT ECHO OR XRAYS 335 DO WE HAVE TO VACCINATE DOGS AGAINST 311 VISCERAL LEISHMANIASIS? POINT OF CARE ECHOCARDIOGRAPHY - KEY 336 DISEASES TO RECOGNIZE UPDATE ON DOG-ASSOCIATED RABIES 313 FOUR CRITICAL ARRHYTHMIAS- HOW TO DIAGNOSE INTERDISCIPLINARY APPROACH-AN EFFECTIVE AND TREAT 338 TOOL FOR RABIES CONTROL IN SIKKIM, INDIA 314 SHARE THE BOWL 315 5 EASY STEPS TO MANAGE ACUTE CONGESTIVE 339 HEART FAILURE 14 WSAVA GLOBAL COMMUNITY CONGRESS

0001 Table 1. Species of Babesia described in dogs and cats UPDATE ON CANINE AND FELINE BABESIOSIS Species Location Vector Comments and Clinical Significance P. Irwin CANINE BABESIA SPP. Murdoch/Australia B. vogeli Worldwide Rhipicephalus Urban and kennel environments. tropics and sanguineus Complicated babesiosis in pups < Qualifications: subtropics, 12 weeks old, often subclinical in Southern US adult dogs. Coinfections with other Peter John Irwin & Southern R. sanguineus-transmitted infections Europe common. BVetMed, PhD, FANZCVS, MRCVS B. canis Europe Dermacentor Rural and hunting dogs. Subclinical [email protected] reticulatus à complicated. Vaccine available in some countries. School of Veterinary Medicine, Murdoch University, MURDOCH, Western Australia, 6150 Asia, Japan, Endemic to and probably tick-trans- Babesia spp. are tick-borne protozoan parasites that belong to the phylum Korea, Europe, Haemaphysalis mitted in Asia. Main route of trans- Apicomplexa, Order Piroplasmida and family Babesiidae. Often referred to collectively (with Theileria spp. and Cytauxzoon spp.) as piroplasms, B. gibsoni North America longicornis and mission in other regions is by blood Babesia spp. infect erythrocytes of domestic and wild animals, and humans. Although canine babesiosis is more often recognised than feline & globally H. hystricis exchange (fight/bite). Subclinical à babesiosis, reports in the scientific literature of novel Babesia parasites in cats are increasing, especially since molecular diagnostic techniques sporadically. complicated. have become widely available (Table 1).1 B. rossi Sub Saharan Haemaphysalis Native host = Black-backed jackal. Babesia undergo three life cycle phases: (1), Merogony occurs in the Africa elliptica Multiple and severe clinical signs blood of the dog or cat, and is the phase responsible for causing clinical (complicated babesiosis) illness. Intra-erythrocytic trophozoites and intra-erythrocytic or free mero- zoites of this life cycle phase may be observed in blood smears, especial- B. conradae Western US, Unknown Native host(s) unknown. Was ly in acute babesiosis. (2), Gamogony (sexual reproduction), occurs in the Oklahoma originally named B. gibsoni (USA) tick’s gut lumen whereafter motile zygotes spread through the tick’s body prior to proper description. Sporadic, as kinetes, ultimately arriving at the salivary glands where (3), Sporogony reported in rural settings and hunting results in sporozoites ready to be transmitted at feeding. Transmission dogs. Transmission also by blood of Babesia spp. is relatively slow (starts within about 48h of attachment), exchange. Subclinical à complicated. in marked contrast with some other tick-transmitted infections, Ehrlichia canis for example, for which transmission occurs within just a few hours. Native host = red and grey foxes. One of the most active areas of research in recent years has been with re- B. vulpes Holarctic: Ixodes sp. or sp. Also transmitted by blood exchange. spect to classification of the piroplasms through taxonomy and molecular Europe, North Dermacentor Previous names include Theileria phylogeny, the latter being a process that infers evolutionary relationships America, and suspected annae, Babesia microti-like, Babesia between different species. In the past, Babesia spp. were grouped pheno- Asia - China Spanish dog isolate. Subclinical à typically as ‘large’ or ‘small’ (with reference to the size of the trophozoites in erythrocytes), or by other apparent characteristics such as morpholog- severe babesiosis. ical types (e.g. tetrad formation), vertebrate host(s), vector specificity, antigenic properties, etc. Phylogenetic studies have typically used 18S B. negevi Israel only to Ornithodoros Native host unknown. Moderate to rRNA gene sequences, however other genes may be similarly informative date tholozani (?) severe pathogenicity. Complicated and/or help to resolve phylogenetic ambiguities. The process of formally by coinfections (Borrelia persica naming new parasites requires a rigorous process – see Babesia vulpes and Hepatozoon canis) in the small as an example.2 The piroplasms have been grouped into five3, six4, or number of dogs reported. ten5 clades, according to the methodology used. FELINE BABESIA SPP. Babesiosis has a global distribution and veterinarians should be mindful of this disease presenting to their clinics regardless of where in the world B. felis Southern AfricaUnknown Sporadic reports globally in cats they work. Questions at every consultation should seek information about with travel/export history from South ectoparasite history, the application of ectoparasiticides (acaricides in Africa. Also transmitted by blood particular), and travel from an area where tick-borne diseases are endem- exchange. Subclinical à severe ic. The latter does not simply refer to where the owners may have been disease. Coinfections (haemotropic on holiday with their pet (although this is important), but should include Mycoplasma, FIV, FeLV) common. questions about how long the dog or cat has been in the owners’ posses- sion, and whether the pet may have originated from an endemic area (e.g. B. canis sub- Israel (Portu- Unknown Subclinical à Severe. Coinfections rehomed via animal welfare agencies). sp. presentii gal?) (FIV and haemotropic Mycoplasma) in the small number of cats reported. B. hongkon- Hong Kong SARUnknown Asymptomatic infection in the single gensis and China case report. In addition to the classical tick-borne route of infection described above, Babesia parasites can be transmitted by blood transfer. Potential blood donors should be screened before collection and owners should be asked questions about their pet’s fight/bite history. Transplacental transmission has been recorded for some Babesia species, but this seems to be an uncommon occurrence. Babesiosis is characterised by a spectrum of disease severity referred 15

13–15 NOVEMBER, 2021 to as being uncomplicated or complicated in its clinical characteristics. B. negevi Small Imidocarb dipropionate Dose not stated by the The respective Babesia species is the most significant factor determin- authors ing clinical outcome, yet host factors such as age, immune status and B. felis Small Primaquine phosphate the presence of concurrent infections all play a role. Clinical signs are 0.5mg/kg PO once, or 3x at non-specific and include lethargy, reduced appetite, pyrexia, pallor, icterus, B. canis Large Imidocarb dipropionate 72h intervals pigmenturia, bleeding diatheses and, in complicated cases, hypovolaemia, presentii collapse, respiratory distress and CNS signs. The pathophysiology of 2.5mg/kg IM once (note babesiosis reflects systemic inflammation and a haemolytic syndrome; different dose to dogs) researchers have studied the mechanisms of anaemia, Babesia-induced renal injury6, cardiac biomarkers, endocrine dysfunction, haemostasis7, References and cytokine profiles.8 Unsurprisingly numerous cytokine abnormalities are consistent with a pro-inflammatory storm and the widespread acute • Penzhorn BL and Oosthuizen MC (2020) Babesia species of domestic phase protein response. A study into the transcriptomics of canine cats: Molecular characterization has opened Pandora’s box. Frontiers in babesiosis (using B. rossi) was published recently9 that identified genes Vet Science 7: 134. and cellular pathways involved in the responses to haemolysis, metabolic changes, and immune responses. • Baneth G et al. (2019) Establishment of Babesia vulpes n. sp. (Apicom- plexa: Babesiidae), a piroplasmid species pathogenic for domestic dogs. In marked contrast to the advances in understanding of Babesia specia- Parasites Vectors 12: 129. tion and pathophysiology in recent years, there has been disappointingly little practical progress with respect to the specific treatment of canine • Schreeg ME et al. (2016) Mitochondrial genome sequences and and feline babesiosis. This is despite a plethora of published experimental structures aid in the resolution of Piroplasmida phylogeny. PLoS One studies that, to date, have not translated into registered products. The DOI:10.1371/journal.pone.0165702. same caveats that have existed for many years remain; most antiba- besial drugs are relatively ‘old’ and not originally tested robustly, most • Schnittger L et al. (2012) Babesia: A world emerging. Infection, Genetics have variable efficacy, and some have significant side-effects. Different and Evolution 12: 1788–1809. Babesia spp. have dissimilar drug susceptibilities yet, regardless, sterilisa- tion of the infection (‘cure’) seems to be achieved only rarely. Newer drug • Jalovecka M et al. (2019) Babesia life cycle – when phylogeny meets combinations include atovaquone and azithromycin for the treatment of biology. Trends Parasitol 35: 356-368. B. gibsoni and other ‘small’ Babesia spp.; and metronidazole, clindamy- cin, and doxycycline with imidocarb or diminazine (Table 2). Controlled • Kuleš J et al. (2018) Glomerular and tubular kidney damage markers studies are lacking, however. in canine babesiosis caused by Babesia canis. Ticks Tick-borne Dis 9: 1508-1517. Table 2. Specific treatment protocols for Babesiosis • Kuleš J et al. (2017) Alteration of haemostatic parameters in uncompli- Babesia Size Drug (or combination) Dose(s) and route(s) cated canine babesiosis. Comp Immunol Microbiol Infect Dis 53: 1-6. B. vogeli Large Imidocarb dipropionate 5-6.6mg-7.5/kg IM (or SC) • Leisewitz A et al. (2019) Disease severity and blood cytokine concentra- repeated at 14 days tions in dogs with natural B. rossi infection. Parasite Immunol 41:e12630. B. canis Large Imidocarb dipropionate; OR 5-6.6-7.5mg/kg IM (or SC) • Smith RL et al. (2021) Experimental Babesia rossi infection induces Diminazene repeated at 14 days hemolytic, metabolic, and viral response pathways in the canine host. BMC Genomics 22: 619. 3.5mg/kg IM once 5-6.6-7.5mg/kg IM (or SC) Imidocarb dipropionate, OR repeated at 14 days B. rossi Large Phenamidine isethionate, OR 15mg/kg SC once, or repeat Diminazene at 24 hours 3.5mg/kg IM once Babesia sp. Large Imidocarb dipropionate 6.6mg/kg IM (or SC) repeat- ed at 14 days Atovaquone + Azithromycin; OR13.3mg/kg PO q8h + 10mg/ kg PO q24h x 10-17 days Clindamycin + Diminazene + B. gibsoni Small Imidocarb; OR 30mg/kg PO q12h + as above Metronidazole + Doxycycline + 15mg/kg PO q12h + 5mg/kg Clindamycin q12h PO + 25mg/kg PO q12h B. conradae Small Atovaquone + Azithromycin 13.3mg/kg PO q8h + 10mg/ kg PO q24h x 10-17 days B. vulpes Small Atovaquone + Azithromycin 13.3mg/kg PO q8h + 10mg/ kg PO q24h x 10-17 days 16 WSAVA GLOBAL COMMUNITY CONGRESS

0002 situations. Dogs with acute diarrhea recovered faster after receiving a probiotic mixture than after treatment with metronidazole. In dogs with ACUTE DIARRHEA IN THE DOG - WHY ANTIBIOTICS AHDS, a highly concentrated multi-strain probiotic shortened the recovery ARE ONLY RARELY NEEDED time compared to placebo and accelerated the normalization of the gut microbiome. F. Gaschen Fecal Microbiota Transplantation (FMT) is an important treatment mo- Baton Rouge/United States of America dality for people infected with Clostridioides difficile. FMT also has the potential to promote the restoration of a normal gut microbiota in small Qualifications: animals. FMT has been used with success in dogs with acute diarrhea. A recent study comparing the use of FMT with metronidazole in dogs with Frederic Gaschen acute uncomplicated diarrhea reported no significant differences in clini- cal improvement. However, FMT resulted in a more rapid recovery of both Dr.med.vet, Dr.habil., DACVIM (SAIM), DECVIM-CA (IM) the fecal microbiome and the fecal metabolome. Remarkably, in puppies Professor, Louisiana State University School of Veterinary Medicine with parvovirus infection, repeated FMT shortened the time to resolution of diarrhea and to hospital discharge. [email protected] 4) Conclusion 1) Effects of Antibiotics on Gut Microbiota in Healthy Dogs and Cats Taken together, these studies underscore the fact that antibiotic adminis- tration has important effects on the gut microbiota that must be consid- Over the past decade, several studies performed in dogs have shown ered. The appropriateness of prescribing antibiotics should be assessed the effects of various antibiotics such as amoxicillin (with or without on a case-by-case basis, rather than as the standard of care for digestive clavulanic acid), metronidazole, and tylosin on the fecal microbiota. Some disorders. Ultimately, the decision to prescribe antibiotics will depend on of these antimicrobials can cause diarrhea. In general, their effects are the clinical picture, the results of the laboratory tests, and the veterinari- characterized by a decrease in microbial richness, a decreased abundance an’s experience. Alternatives like probiotics and possibly FMT should be of useful microorganisms and an increased abundance of potentially considered. harmful microorganisms. The changes are most pronounced while the animals are on antibiotics, but often persist for weeks after the drugs are References: discontinued. In addition, dysbiosis also affects the fecal metabolome as exemplified with increased lactate and decreased secondary bile acid Chaitman J, Ziese A-L, Pilla R, et al. (2020). Fecal Microbial and Metabolic fecal concentrations. Profiles in Dogs With Acute Diarrhea Receiving Either Fecal Microbiota Transplantation or Oral Metronidazole. Front. Vet. Sci. 7:192. https://doi. Based on studies from human medicine, the resilience of the microbiome org/10.3389/fvets.2020.00192 after a disruption by antibiotics depends on key characteristics such as type, timing, duration and spectrum of the antibiotic course as well as on Manchester AC, Webb CB, Blake AB, et al. (2019). Long-term impact of ty- modulation factors of the microbiome such as age, underlying disease, losin on fecal microbiota and fecal bile acids of healthy dogs. J Vet Intern antibiotic resistance pattern and diet. Med. 33:2605–2617. https://doi.org/10.1111/jvim.15635 2) Use of antibiotics for acute digestive diseases Pereira GQ, Gomes LA, Santos IA et al. (2018). Fecal microbiota transplan- tation in puppies with canine parvovirus infection. J Vet Intern Med. 32. Antibiotics have traditionally been used in dogs with acute diarrhea, es- https://doi.org/10.1111/jvim.15072 pecially if the diarrhea was bloody. In recent years, several recent studies have documented that antibiotics offer no significant benefit under these Pilla R, Gaschen FP, Barr JW, et al. (2020). Effects of metronidazole on the circumstances. The use of amoxicillin and clavulanic acid in dogs with fecal microbiome and metabolome in healthy dogs. J Vet Intern Med. 34: acute hemorrhagic diarrhea syndrome (AHDS) had no positive effect on 1853–1866. https://doi.org/10.1111/jvim.15871 clinical improvement or length of hospital stay. The same was docu- mented in a study of dogs with uncomplicated diarrhea from Germany. In Shmalberg J, Montalbano C, Morelli G and Buckley GJ (2019) A Random- addition, the fecal dysbiosis index did not normalize faster in dogs given ized Double Blinded Placebo-Controlled Clinical Trial of a Probiotic or antibiotics. Importantly, the proportion of resistant fecal E. coli increased Metronidazole for Acute Canine Diarrhea. Front. Vet. Sci. 6:163. https:// during antibiotic treatment as could be expected and remained high for at doi.org/10.3389/fvets.2019.00163 least 3 weeks after discontinuation. Unterer S and Busch K (2021). Acute hemorrhagic diarrhea syndrome It should be noted, however, that antibiotic use is recommended in a in dogs. Vet Clin Small Anim. 51; 79–92. https://doi.org/10.1016/j. subset of dogs with AHDS. This group consists of dogs that show signs cvsm.2020.09.007 of sepsis (e.g. fever or hypothermia, hypotension, marked neutrophilia or neutropenia, hypoglycemia, hyperbilirubinemia), disseminated intravascu- Werner M, Suchodolski JS, Straubinger RK, et al. (2020). Effect of amoxi- lar coagulation (DIG), or massive intestinal protein loss, or are not getting cillin-clavulanic acid on clinical scores, intestinal microbiome, and amoxi- better after 24-48 h of treatment. cillin-resistant Escherichia coli in dogs with uncomplicated acute diarrhea. J Vet Intern Med. 34:1166–1176. https://doi.org/10.1111/jvim.15775 3) Alternative to antibiotics Ziese A-L, Suchodolski JS, Hartmann K et al. (2018). Effect of probiotic Prebiotics promote a desirable intestinal microbiota. They are found in treatment on the clinical course, intestinal microbiome, and toxigenic several commercially available foods for dogs with acute and chronic Clostridium perfringens in dogs with acute hemorrhagic diarrhea. PLoS gastrointestinal disorders. ONE 13(9): e0204691. https://doi.org/10.1371/journal.pone.0204691 The benefits of probiotics have been recently highlighted in several 17

13–15 NOVEMBER, 2021 0003 Techniques DENTAL RADIOLOGY TECHNIQUES Parallel Technique M. Burley The Parallel Technique can be utilised in the areas of the mouth where the film can be positioned parallel to the root, ie mandibular premolars Brisbane/Australia and molars. The film is positioned lingually to the teeth of interest with the margins beyond the ventral aspect of the mandible and dorsal to the Qualifications: crowns of the teeth in order to image the crowns, roots and surrounding bone structure. The xray generator is then positioned perpendicular to Mrs Maggie Burley the film ensuring that the area of interest is centred and fits within the circumference of the tube head. If larger phosphor plates (sizes 4 and 5) Cert IV VN, Dip VN (Dental), VTS (Dentistry), RVN are being utilised, the fine focal distance may need to be increased (to a maximum of 40cm) in order to allow for the beam’s divergence to expose [email protected] the entire plate. The importance of dental radiography in the care and management of the canine and feline patients of the small animal general practice cannot be Bi-secting Angle Technique understated. Radiographic examination forms an integral step in the Com- prehensive component of the Comprehensive Oral Health Assessment The bisecting angle technique is the most common intraoral technique (COHAT). Numerous studies and papers have demonstrated that dental used and is the most scientifically correct way to image veterinary pa- radiographs are almost always indicated and that they are often critical tients. This technique utilises the theory of equilateral triangles to create for proper diagnosis and treatment of oral and dental disease.1 an image that accurately represents the tooth and roots.1 It is used when a boney structure (eg maxilla, palatine, mandibular symphysis) precludes The veterinary patient presents a diagnostic challenge to the Clinician as us from being able to place the film parallel to the tooth root. they often fail to show any outward sign of discomfort or pain. Our clini- cians are not able to access the variety of diagnostic methods available This technique can be difficult to grasp. But let me put it into perspec- to dentists utilising patient feedback to assess their human patients. tive for you. The bisecting angle is simply an imaginary line. It is found Dental radiography then becomes a valuable tool for the visualisation halfway between the long-axis of the tooth (from cusp to apex) and the of subgingival structures in conjunction with the interpretation of the long-axis of the film. The radiographic beam is then directed perpendicular patient’s history, clinical presentation, physical and periodontal examina- to the bisecting angle producing the most accurate representation of the tions. Without intraoral radiography, the full extent of disease can easily tooth onto the film. In essence, we are trying to cast a shadow of the tooth be underestimated, leading to inappropriate treatment recommendations (and root) onto the film that is the same length as the height of the tooth. and failure to detect painful disease conditions.2 Think of it in terms of the sun casting a shadow of a tall tree standing in a flat field. The sun will cast a shadow that is the same length as the height Producing diagnostic dental radiographs certainly provide their own chal- of the tree onto the ground at certain times of the day – approximately lenges. They can be seen as costly, time consuming, technically difficult mid-morning, and mid-afternoon. The shadow will be shorter the higher and contribute to the extension of the dental procedure. However, these the sun is in the sky (towards noon), and the shadow long when the sun is challenges can be overcome by engaging in additional training in oral low in the sky (eg sunset). The same can be applied to the angulation of anatomy, dental radiography techniques and practice. the tube head. Patient Positioning Simplified Technique Positioning of the patient to capture radiographic images is the preference The Simplified Dental Xray Technique developed by Dr Tony Woodward of the clinician. The area of interest (or arcade) is positioned uppermost uses this premise along with the approximate angles that will form to the radiographic beam. This means the patient can be positioned in between the film and the teeth when the film is placed parallel to the hard dorsal or lateral for all mandibular images, and ventral or lateral for the palate in combination with the parallel technique rather than relying on di- maxillary images. rect measurements of angles. This is not the most scientifically accurate method, but consistently produces diagnostic images.3 There are only Plate Positioning three angles used in this technique – 20o, 45o and 90o. Regardless of the system available, whether Dental Film, photo-stimulable Extra-Oral or Near-Parallel Technique phosphor Plate or Digital Sensor (I will refer to all collectively as ‘film’), the positioning of the film is as critical a detail as the technique chosen. These techniques are utilised to image the maxillary premolars and molar Radiographic faults will occur when the film is not positioned within the teeth in the cat should the clinician require good visualisation of these oral cavity in order to capture the image. teeth if obscured by the superimposition of the zygomatic arch, which often occurs when the bisecting angle technique is used. This tech- Some helpful tips in positioning the plate include ensuring the bulk of the nique requires the patient to be positioned laterally and the film placed film is within the oral cavity. This can be achieved with aligning the cusp extra-orally, the mouth in an open position and the beam perpendicular to of the crowns on the outermost edge of the film (regardless of whether bi- the film. secting or parallel techniques are used); the film is held in place with fold- ed gauze swabs, paper towel or similar item (care must be taken to ensure Temporomandibular Joint these items are removed from the oral cavity when the radiographic exam is concluded); a protective slip placed on sensors increasing friction will Radiographic views of the TMJ are taken with the x-ray beam directed in reduce movement; the lingual frenulum can often restrict the depth the a DV or lateral direction through the TMJ.4 The images can be produced film can be placed within the oral cavity to image the mandibular canine using either dental film or large film placed extra-orally. The patient is roots therefore placing the tongue into its natural anatomical position, and positioned in sternal recumbency with the head and neck extended for the the film placed on the dorsal surface, can correct this. dorsoventral view. The lateral view is obtained with the patient positioned in lateral recumbency with midline of the maxilla parallel to the film. In 18 WSAVA GLOBAL COMMUNITY CONGRESS

this position, the temporomandibular joints will be superimposed on each 0004 other - the nose is elevated approximately 30o to separate the joints. The joint closest to the beam will appear forward to the farthest from the film ORAL EXAM AND CHARTING when produced in the image. G. Morgenegg Orientation OBFELDEN/Switzerland Once the images are produced, they are evaluated for technical quality and correctly oriented for proper interpretation. Firstly, evaluate the Qualifications: images produced for the quality of exposure or the presence of any pro- cessing errors. Secondly, assess for positioning errors. Confirm the area GOTTFRIED MORGENEGG of interest has been captured. A sound knowledge of the oral anatomy of the species is required in order to assess that all dentition and sur- DVM rounding structures have been imaged. Further assess the image for any foreshortening, elongation, blurriness due to movement (of the generator [email protected] or patient), distortions, opacities or cone-cutting (appears as a white ORAL EXAMINATION AND CHARTING crescent). Other factors to consider are the summation effect, tangential effect and the need for the ‘tube shift’ technique to locate the position of Gottfried Morgenegg overlapping structures. An accurate oral diagnosis is based on the results of the case history, Dental radiographs are oriented using a ‘labial/buccal mounting’ tech- clinical examination and recording, dental radiographs and laboratory nique. The images are rotated into the following position: the roots of the tests if indicated. The examination must be performed in a systematic maxillary teeth should be pointing upward and the roots of the mandibular way to avoid missing important details. All findings should be recorded in teeth downward. The occlusal views are then placed centremost with the the medical record (Niemiec et al., 2020). first incisors oriented at midline and the molar teeth to the periphery. This orientation now reflects the patient facing you – where what appears to It is of great importance to follow a prescribed protocol during the ex- you on the right, is the left side of the patient and what appears to you on amination to avoid overlooking details. Experience has shown that many the left being the right side of the patient. inexperienced examiners forget to note the missing teeth. In order to efficiently produce diagnostic dental radiography, it is vital A complete examination contains: to not only have a sound knowledge of the oral anatomy (including the subgingival structures), but the ability to utilise multiple radiographic Recording of the situation with photographs techniques to suit the variations seen in the anatomy of the small animal general practice patient. Visual inspection of head and oral cavity Sources: Tactile examination of dental crowns (dental explorer) and the periodon- tium (periodontal probe) • Lobprise, H., & Dodd, J. (2019). Wiggs’s Veterinary Dentistry Principles and Practice, 2nd Edition. Hoboken, NJ: John Wiley & Sons Inc. Dental radiographs • Bellows, J., Berg, M., Dennis, S., Harvey, R., Lobprise, H., Snyder, C., . . . Recording of the results manually or digitally Van de Wetering, A. (2019). 2019 AAHA Dental Care Guidelines for Dogs and Cats. Retrieved from American Animal Hospital Association: JAAHA. Oral/Dental Examination org Examination on conscious patient • Niemiec, B., Gawor, J., Nemec, A., Clarke, D., McLeod, K., Tutt, C., . . . Jouppi, R. (2020). World Small Animal Veterinary Association Global Some parts of the examination can be performed on a conscious patient. Dental Guidelines. Journal Small Animal Practice, Vol 61. The clinical investigation begins with inspection of the head, by assessing the eyes, symmetry of the head, swellings, lymph nodes, nose and lips. • Dupont, G., & DeBowes, L. (2009). Atlas of Dental Radiography in Dogs Then, the occlusion and the functionality of the temporomandibular joint and Cats. St. Louis, Missouri: Saunders Elsevier. (TMJ) should be evalu­ ated. The dental examination includes noting the stage of dentition (primary/permanent), as well as any missing, fractured, or discoloured teeth. The examination of the soft tissues of the oral cavity includes oral mucosa, gingiva, palate, dorsal and ventral aspect of the tongue, tonsils, salivary glands and ducts. The examiner should evaluate the oral soft tissues for masses, swelling, ulcerations, bleeding and inflamma­tion. The conscious periodontal examination should focus on gingival inflammation, calculus deposits and gingival recession. The identification of individual teeth should be performed according to the modified Triadan System (Floyd, 1991). Examination under general anaesthesia A thorough examination can only be performed under general anaesthe- sia. After induction of anaesthesia, placement of the ET tube, inflation of the cuff and fixation of the ET tube, and stabilisation the patient, the ex- amination should be performed in a detailed and systematic manner with the charting performed simultane­ously. After the visual inspection of the entire oral cavity, the tactile examination is carried out in two steps using the appropriate instruments. First, the dental crowns examined for defects such as tooth wear, resorption, caries, pulp exposure, and enamel disease with a dental explorer. Then, sulcus/pocket and furcation exposure are 19

13–15 NOVEMBER, 2021 evaluated with a periodontal probe. Mobility: the grade of mobility has to be determined Examination Step-by-Step (Niemiec et al., 2020): Total Mouth Periodontal Score (TMPS): this method allows for a very accurate determination of the patient’s periodontal health. Inspect the oropharynx: it is advisable to make a quick inspection of the oropharynx and tonsils in the fauces before endotracheal intubation and Expose dental radiographs: dental radiographs are a very important part of placing a throat pack. the dental examination and should be taken when­ever possible. Take preoperative photographs: preoperative photographs should be taken Staging of periodontal disease: staging can be performed by combining before any procedure. It is recommended to take one of each side and one the clinical findings and the dental radiographs (AVDC Nomenclature from the rostral aspect. The photographs serve as proof of pre-operative Committee 2021) dental condition as well as provide visual evidence to the owner. Definitive cleaning and polishing Decrease the bacterial load: rinse the oral cavity with 0.12% chlorhexidine oral rinse. Additional therapy: Based on all available information (visual, tactile, and radiographic) determine and execute the final treat­ment plan. Assess and identify the dentition: primary, permanent, or mixed. Postoperative radiographs and photographs Assess the soft tissue: the entire oral cavity and vestibular tissues should be examined, including oral mucous membranes (for colour, moistness, Recording swelling), lips and cheeks, palate, tongue and sublingual tissue for abnor- malities and oral masses. Manual Scoring Initial scaling of the teeth: for better visibility of the tooth surfaces and The clinical findings can be recorded manually. Dental charts for several gingiva an initial cleaning with a dental scaler is recommended. species are available for free download at the website of the British Veterinary Dental Association (www.bvda.co.uk/bvda-articles/808-den- Intraoperative photograph: it is advised to take a photograph of any tal-charts) . The results can either be hand drawn into a dental chart or pathology revealed by the scaling marked in an attached multiple-choice spreadsheet. The most common signs for dental recording are a circle for a missing tooth (O), a hash mark Dental examination with dental explorer: for a fractured tooth (#) and a cross for an extracted tooth (X). For more detailed instructions see the periodontal therapy section. Single tooth: each tooth must be examined with a dental explorer, begin- ning with the first incisor of each quadrant and progressing caudally tooth Electronic Scoring by tooth to cover the entire arch. A normal tooth surface is smooth; any roughness is an indication of pathology. The entire surface of each tooth The results can also be recorded digitally. A free online dental chart- should be explored, especially the area just below the gingival margin to ing software (electronic Veterinary Dental Scoring) is available for all detect resorptive lesions. The examination should note: veterinarians and technicians in ten screen (English, English (US), French, German, Spanish, Portuguese, Dutch, Russian, Czech, Chinese) and eleven Presence (or absence) of the teeth: the absence of a tooth can mean hy- print languages (plus Italian). It is a simple tool to support the practitioner podontia (congenitally missing tooth), an unerupted (or impacted) tooth, in their daily work. The basic clinical findings can be scored with a simple a retained tooth root, or a previously extracted or exfoliated tooth. Dental mouse click onto the dental charts. radiographs are always indicated for every instance of a “missing” tooth. Supernumerary teeth may be present. Tier 2 & 3 are recommended to use a more detailed commercial pro- gram. There are several options available (in alphabetical order, without Tooth surface: any irregularity is suspicious for a pathologic process. claiming completeness: www.animaldentalchart.com, www.chartific.com; Differentials for a roughened tooth surface include tooth fracture, enamel www.e-vds.vet ; www.vetdentalcharts.com). defect, caries, attrition/abrasion or tooth resorption. Key Points: Colour: Intrinsic staining (a purple, yellow, pink or gray tooth) indicates pulpitis (i. e. a nonvital tooth) or the use of certain antibiotics during The conscious examination is important but is of very limited value, as a tooth development. Teeth suspected to have pulpitis or pulp necrosis complete examination is only possible under general anaest­hesia. require root canal therapy or extraction. Extrinsic staining may be due to wear, metal chewing. These teeth generally require no therapy, but dental A thorough oral examination MUST be part of every dental procedure. radiographs are indicated. The Modified Triadan Systems and anatomical names can be used for Periodontal examination: recording dental examination and treatment. Periodontal probing depth (PPD): the periodontal probing depth has to be The examination of the oral cavity must be performed in a systematic and measured with a graduated periodontal probe. The sulcus/pocket must repeatable fashion. be measure circumferentially around the whole tooth and recording of 4-6 places can be done. (Some charts only record the deepest pocket as it is Dental radiographs are an essential part of the examination. the most significant). The normal PPD in dogs is 0-3 mm, and in cats in cats 0-1 mm. Proper recording of clinical findings and treatments is crucial. Gingival enlargement: enlargement of the gingiva can lead to pseudo References: pockets American Veterinary Dental College Nomenclature (https://avdc.org/ Gingival recession: is an indication of periodontal disease although the avdc-nomenclature) accessed 12th September 2021 PPD does not necessarily increase Floyd M. R. (1991). “The Modified Triadan System: Nomenclature for Vet- Furcation involvement: furcation involvement indicates bone loss between erinary Dentistry”. J Vet Dent, 18-19. DOI:10.1177/089875649100800402 the roots of multi rooted teeth Niemiec B. A., Gawor J., Nemec A., Clarke D., Tutt C., Gioso M., Steagall P., 20 WSAVA GLOBAL COMMUNITY CONGRESS

Chandler M., Morgenegg G., Jouppi R. (2020). ”World Small Animal Veteri- 0005 nary Association Global Dental Guidelines”. JSAP, Vol 61. DOI: https://doi. org/10.1111/jsap.13132 THE STATUS QUO OF RABIES: FROM GLOBAL TO LOCAL T. Scott1, A. Coetzer2, L. Nel2 1Luxembourg/Luxembourg, 2Pretoria/South Africa Qualifications: Dr. Terence Peter Scott PhD Microbiology (Virology; Rabies) [email protected] Rabies remains endemic in more than 150 countries globally, with a per- son dying from the disease every 9 minutes. Africa and Asia remain the most affected regions with the highest burden of disease. Approximately 35 000 people die from rabies every year in Asia alone, accounting for more than half of the global burden which is estimated to be 59 000 hu- man deaths each year1. While Africa accounts for fewer deaths annually, it has the highest per capita death rate globally. In other regions such as Europe and North America, dog rabies has been eliminated, significantly reducing the public health threat from the disease. However, wildlife vari- ants of the disease exist in raccoons, skunks, and bats in North America, while Europe has eliminated the fox rabies variant in wildlife popula- tions through mass oral bait vaccination. Yet, the public health risk for rabies remains – even in these dog-rabies free areas – as rabies-related lyssaviruses (all of which cause the disease rabies) are present in Europe. Furthermore, the risk remains for the re-introduction of rabies via dog importation, with a particular risk arising from illegal puppy trafficking2. While rabies has been documented for more than 3 000 years, the disease remains neglected. In fact, rabies was only recently officially recognised and listed as a Neglected Tropical Disease by the World Health Organi- zation, when the list of 12 diseases from the London Declaration in 2012 was expanded to 20 recognised NTDs that now includes rabies3. Human rabies is the only vaccine preventable neglected tropical disease (NTD), making it the strongest – and most feasible candidate – for elimination under the United Nation’s Sustainable Development Goals (UN SDGs). Yet, due to the lack of political will and limited action towards its elimination at both the international and national level, the disease continues to threaten the lives of tens of thousands of people and animals globally – resulting in an estimated financial burden of USD8,6 billion in losses. While rabies is typically considered a rural disease, this is in fact untrue, as urban rabies outbreaks are well documented and typically pose a higher risk to communities. Rather, rabies is a disease of the poorest and most underserved communities, which are often those living in rural areas where access to healthcare and veterinary services are lacking. While there is no treatment for rabies after the onset of symptoms, the disease is 100% preventable through mass dog vaccination (MDV) of at-risk pop- ulations, coupled with education, awareness, and prophylactic treatment of exposed people. MDV is the most cost-effective and efficient means to eliminate dog rabies, which would result in the elimination of 99% of human rabies deaths globally4. In addition to preventing human rabies deaths, the elimination of dog rabies would also result in a significantly reduced risk of rabies to wildlife populations – in particular to endangered species such as Ethiopian wolves (Canis simensis) and African Wild Dogs (Lycaon pictus). While MDV remains key, the ability to implement suc- cessful and impactful MDV campaigns that target the at-risk population in sufficient capacity to eliminate the disease is a multi-faceted challenge reliant upon coordinated efforts from multiple partners and stakeholders. Until relatively recently, a globally accepted and coordinated approach for rabies elimination was lacking, with national governments and interest- 21

13–15 NOVEMBER, 2021 ed parties reliant upon individual efforts and actions. The international such as rabies. Many setbacks were experienced for rabies elimination ef- community lacked a standardised and coordinated approach that uses forts in both dog-rabies free and endemic countries, including a significant best practice, addresses the transboundary nature of the disease, and reduction in vaccination coverage, laboratory diagnosis, and awareness in is effective. To address this, the End Rabies Now (ERN) campaign was rabies endemic countries, but also in terms of pre- and post-exposure pro- launched in 2015 to advocate for a global goal for dog-mediated human phylactic treatment seeking behaviour for travellers and the importation of rabies elimination by 2030, which aligned with the UN SDGs. After the rabies cases into dog-rabies free countries. Despite these (and many oth- success of the ERN campaign, a global conference was held in December er) setbacks experienced, many positives can be taken, and lessons must 2015 by the OIE, WHO and FAO (tripartite) and Global Alliance for Rabies be learned from the COVID-19 pandemic to better guide rabies elimination Control (GARC), where the “Zero by 30” goal for rabies was set, providing efforts globally. It is thus essential that the rabies community re-ignites dog-rabies endemic countries with a clear goal to achieve rabies elimina- interest on all levels – from community to political – and reinitiates the tion. Following this, the Global Strategic Plan for the Elimination of Dog momentum gained over the last few years to ensure that the goal of Zero mediated human rabies by 2030 (GSP) was developed by the tripartite and by 30 remains feasible and practically achievable. GARC and launched in 2018, providing the global rabies community with a clear strategy to achieve the goal 5. References: The Zero by 30 GSP is based on a country-centric approach with the im- 1. Hampson K, Coudeville L, Lembo T, et al. Estimating the global burden petus being placed on national governments to act and prioritize the elim- of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709. ination of this preventable disease. This country-centric approach takes doi:10.1371/journal.pntd.0003709 lessons learned from past rabies elimination programs, as well as from the successes of both smallpox and rinderpest elimination. No previous 2. Maher J, Wyatt T. European illegal puppy trade and organised crime. rabies control or elimination program that was primarily funded or driven 123AD. doi:10.1007/s12117-021-09429-8 through international aid or agencies has been successful in achieving sustained disease control or elimination. Therefore, the importance of 3. WHO. Ending the Neglect to Attain the Sustainable Development Goals: the need for national governments to take ownership and drive their own A Road Map for Neglected Tropical Diseases 2021-2030. Geneva: World rabies control and elimination efforts remains critical to success and Health Organization; 2020. https://www.who.int/neglected_diseases/End- achieving the goal of “Zero by 30”. While the approach remains coun- ing-the-neglect-to-attain-the-SDGs--NTD-Roadmap.pdf. try-centric to achieve sustainable dog rabies elimination, support from the international community and non-governmental partners will be critical 4. Franka R, Smith TG, Dyer JL, Wu X, Niezgoda M, Rupprecht CE. Current through the provision of expertise, tools, and resources (both financial and future tools for global canine rabies elimination. Antiviral Res. and non-financial) that are made available to governments to help achieve 2013;100(1):220-225. doi:10.1016/j.antiviral.2013.07.004 rabies elimination – a public health good. Public-private partnerships form an important part of the GSP, ensuring that all stakeholders involved in 5. WHO, OIE, FAO, GARC. Zero by 30: The Global Strategic Plan to End rabies control and elimination work together in a considered and unified Human Deaths from Dog-Mediated Rabies by 2030. Geneva; 2018. https:// manner to ensure success. Thus, the GSP encourages the private sector to rabiesalliance.org/resource/zero-30-global-strategic-plan-end-human- be involved in the development and implementation of a country’s national deaths-dog-mediated-rabies-2030. rabies control and elimination strategy. The benefit for the private sector – more specifically private veterinarians - includes improved community trust and improved education and awareness surrounding the need for responsible dog/pet ownership, including regular veterinary care. While much effort has been directed towards better engaging govern- ments and promoting their efforts towards rabies control and elimination through advocacy and support, the non-governmental partners are typical- ly engaged to a far lesser extent, despite their ability to positively contrib- ute to national elimination plans. Recognizing the importance of the roles of individual non-governmental partners and groups, GARC used the initial End Rabies Now campaign and repurposed it to focus on local groups, charities, partners, and associations that contribute to rabies control. The re-envisioned ERN campaign is designed to highlight the work that is be- ing done by local partners – including private practice practitioners – and provide a platform to share their stories, successes and promote the work that is being done. The platform also aims to improve communication be- tween these non-governmental stakeholders and enable those working in the same regions to identify potential partners and collaborators to further improve the impact of their work. Where appropriate, GARC supports this through the promotion of the work, the provision of tools and resources, as well as helping to build partnerships with government focal persons to unite activities in dog-rabies endemic countries for a coordinated and effective rabies elimination strategy that includes all stakeholders. The momentum that was steadily building since 2015 - when the global target for the elimination of dog-mediated human rabies elimination by 2030 was announced – has experienced a significant setback with the emergence of the COVID-19 pandemic. With both medical and veterinary experts supporting COVID-19 responses globally, the focus has under- standably shifted away from many other diseases, especially those NTDs 22 WSAVA GLOBAL COMMUNITY CONGRESS

0006 better resourced human health sector can be used to address the issue of rabies at the source – in the dog population – rather than responding RABIES: PRACTICAL DELIVERY OF ONE HEALTH to cases and using the allocated resources on human prophylaxis3. While both pre- and post-exposure prophylaxis for people is essential T. Scott1, A. Coetzer2, L. Nel2 and should not be ignored, investment into the vaccination of dogs would result in a significant reduction in expenditure once dog-mediated rabies 1Luxembourg/Luxembourg, 2Pretoria/South Africa has been eliminated. Qualifications: To make a case for the sharing and allocation of resources towards jointly combatting rabies using a One Health approach, there is a clear need for Dr. Terence Peter Scott effective surveillance within each of the sectors, but also a dire need for effective and transparent data sharing among sectors. For human health PhD Microbiology (Virology; Rabies) to adequately invest in rabies elimination through mass dog vaccination, the evidence-base is needed to identify which areas should be targeted [email protected] for dog vaccination based on bite incidents and human rabies cases. Rabies is a deadly zoonotic disease that kills both animals and humans Therefore, the human health sector needs to collect, analyze, and share equally effectively. While the majority of the focus for rabies advocacy this data in a timely manner with the relevant stakeholders in the animal and elimination presently lies with the public health impact of the disease, health sector for reactionary interventions. Similarly, the animal health this does not detract from the fact that in addition to the estimated 59 sector must share their data to help identify areas that need attention, 000 human deaths each year, rabies also kills hundreds of thousands helping to direct the allocation of therapeutics and biologicals to health of non-human mammals. Critically, rabies is entirely preventable in both facilities in high-risk areas. Only through such concerted efforts can dog human and canine populations through mass vaccination, and the most rabies elimination be achieved in a timely and cost-effective manner. By effective means to eliminate the disease in humans is to eliminate the targeting hotspots and high-risk areas with strategic interventions (rather disease in dog populations in endemic countries. Not only is this possible, than through a blanket approach required to achieve herd immunity in the but this approach has been demonstrated to be the most practicable and entire dog population), further cost-savings can be made. economically viable. Thus, rabies is an excellent example for the practical delivery of One Health and should be considered the ‘flagship’ disease to While the roles of both human and animal health are critical and most demonstrate the concept. prominent for dog rabies elimination, the environmental sector is often overlooked. While scientific studies are lacking as to the direct role of the One Health has many definitions, the majority of which remain vague and environment on rabies elimination, there have been suggestions as to its generalized and are often biased towards the goals of the organization or importance through various factors. For instance, in dog-rabies endemic group that defined it. However, the One Health Commission has developed countries, the environment has the potential to affect the size, distri- a more inclusive definition for One Health as follows: “One Health is a bution, and turnover of dog populations through the availability of food collaborative, multisectoral, and trans-disciplinary approach - working at resources and the carrying capacity of the area. With a larger carrying local, regional, national, and global levels - to achieve optimal health and capacity, a larger – typically unwanted - dog population is possible in well-being outcomes recognizing the interconnections between people, areas where free-roaming dogs are prominent. These free roaming dog animals, plants and their shared environment.”1. Despite the presence of populations are typically more challenging to vaccinate and thus affect multiple definitions, the principal aspects of One Health remain consistent the resources required to achieve herd immunity in these areas. On the in the fact that human, animal, and environmental health are inter-depen- other hand, environmental factors can contribute to rabies elimination dent. This epitomizes the need for collaboration for the effective control efforts and the prevention of the re-introduction of the disease from and elimination of rabies, whereby the three health systems (human, neighboring areas. Geographical barriers have been successfully used to animal and environmental) are critical to achieving success. For rabies, create vaccination corridors that create a buffer zone between rabies-free animal health should be considered the keystone to achieving elimination, areas and those that remain dog-rabies endemic4. Lastly, climate change as human health is directly and inextricably linked to animal health, and and the migration of reservoir species into new territories poses a risk animal health is linked to environmental health, yet human health is not for the introduction of new rabies variants. This is most evident with the reliant upon environmental health. Therefore, the animal health sector northerly migration of vampire bat species from Latin America into North is crucial for the operationalization of the One Health approach for dog America which now poses a risk of the introduction of vampire bat rabies rabies control and subsequent elimination. virus variant into the United States. Many countries have drastically reduced the number of human rabies To support the efforts to operationalize One Health, rabies has the tools deaths to nearly zero through preventative pre-exposure prophylaxis and technologies available to effectively implement these concepts. The (PrEP) and timely and adequate treatment of exposed individuals with Stepwise Approach towards Rabies Elimination (SARE) tool is integral to post-exposure prophylaxis (PEP)2. However, these measures are solely the Global Strategic Plan, and both encourages and fosters One Health preventative and reactionary measures that do not address the issue at its collaboration through a joint landscape analysis and the development source, resulting in the need for expensive and continued human health of an inter-sectoral work plan5. Similarly, surveillance tools such as the interventions in perpetuity. In contrast, many of the countries that have Rabies Epidemiological Bulletin have been designed for transparent, ef- controlled and eliminated both dog-mediated human rabies and dog rabies fective, and real-time data sharing between sectors and partners, ensuring have done so through effective mass dog vaccination strategies. While that effective decisions can be made towards the joint goal of eliminating mass dog vaccination has been demonstrated to be the most cost-effec- dog-mediated human rabies. tive and practical means to eliminate almost all human rabies deaths, there remains a disparity in resource allocation and availability for the With the emphasis of the One Health approach in the Sustainable Develop- implementation of these programs in dog-rabies endemic countries. While ment Goals, as well as in various recent international guidance documents veterinarians and animal health practitioners are tasked with multiple such as the WHO Neglected Tropical Diseases Roadmap, as well as the responsibilities for rabies control and elimination, it is understood that in emphasis for the need for One Health from international political leaders general, the veterinary sector remains poorly funded and resourced. It is at the recent G20 summit, it is essential that the global community is ca- for this reason that there lies the need for true One Health collaboration pable of operationalizing this concept into an effective approach. Rabies between human and animal health, so that funding and resources from the presents as the ideal candidate disease to operationalize One Health in 23

13–15 NOVEMBER, 2021 all capacities, not only directly through the human health, animal health 0007 and environmental health sectors, but also with others such as education, communication, and finance, all of whom play a critical role in the efforts ANTICOAGULATION – WHO, WHEN AND HOW? to achieve the goal of Zero dog-mediated human rabies deaths by 2030. C. Sharp References: Murdoch/Australia 1. One Health Commission. What is One Health? https://www.onehealth- commission.org/en/why_one_health/what_is_one_health/. Accessed Qualifications: September 24, 2021. Claire R. Sharp 2. Taylor E, Del Rio Vilas V, Scott T, et al. Rabies in the Middle East, Eastern Europe, Central Asia and North Africa: Building evidence and deliver- BSc(Hons), BVMS, MS, DACVECC ing a regional approach to rabies elimination. J Infect Public Health. 2021;14(6):787-794. doi:10.1016/j.jiph.2021.02.009 [email protected] Recommendations in this lecture are based on the American College 3. Scott TP, Coetzer A, Nel LH. Chapter 21 - Strategies for the elimination of Veterinary Emergency and Critical Care (ACVECC) Consensus on the of dog-mediated human rabies by 2030. In: Fooks AR, Jackson AC, eds. Rational use of Antithrombotics in Veterinary Critical Care (CURATIVE) Rabies (Fourth Edition). Fourth Edi. Boston: Academic Press; 2020:671- guidelines, published in early 2019.1 688. doi:https://doi.org/10.1016/B978-0-12-818705-0.00021-2 Pathophysiology and clinical consequences of thrombosis 4. Russell CA, Real LA, Smith DL. Spatial control of rabies on hetero- geneous landscapes. PLoS One. 2006;1(1):e27. doi:10.1371/journal. Thrombosis refers to excessive or inappropriate clotting. Thromboem- pone.0000027 bolism refers to a clot that embolizes distal to the site of its formation (eg. aortic thromboembolism in cats with cardiomyopathy). Virchow’s 5. WHO, OIE, FAO, GARC. Zero by 30: The Global Strategic Plan to End triad describes some of the factors predisposing to thrombosis, notably Human Deaths from Dog-Mediated Rabies by 2030. Geneva; 2018. https:// hypercoagulability, endothelial damage/activation, and turbulent blood rabiesalliance.org/resource/zero-30-global-strategic-plan-end-human- flow/stasis. deaths-dog-mediated-rabies-2030. Thrombosis is potentially deleterious due to ischemia and reperfusion injury. Thrombosis can occur in either the arterial or venous circulation. Potential locations of arterial thrombosis include the coronary arteries (as in a myocardial infarction, cerebral arteries (as in a cerebrovascu- lar accident [CVA] (stroke), or aorta (as in aortic thromboembolism). Potential locations of venous thrombosis include deep vein thrombosis, pulmonary thromboembolism [PTE], portal vein thrombosis, and splenic vein thrombosis. Arterial thrombi tend to contain a higher concentration of platelets and fewer RBCs. Venous thrombi contain fewer platelets but are rich in fibrin and trapped RBCs. These differences influence the first choice anti- thrombotic in humans, and have also influenced our recommendations in veterinary medicine; antiplatelet drugs are recommended as the first line antithrombotic in patients with or at risk of arterial thrombosis, while anticoagulant drugs are recommended first in patients with or at risk of venous thrombosis. Anticoagulation - Who? CURATIVE Domain 1 defined small animal populations most at risk of thrombosis,2 and this will be expanded in the CURATIVE 2.0 guidelines due early 2022. Antithrombotic drugs are recommended in patients at high risk of thrombosis, or those that have already experienced throm- bosis/thromboembolism. The CURATIVE Guidelines define high risk of thrombosis as: Dogs with IMHA, PLN or heartworm disease Cats with cardiomyopathy and associated risk factors (eg. left atrial enlargement, spontaneous echo contrast); and Dogs and cats with > 1 disease or risk factor for thrombosis. Antithrombotics can be considered in patients with low/moderate risk of thrombosis, but are not routinely recommended. The CURATIVE guidelines define low/moderate risk as: Dogs or cats with a single risk factor or predisposing disease Dogs or cats with a known risk factor or disease that, with treatment, is 24 WSAVA GLOBAL COMMUNITY CONGRESS

likely to resolve in days to weeks. with ACT, or aPTT), lower cost than LMWH, availability of an antidote (protamine), and rapid onset of action. UFH is most commonly used as a Antithrombotics are not recommended in the treatment of hyperadreno- CRI in veterinary patients undergoing extracorporeal therapy.5 Potential corticism in dogs, and a variety of diseases in cats (IMHA, PLN, exoge- disadvantages of UFH include the need for parenteral administration, nous use of corticosteroids, and hyperadrenocorticism). short half-life (necessitating IV CRI or frequent SQ dosing), unpredictable response (in large part due to non-specific protein binding) and risk of Anticoagulation - When? bleeding complications. As such, when UFH is used, therapeutic monitor- ing is recommended.6 Antithrombotic drugs are recommended in patients at high risk of thrombosis, or those that have already experienced thrombosis/thrombo- Low molecular weight heparin (LMWH) embolism. In patients with thrombosis, treatment involves antithrombotic medications, treating the underlying disease, and supportive care. Heparin can also be processed to produce LMWH, which, owing to its standardized size has more predictable biologic effects. By definition, Anticoagulation – What and How? LMWHs have a lower average molecular weight than UFH preparations. Unlike UFH which can bind to both AT and thrombin, most of heparin mol- Antithrombotics diminish/inhibit the formation of new clots, but do not de- ecules in LMWH are only able to interact with AT alone (or AT and FXa), grade existing clots. Amongst the antithrombotics, are antiplatelet drugs such that the anti-Xa activity of LMWH is much greater than the anti-IIa and drugs that inhibit clotting factor activity (eg. Anticoagulants). activity. Like UFH, LMWHs are very efficacious anticoagulants. In humans, LMWHs have a long half-life facilitating once or twice-daily dosing, and a Platelet antagonists more predictable response negating the need for laboratory monitoring. Ideally however, monitoring is performed in the hospital, which requires Aspirin and clopidogrel are the most commonly used antiplatelet drugs. measurement of anti-Xa activity. Potential disadvantages include a longer Aspirin (acetylsalicylic acid) is widely availability (over the counter), easy onset of action, higher cost, the need for SQ injection (not given IV), and to dose (oral SID), and low cost. However, aspirin is less effective in dogs difficulty in reversing the effects (protamine less effective than for UFH). and cats than in people. Aspirin inhibits COX-1, which prevents throm- boxane A2 (TXA2) production leading to diminished platelet aggregation. Different LMWHs are available (eg. dalteparin, enoxaparin). The CURATIVE However, TXA-2 induced aggregation is not the only physiologic route to guidelines suggest an initial dalteparin dose of 100-175 U/kg SC q8h in activating platelets, and it is varying degrees of reliance on this mecha- dogs, and 75U/kg SC q6h in cats.4 Although limited data is available in nism may explain the different antithrombotic efficacy of aspirin across veterinary medicine to guide LMWH dosing, we aim for a target anti-Xa species. Disadvantages of aspirin include lack of platelet specificity, activity of 0.5-1.0 U/mL 2h post-dose.7 systemic side effects (such as GI bleeding), and potential for aspirin resis- tance. Aspirin can also be difficult to dose due to the large tablet size and Factor Xa inhibitors a low anti-platelet dose (0.5-1.0mg/kg PO q 24 hours in dogs). That being said, the ideal dose of aspirin for thromboprophylaxis in dogs or cats is Rivaroxaban was the first orally active direct factor Xa inhibitor available not known. Reported doses in cats vary from 5-81mg/cat every 48-72 on the market and is the most widely studied of the class in dogs and hours. Decreased dosing frequency is indicated in cats due to their rela- cats. The CURATIVE guidelines suggest that the use of either direct tive deficiency of hepatic glucuronidation resulting in a longer elimination Xa inhibitors or LMWH in dogs and cats is reasonable for anticoagula- half-life. Based on the FATCat study,3 clopidogrel is now recommended in tion.8 Based on preliminary data the recommended dose is 1-2mg/kg/day preference to aspirin for cats at risk of thromboembolism. in dogs, and 0.5-1 mg/kg/day in cats.4 The primary mechanism of action of clopidogrel is inhibition of P2Y- Duration of therapy with antiplatelet or anticoagulant drugs, depends on 12, the thrombocyte ADP receptor. Like aspirin, clopidogrel is an oral many factors. Antithrombotic therapy should be life-long for incurable medication and undergoes hepatic metabolism, but unlike aspirin requires diseases (eg. PLN, cardiomyopathy). In contrast diseases which are metabolism to an active metabolite. This need for hepatic activation and expected to be controlled with medication (eg. IMHA) may just require elimination results in a delayed onset of antiplatelet effects and signifi- antithrombotic therapy for the high-risk period of their disease. Curative cant variability in efficacy in people. Advantages of clopidogrel include Domain 5 provides information about how do adjust anticoagulant medi- potential for greater anti-platelet efficacy (vs. aspirin) and more conve- cation in patients that require surgery.9 nient dosing (2mg/kg/day dosing, 75mg and 300mg tablets). Potential adverse effects, although uncommon, include hepatotoxicity, bleeding, References: and gastrointestinal signs. The recommended clopidogrel dose is 1-3mg/ kg/day in dogs (may consider a 4-10mg/kg loading dose on day 1), and 1. Goggs, R., et al. ACVECC CURATIVE guidelines: Small animal. J Vet 18.75mg/cat/day for cats (ie. ¼ of a 75mg tablet, may consider a 37.5mg Emerg Crit Care 29, 12-36 (2019). loading dose).4 2. deLaforcade, A., et al. CURATIVE: Domain 1-Defining populations at Anticoagulants risk. J Vet Emerg Crit Care 29, 37-48 (2019). Anticoagulants include warfarin, heparins, FXa inhibitors (eg. rivarox- 3. Hogan, D.F., et al. Secondary prevention of cardiogenic arterial throm- aban), and direct thrombin inhibitors. The CURATIVE guidelines suggest boembolism in the cat: The double-blind, randomized, positive-controlled that warfarin should not be used in dogs and cats because of a narrow feline arterial thromboembolism; clopidogrel vs. aspirin trial (FAT CAT). J therapeutic index and lack of evidence of improved outcomes. Heparins Vet Cardiol 17 Suppl 1, S306-317 (2015). and rivaroxaban are used most commonly in veterinary medicine. 4. Blais, M.C., et al. CURATIVE: Domain 3-Defining antithrombotic proto- Unfractionated heparin (UFH) cols. J Vet Emerg Crit Care 29, 60-74 (2019). Heparin and its derivatives disrupt secondary hemostasis by activating 5. Ross, S. Anticoagulation in intermittent hemodialysis: pathways, proto- antithrombin (AT), resulting in inactivation of thrombin and factor Xa. UFH cols, and pitfalls. Vet Clin North Am Small Anim Pract 41, 163-175 (2011). exists as many polymers of variable size and molecular weight. Potential advantages of UFH include proven efficacy, easy monitoring (in-hospital 6. Sharp, C.R., et al. CURATIVE: Domain 4-Refining and monitoring anti- thrombotic therapies. J Vet Emerg Crit Care 29, 75-87 (2019). 25

13–15 NOVEMBER, 2021 7. Lynch, A.M., et al. Clinical experience of anti-Xa monitoring in critically 0008 ill dogs receiving dalteparin. J Vet Emerg Crit Care 24, 421-428 (2014). ANTIFIBRINOLYTICS – WHAT IS THE EVIDENCE? 8. Goggs, R., et al. CURATIVE: Domain 2-Defining rational therapeutic C. Sharp usage. J Vet Emerg Crit Care 29, 49-59 (2019). Murdoch/Australia 9. Brainard, B.M., et al. CURATIVE: Domain 5-Discontinuation of anticoagu- lant therapy in small animals. J Vet Emerg Crit Care 29, 88-97 (2019) Qualifications: Dr Claire R. Sharp BSc, BVMS(Hons), MS, DACVECC [email protected] Fibrinolysis The goal of the coagulation cascade is the formation of a stable fibrin clot to achieve hemostasis. Fibrinolysis (Figure 1) is the process of removal of intravascular fibrin clots; in health this should occur after the clot is no longer needed. Fibrinolytic disorders result from a disturbance in the balance of fibrinolytic activators and inhibitors, and are becoming increasingly recognized in veterinary medicine. This discussion will focus on hyperfibrinolysis and the use of antifibrinolytics to treat associated bleeding. Diagnostic approach to disorders of fibrinolysis Assessment of fibrinolysis may be indicated in patients with inappropriate bleeding that cannot be explained by disorders of primary or secondary hemostasis. Fibrinolysis may be assessed with measurement of FDPs, D-dimers, and viscoelastic tests (thromboelastography [TEG], rotational thromboelastometry [ROTEM]), however all have significant limitations. Antifibrinolytic drugs Lysine analogs are the mainstay treatments for hyperfibrinolysis. These drugs reversibly block the lysine binding site of plasminogen, preventing its activation to plasmin. The two commercially available lysine analogs are tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), in both IV and PO formulations. Availability does vary from country to country. EACA is less potent than TXA. Reported doses vary considerably in dogs from 15-40mg/kg IV as a loading dose, followed by 500-1000mg PO q8h for 5 days. Other authors have used a dose of 50-100mg IV or PO q6-8h. Adverse effects include nausea, vomiting, abdominal pain, and diarrhoea. TXA is more potent and has a longer half-life than EACA. The ideal dosing regimen of TXA in dogs is not known but the author doses at 15mg/kg IV q 8 hours (diluted, slow IV) during the perioperative period for dogs at risk of, or with documented, hyperfibrinolysis. Some authors use 10mg/ kg as an IV bolus, followed by CRI of 10mg/kg/hr for three hours.(1) Adverse effects of TXA include gastrointestinal (2,3), anaphylaxis (4), and 26 WSAVA GLOBAL COMMUNITY CONGRESS

thrombotic events. One study in veterinary medicine has shown that TXA improvement after commencement of EACA (33mg/kg IV q6h).(11) This induced vomiting can be prevented with maropitant.(2) Another study has dog also had hyperfibrinolysis document on TEG that resolved with EACA. specifically investigated its use as an emetic, and shown that at 60mg/kg (11) My approach is to use antifibrinolytic drugs in trauma patients with IV TXA reliably induces emesis.(3) active bleeding severe enough to require blood transfusion. Once the bleeding has stopped, I then discontinue the antifibrinolytic. Hyperfibrinolysis – who to treat? 3. When all else fails / you have no other options to stop bleeding Since the diagnosis of hyperfibrinolysis is difficult in clinical practice it seems reasonable that antifibrinolytic therapy could be considered In these cases the perceived benefit of the antifibrinolytic must outweigh empirically in certain situations. In my opinion, there are 3 scenarios when the potential risks of adverse events. I would consider the use of antifibrinolytic drugs. One such patient population are dogs with hemoperitoneum that are 1. Animals with diseases associated with hyperfibrinolysis that are at risk severe enough to require blood transfusion but whose owners decline of bleeding surgery. My rationale is that dogs with hemoperitoneum have been shown to be more hyperfibrinolytic than age and breed matched controls with This includes dogs with acute liver failure (ALF) and chronic hepatopa- the use of tPA-TEG.(12) In contrast, I don’t give antifibrinolytic drugs for thies. ALF has been associated with multifactorial coagulation distur- hemoperitoneum in which I am able to rapidly obtain surgical hemostasis. bances in dogs, including thrombocytopenia, increased PT/aPTT, DIC, Part of my rationale is that dogs undergoing splenectomy for splenic increased FDPs and increased D dimers.(5) In the same study 25/49 masses (a large proportion of our hemoperitoneum cases) are at risk of (51%) had evidence of hemorrhage.(5) Another study of TEG in dogs with thrombotic complications in the perioperative period.(13) Additionally, a ALF identified that 10/21 dogs were hypocoagulable based on the G value, retrospective study in dogs with surgically treated hemoperitoneum, found while 8/21 were hyperfibrinolytic based on LY30, and hyperfibrinolysis was no difference in RBC transfusion requirements or post-operative bleeding associated with more severe disease.(6) As such, I use antifibrinolytic tendency between dogs that received TXA at least 30 minutes prior to therapy in dogs with ALF with clinical evidence of bleeding. surgery, and those that did not.(14) A proportion of dogs with chronic hepatopathies are also hypocoagula- The literature documents the use of antifibrinolytic drugs in a wide variety ble and/or hyperfibrinolytic on TEG.(7) Additionally, one dog in this case of other diseases, however at this stage the evidence is minimal. series had evidence of gastrointestinal bleeding that resolved with EACA treatment.(7) Based on this study I administer an antifibrinolytic drug to References: dogs with chronic hepatopathy that are bleeding, or require an invasive procedure such as liver biopsy. 1. Kelmer E, et al. Effects of intravenous administration of tranexamic acid on hematological, hemostatic, and thromboelastographic analytes in 2. Animals with diseases / conditions where antifibrinolytic therapy has healthy adult dogs. J Vet Emerg Crit Care. 2015;25(4):495-501. been shown to help 2. Kantyka ME, et al. Prospective, controlled, blinded, randomized This includes greyhounds having surgery and patients with bleeding sec- crossover trial evaluating the effect of maropitant versus ondansetron ondary to severe trauma (based on the human literature). on inhibiting tranexamic acid-evoked emesis. J Vet Emerg Crit Care. 2020;30(4):436-41. Approximately ¼ to 1/3 of Greyhounds experience delayed postoperative hemorrhage after routine procedures such as spay / neuter, compared 3. Kakiuchi H, et al. Efficacy and safety of tranexamic acid as an emetic in to 0-2% in other breeds. This bleeding tends to occur 24-72 hours after dogs. Am J Vet Res. 2014;75(12):1099-103. surgery and is thought to be due to a problem with clot maintenance or fibrinolysis. In a randomized, blinded, placebo controlled clinical trial grey- 4. Choi JY, Kim JH, Han HJ. Suspected anaphylactic shock associ- hounds treated with EACA (500mg PO q8h for 3 days after surgery), were ated with administration of tranexamic acid in a dog. J Vet Med Sci. significantly less likely to experience delayed postoperative hemorrhage 2019;81(10):1522-6. (5/50, 10%) than those receiving placebo (15/50, 30%).(8) A retrospec- tive case series from the same group also described the use of EACA to 5. Lester C, et al. Retrospective evaluation of acute liver failure in dogs prevent postamputation bleeding in greyhounds with appendicular bone (1995-2012): 49 cases. J Vet Emerg Crit Care. 2016;26(4):559-67. tumours.(9) EACA was dosed somewhat differently, in that an IV dose of 500-1000mg of EACA was given immediately post-operatively, followed 6. Kelley D, et al. Thromboelastographic Evaluation of Dogs with Acute by 500-1000mg PO q8h for 5 days.(9) Again, those receiving EACA were Liver Disease. J Vet Intern Med. 2015;29(4):1053-62. significantly less likely to experience delayed post-op bleeding and no adverse effects of the drug were noted.(9) 7. Fry W, et al. Thromboelastography in Dogs with Chronic Hepatopathies. J Vet Intern Med. 2017;31(2):419-26. Based on the findings of these studies it is recommended that all grey- hound are treated with EACA or TXA in the perioperative period to reduce 8. Marin LM, et al. Epsilon aminocaproic acid for the prevention of delayed the risk of post-operative hemorrhage. It should be noted that a small postoperative bleeding in retired racing greyhounds undergoing gonadec- proportion (perhaps 10%) of greyhounds may still experience delayed tomy. Vet Surg. 2012;41(5):594-603. post-operative hemorrhage, which if severe should be treated with plasma transfusion. 9. Marin LM, et al. Retrospective evaluation of the effectiveness of epsilon aminocaproic acid for the prevention of postamputation bleeding The use of TXA in human patients with significant hemorrhage after in retired racing Greyhounds with appendicular bone tumors: 46 cases trauma, has become widely accepted based on the results of the CRASH-2 (2003-2008). J Vet Emerg Crit Care. 2012;22(3):332-40. trial.(10) That study identified that early administration of TXA within 1-3 hours of trauma (1g bolus, followed by 1g CRI over 8h) was associated 10. CRASH-2 trial collaborators, et al. Effects of tranexamic acid on death, with reduced all-cause mortality and reduced deaths from bleeding, vascular occlusive events, and blood transfusion in trauma patients with but that there was no benefit of later administration.(10) A case report significant haemorrhage (CRASH-2): a randomised, placebo-controlled in a dog with intra-thoracic hemorrhage after thoracotomy to repair a trial. Lancet. 2010;376(9734):23-32. diaphragmatic hernia and lung lobe laceration also reported rapid clinical 11. Yoo SH, et al. Thromboelastographic evidence of inhibition of fibrinoly- sis after epsilon-aminocaproic acid administration in a dog with suspect- 27

13–15 NOVEMBER, 2021 ed acute traumatic coagulopathy. J Vet Emerg Crit Care. 2016;26(5):737- 0009 42. EVERYTHING A GENERAL PRACTITIONER NEEDS 12. Fletcher DJ, et al. Assessment of the relationships among coagulopa- TO KNOW ABOUT CANINE EPILEPSY thy, hyperfibrinolysis, plasma lactate, and protein C in dogs with sponta- neous hemoperitoneum. J Vet Emerg Crit Care. 2016;26(1):41-51 L. Garosi 13. Wendelburg KM, et al. Risk factors for perioperative death in dogs IPER/United Kingdom undergoing splenectomy for splenic masses: 539 cases (2001-2012). J Am Vet Med Assoc. 2014;245(12):1382-90. Qualifications: 14. Sigrist N, et al. Effect of tranexamic acid on intra- and postoperative Laurent Garosi haemorrhage in dogs with surgically treated hemoperitoneum. Schweiz Arch Tierheilkd. 2018;160(5):305-12. DVM, Dip ECVN, FRCVS RCVS & EBVS specialist in veterinary neurology [email protected] INTRODUCTION Idiopathic epilepsy is a term that is reserved for patients with chronic, recurring seizures but no detectable underlying cause; these seizures are presumed to be genetic in origin. Canine idiopathic epilepsy most com- monly starts between the ages of 6 months and 6 years. If seizures start outside this age range, then it is important to consider the likely possibility of other causes. One of the key features of idiopathic epilepsy is the absence of neuro- logical deficits in the inter-ictal period. Therefore, when abnormalities are present in the inter-ictal period this would usually exclude idiopathic epilepsy from the differential diagnosis list. However, there are two excep- tions to this rule: Depression of forebrain activity occurs during the period immediately following an epileptic seizure (so-called post-ictal depression). During this period subtle neurological deficits, including conscious proprioceptive deficits, may be evident. Post-ictal depression can last a variable amount of time, but most cases return to normal a few hours (up to a day) follow- ing the seizure episode. Neurological deficits may also result secondary to severe or prolonged seizures due to hypoxic injury or the so-called excitotoxicity phenomenon. Sequential neurological examinations at 2 to 3 day intervals following the seizure are recommended if in doubt about the origin of the neurological deficits (i.e. whether they are post-ictal versus relating to a potential underlying structural intracranial or extracranial cause). A diagnosis of idiopathic epilepsy therefore requires normal results of physical and neurological examinations and is essentially a diagnosis of exclusion. WHAT MINIMUM DATABASE TO PERFORM? An extra-cranial work-up is indicated ideally in every seizuring patient. Baseline blood work should include a complete blood count and fasted chemistry profile (ensuring blood glucose, resting bile acids, Na+, K+, Cl-, and Ca2+ are performed) to rule-out systemic/metabolic causes of seizures. Liver function should be crudely assessed by evaluating glucose, albumin, urea and cholesterol concentrations. Further liver function tests such as dynamic bile acids are indicated when there is clinical and clinico- pathological evidence of liver disease. Urinalysis is also a key part of this process with particular emphasis placed on specific gravity, proteinuria and glucosuria. WHEN TO CONSIDER FUTHER INVESTIGATIONS? If any of the following criteria are met in the presence of a normal ex- tra-cranial work-up then intracranial investigation (MRI +/- CSF analysis) is indicated: 28 WSAVA GLOBAL COMMUNITY CONGRESS

- Abnormal neurological examination cause of the seizures - Seizures starting outside the 6 month to 6 year age range - Post-ictal signs are objectionable (e.g. aggression) - Abnormal behaviour in between the seizures Phenobarbitone (2 to 3 mg/kg q.12 hours orally) is the first choice of many clinicians for dogs and cats with idiopathic epilepsy. In dogs, - Loss of learned behaviour (e.g. loss of toilet training) repeated phenobarbitone administrations are known to alter estimated steady state serum concentration as a consequence of enzyme induction - Circling/pacing (cytochrome P450 induction). This results in the need to regularly monitor serum phenobarbitone level and progressively increase oral dosage with - Visual impairment/bumping into things time in order to maintain steady state therapeutic level. This phenomenon of enzyme induction following repeat administration of phenobarbitone - Does not respond to appropriate anti-epileptic drug therapy is negligible in cats. Recommended therapeutic range in dogs is 20 to 35 ug/ml. This therapeutic range is only an indication in the adaptation of the AIMS OF ANTI-EPILEPTIC TREATMENT oral dosage. Most dogs will “respond” (reduction in frequency, intensity and severity of the seizures with minimal side effects) with serum level The aim of any anti-epileptic treatment is to “control” the seizures by within this range. However, some dogs might need to be in the upper limit reducing their frequency, intensity and severity with minimum side effects of this range while others might need to be below the lower limit. Ime- while maximizing the owner’s and dog’s quality of life. Owners should pitoin suppresses seizure activity in a similar manner to other AEDs. The be appropriately advised to ensure that their expectations are realistic recommended dose is 10-30 mg/kg twice daily. The starting dose is usu- from the outset. Unless idiopathic or cryptogenic epilepsy is considered ally 10mg/kg twice daily to control seizure ie a 30kg Golden Retriever will to be the primary differential diagnosis for the seizure activity, specific receive 300mg twice daily. They do include PuPd, polyphagia, ataxia, rest- treatment of the underlying cause is essential and the success of this will lessness and sedation. They can also cause gastrointestinal side effects. determine the need for symptomatic seizure therapy. Blood tests are not required to check on this drug. This drug tends to be most effective in dogs with few seizures and it is not often recommended IMPORTANT MESSAGES TO PROVIDE TO THE OWNER OF AN on its own where multiple seizures are seen, or where epilepsy is proving EPILEPTIC ANIMAL progressive. An animal is defined as refractory to anti-epileptic treatment when the patient quality of life is compromised by frequent and severe - The therapy for epileptic seizures does not aim at curing the epilepsy but seizures despite appropriate drug therapy (serum level in the high end of aims at “controlling” it. the therapeutic range) or side effects of the medication. The incidence of refractory epilepsy is unknown in dogs but could be as high as 25% of epi- - Therapy for epileptic seizures may have side effects that in rare occasion leptic patient. Therapeutic options in refractory epilepsy consist mainly in can be worse than the seizures themselves. adding (or replacing for dogs or cats with side effect of phenobarbitone) a second anti-epileptic drug. Second anti-epileptic drugs currently used - Mild side effects are common when first starting treatment with anti-ep- in dogs include bromide (30 mg/kg q.24 hours orally), levetiracetam (10 ileptic drugs. to 30 mg/kg q.8 to 12 hours orally), topiramate (2 to 10 mg/kg q.12 hours orally) and zonisamide (5 to 10 mg/kg q.24 hours o - Therapeutic effects and side effects are related to the serum levels and not the oral dosage of the anti-epileptic drug. - Skipping doses or stopping drugs abruptly can precipitate seizures (dependency effect). - Seizure control may not take immediate effect as a steady serum state is only reached after 5 elimination half-lives (around 2-weeks in phenobarbi- tone and up to 3-months in potassium bromide). - Clients must keep accurate record of the date of any witnessed or sus- pected seizures and must be willing to bring their dog or cat in for periodic examination. - Clients should seek immediate veterinary care for any seizure lasting lon- ger than 10 minutes or for clusters of seizures without recovery to normal between the seizure episodes. - Clients should not alter the treatment without veterinary advice. WHEN TO START ANTI-EPILEPTIC TREATMENT The decision of when to start anti-epileptic treatment is still a subject of controversy. Dogs with a single seizure or isolated seizures separated by long periods of time (more than one month) do not require treatment. Treatment is indicated when: - The animal has a very severe seizure or clusters of seizures, irrespective of the frequency of the seizures or seizure clusters - Seizures occur more than once a month and/or the owner objects to their frequency - Seizures are becoming more frequent or more severe - An underlying progressive intracranial disorder has been identified as the 29

13–15 NOVEMBER, 2021 0010 In both instances, the cat may have normal or abnormal neurological ex- amination in the interictal period. If neurological signs are seen, they are WHAT IS SO SPECIAL ABOUT FELINE EPILEPSY? typically symmetrical and non-localising in term of anatomic diagnosis. Common metabolic causes include hepatic encephalopathy (either due to L. Garosi portosystemic shunt or to cirrhosis), renal encephalopathy, ionic imbal- ance (hypocalcemia, hyponatremia, hypernatremia, hypomagnesemia or IPER/United Kingdom hyperkaliemia), hypoglycaemia, polycythemia, and hyperthyroidism. Com- mon toxic or nutritional disorder seen in cats include lead, ethylene glycol, Qualifications: organophosphate and methaldehyde poisoning and thiamine deficiency. Dr Laurent Garosi DVM, Dip ECVN, FRCVS Intracranial causes of epileptic seizures can further be divided into func- tional and structural forebrain disorder. Most cats with structural forebrain RCVS & EBVS® European Specialist in Veterinary Neurology disorder show neurological signs in the interictal period. These signs are often asymmetric and can localise the lesion. They can refer to a forebrain [email protected] disorder (ipsilateral circling, contralateral postural reaction deficit, contra- RECOGNITION OF AN EPILEPTIC SEIZURE lateral menace response loss with normal pupillary light reflex, contralat- eral abnormal response to stimulation of the nostril, abnormal behaviour) Seizure types can be classified into two major categories: partial and or to a multifocal disorder (cranial nerve or spinal cord involvement). The generalised. Compared to dogs, cats commonly exhibit partial seizures. exception to this is a structural lesion in a “silent area” of the brain (region The focal nature of this seizure type is associated with a higher inci- of the brain which causes only seizures with no other localising signs dence of focal intracranial pathologic change in cats. These can be focal such as the olfactory lobe or prefrontal lobes) or in the early stage of an (partial motor or more often partial complex seizure) seizures: unaltered enlarging (and eventually slowly growing) mass. Structural brain diseas- consciousness with asymmetric localised motor signs such as eyelid or es include: cerebrovascular accident (common known causes in cats facial twitching, clonus of muscle groups of one limb – or psychomotor include cardiomyopathy, glomerulopathy, hyperthyroidism, intoxication by (complex partial) seizures: behavioural seizures pattern involving the lim- anti-coagulant and parasitism), infectious encephalitis (Feline Infectious bic system which may be seen as growling, vocalization, rage, aggression Peritonitis, FIV, FeLV-associated CNS lymphoma, Toxoplasmosis, Borna without provocation, running in circles, floor licking, tail chasing… Com- disease and bacterial meningo-encephalitis), immune-mediated encephali- pared to dogs, cats tend to experience high seizure frequency whatever tis, post-head trauma, primary and metastatic brain tumour, and anoma- the underlying cause. lous (hydrocephalus). The recognition of an epileptic seizure is essentially based on the owners’ A syndrome of complex partial seizures with orofacial automatism (FEP- description of the event. Apart for the unequivocal description of a gen- SO) has been described in cats who will display signs of salivation, facial eralised tonico-clonic seizure, the recognition of a partial or psychomotor twitching, chewing, growling, rapid turning… This syndrome has been seizure can be a real challenge for the clinician. Video footage obtained associated with hippocampal pathology. In human, similar syndrome is by the owner can be for that particular reason of precious help. An epilep- seen with autoimmune limbic encephalitis and is associated with antibody tic seizure can be suspected based on the peracute and unexpected (ex- against VGKC (voltage-gated potassium channel complex). Similar pathol- cept cases of “reflex seizures” where seizures are observed in response ogy has been documented in cats and it is also suspected VGKC complex to specific stimuli such as auditory reflex seizures which we are currently antibody may play an important role in naturally occurring seizure disease investigating) onset and offset, stereotypical pattern (i.e. each seizures in this species. Brain MRI showed bilateral hippocampal T1 hypo- and are fairly similar in following the same pattern), presence of involuntary isointensity and T2 hyperintensity. motor activity and/or abnormal mentation and behaviour and/or autonom- ic signs (salivation, urination and/or defecation), and elimination of other Feline reflex auditory seizure (FARS) is also a newly recognised form of paroxystic events (syncope, acute vestibular attack, myasthenia gravis). epilepsy in cats. It appears to be more common in older cats and Birmans, and is triggered by various high-pitched noises. Myoclonic seizures were CLINICAL EVALUATION OF A CAT WITH SEIZURES one of the cardinal signs of this syndrome in almost all cats, frequently occurring prior to generalised tonic–clonic seizures (GTCSs). Other An epileptic seizure is not a disease entity in itself but a clinical sign gen- features include a late onset (median 15 years) and absence seizures in erally indicative of a forebrain disorder. Neurological examination should a small number of cats, with most seizures triggered by high-frequency therefore focus on detecting forebrain signs (evaluation of mental status, sounds amid occasional spontaneous seizures (up to 20%). Half the popu- presence of circling gait, postural reaction testing, assessment of menace lation had hearing impairment or were deaf. One-third of cats in one of our response and response to nasal stimulation). study had concurrent diseases, most likely reflecting the age distribution. Birmans appear to be predisposed. Aside for avoiding the stimulus if The detection of forebrain signs on neurological evaluation in the inter-ic- possible, levetiracetam gave good seizure control and is more effective tal period rules-out as a general rule the hypothesis of primary epilepsy. than phenobarbital. The only exceptions to this rule are ischaemic necrotic brain lesions secondary to violent seizures (excitotoxicity phenomenon). Such lesions The term primary (or idiopathic) epilepsy implies a functional forebrain are particularly found in cats in the NMDA receptor-rich brain region such disorder causing recurrent epileptic seizures with a normal interictal pe- as the hippocampus. Inter-ictal neurological deficits frequently observed riod and no identifiable toxic, metabolic or structural intracranial causes. include mainly behavioural changes (aggression, fear, hyperexcitability, This type of epilepsy is considered less common in cats as compared to uncontrolled biting, chasing…). dogs and is a diagnosis of exclusion. GENERATING A LIST OF DIFFERENTIALS CHOOSING THE APPROPRIATE DIAGNOSTIC WORK-UP Seizures refer to a forebrain disorder. Their causes may originate outside Baseline blood work including a complete blood count, chemistry profile, (extra-cranial) or inside (intra-cranial) the brain. thyroid profile, bile acids, blood pressure as well as a urinalysis should be performed in all cats with seizures to rule-out metabolic causes. Causes of seizures found outside the brain (extra-cranial) may be found outside the body (toxic disorder) or inside the body (metabolic disorder). Dog with idiopathic epilepsy typically begin to seizure between 1 and 5 30 WSAVA GLOBAL COMMUNITY CONGRESS

years of age and, therefore, a dog meeting these criteria is presumptively 0011 diagnosed with idiopathic epilepsy and advanced diagnostics are often not necessary. Because such typical guidelines are not available for the BRACHYCEPHALIC OBSTRUCTIVE AIRWAY feline idiopathic epileptic, advanced diagnostics are usually recommend- SYNDROME: PATHO-PHYSIOLOGY AND ed for the seizuring cat, even when idiopathic epilepsy is suspected. Such RECOGNITION diagnostics include advanced imaging such as MRI or CT and potentially a CSF tap. Abnormalities on CSF are very sensitive to intracranial disease, J. Ladlow1,2, N. Liu3 but often not specific. However, when evaluated in conjunction with the MRI/CT imaging, it can be a helpful diagnostic tool. Cultures and infec- 1High Wycombe/United Kingdom, 2Cambridge/United King- tious disease titers (Cryptococcus, toxoplasmosis and FIP) may also be dom, 3ES/United Kingdom useful tests to be performed on CSF. Qualifications: MAINTENANCE THERAPY Jane Frances Ladlow The aim of any anti-epileptic treatment is to “control” the seizures by reducing their frequency, intensity and severity with minimum side effects. MA VetMB Cert VR, CertSAS FHEA DipECVS MRCVS Decision to start anti-epileptic treatment is still a subject of controversy. Cats with a single seizure or isolated seizures separated by longs period [email protected] of time do not require treatment. Treatment is indicated when: the first BOAS: Pathophysiology and Recognition seizure is life-threatening (status epilepticus or severe clusters), multiple seizures are observed in a short period of time, seizures occur more than Pathophysiology once a month and/or owners objects to their frequency, the seizures are becoming more frequent or more severe, an underlying progressive Brachycephalic Obstructed Airway Syndrome (BOAS) is clinical signs disorder has been identified as the cause of the seizures. Commonly resulting from upper airway obstruction related to the restricted length of used anti-epileptics in cats are: phenobarbitone (3 mg/kg q12hrs orally), the skull, particularly the nasal cavity. levetiracetam (20 mg/kg q8hrs orally), zonizamide (5 to 10 mg/kg q24hrs orally) and pregabalin (2 to 4 mg/kg q8 to 12 hrs orally). Phenobarbitone Work by the Royal Veterinary College (RVC) suggested that the craniofa- is the first choice of many clinicians for cats with seizures. Compared to cial ratio (CFR), which is muzzle length over cranial length, is correlated dogs steady state serum level tends to drop with time, elimination half-life with BOAS status1. The tissue proportions in the upper airway seem breed in cats is stable at around 34 to 43 hours and therefore drug concentration specific however, reflecting the different types of skull morphology seen in of phenobarbitone are not expected to decrease in cats receiving long- breeds which are labelled as brachycephalic. term therapy without changing the oral dosage. Monitoring of serum level is only justified shortly after the onset of treatment (when steady state The prevalence of BOAS within the extreme breeds is not yet clear. In level is reached after 10 to 15 days) due to the differences in elimination our study population in the UK (excluding clinical cases) we classified kinetics of phenobarbitone between population of cats or when drugs approximately 40% of Bulldogs, 46% of French Bulldogs and 60% of Pugs that might interfere with phenobarbitone’s pharmacokinetic are added. with clinically significant disease.2 Recommended therapeutic ranges have not been properly defined in cats but are considered similar to the recommended one in dogs [20 to 35 ug/ Disease Syndrome-Pathophysiology ml]. Cats should not be considered as refractory to treatment until serum concentrations reach 35 ug/ml unless unacceptable side effects persist. Brachycephalic dogs have a widened and shortened skull and muzzle. Side effects of phenobarbitone in cats include: sedation, ataxia, polyph- Although the skull is shortened, the soft tissues are not always reduced in agia, weight gain, neutropenia, thrombocytopenia, coagulopathy, severe a proportionate manner. cutaneous eruptions and marked lymphadenopathy (idiosyncratic delayed hypersensitivity). The author does not recommend the use of oral bromide The upper airway disease may present as respiratory noise, exercise intol- in cats due to the high incidence of side effect in this species and in erance, heat sensitivity, sleep disorders, dyspnoea, cyanosis or collapse3. particular clinical and radiographic signs similar to feline asthma such as Gastro-intestinal signs include regurgitation and vomiting with oesopha- coughing and/or difficulty breathing. gitis from increased gastro-oesophageal reflux4. Some dogs, particularly with nasal or nasopharyngeal obstruction also have sleeping disorders. Lesion sites In BOAS there are primary congenital abnormalities (stenotic nares, hyperplastic soft palate, hypoplastic trachea, macroglossia, enlargednasal turbinates, nasopharyngeal constriction) that result in restriction to air- flow, tissue swelling and hypertrophy and excessive inspiratory pressures in the upper airway. These lesions can cause secondary areas of collapse and inflammation, notably laryngeal collapse. The increased thoracic pres- sures may result in gastrointestinal signs of reflux and hiatal hernia with the accompanying risk of aspiration pneumonia or bronchial collapse. It is not always clear which lesions are primary and which are secondary and these may alter between breeds. In the early papers on BOAS, the stenotic nares were thought to be of paramount importance, and we have found similar results in the French Bulldog in particular, with a marked increased risk of BOAS if the nostrils are moderately or severely stenosed. We have modified a nostril grading system5 (Figure 5). Grade 0 and 1 are not associated with a greater risk of airway disease whereas grade 3 31

13–15 NOVEMBER, 2021 (moderate stenosis) and grade 4 (severe stenosis) are linked to a fourfold airflow moving across it. increase in risk of developing BOAS6. Figure 6. A trace from WBBP performed on a French bulldog, from these Figure 5. Nostril grading system traces parameters that can be generated include breathing frequency; total inspiratory volume, time and peak flow; total expiratory volume, time Oechtering et al. published on the CT imaging of the brachycephalic nose. and peak flow; lags between breath cycles (if any) and hence minute They found abnormal conchal formation in these dogs, with nasal ob- respiration volume. struction from a rostrally positioned ventral turbinate and nasopharyngeal obstruction from caudal aberrant turbinates, originating from the middle This test has been developed to give a BOAS index; a numerical score or ventral nasal conchae (seen in 43% of these dogs). The turbinates, in from 0–100% to describe how severely an individual dog is affected with addition to being abnormally positioned, had a lower level of branching BOAS, where 0% is non-affected and 100% is our most severely affected compared with a normocephalic dog7. individuals2. Both severely and mildly affected dogs may have aberrant turbinates, ste- The BOAS index is important as we now have an objective measurement notic nares and elongated soft palates to some extent with the severely with which to evaluate risk factors for BOAS and the effectiveness of affected dogs more likely to have grossly thickened soft palates and other our surgical treatments, looking at the whole upper airway rather than anatomical changes. This demonstrates how difficult it is to look at lesion individual sections. sites independently and we also need to remember that static images on endoscopy, radiography or CT may be affected by the presence of an ET Imaging tube, phase of respiration, head position and degree of mouth opening, and thus need to be interpreted with caution. As usual in veterinary medicine, this depends on the owner’s budget. Direct laryngoscopy is sufficient to evaluate the larynx, tonsils and gives a Disease recognition and Functional Grading good idea of soft palate length and thickness. A lateral radiograph of the skull will allow visualisation of the nasopharynx and soft palate. CT scan A major problem with BOAS is that it is often under recognized by both of the head will reveal turbinate morphology and the soft palate thickness. the public and veterinary professionals. A questionnaire-based study on Rhinoscopy is probably a more accurate method of assessing turbinate disease recognition revealed that approximately 60% of owners did not crowding, with a rigid scope used for the rostral nasal cavity combined perceive their dogs to have airway obstruction when clinical examination with a flexible scope to assess caudal aberrant turbinates, trachea and and history were compatible with the disease 5. bronchi and oesophageal lesions. For diagnosis we use a functional grading system for BOAS that includes CT of the thorax enables assessment of bronchial collapse, aspiration an exercise test. We exercise the dogs at a moderate trot (4 mph) for 3 pneumonia, oesophageal diverticulum and may detect hiatal hernia. minutes and note airway noise, effort, and extreme respiratory signs pre Radiographs of the thoracic cavity may show aspiration pneumonia if CT and post exercise. is not possible. When we auscultate these dogs we listen directly over the side of the lar- If finances are very limited, then it is reasonable to treat without imaging. ynx, not ventrally. We are listening for stertor (awake snoring) and stridor However, in cases that do not respond successfully to conventional sur- (higher-pitched noise originating from the larynx). gery, nasal obstruction or aspiration pneumonia may have been missed. https://youtu.be/_dADh1gbExs References https://youtu.be/pQd0xbddfvY • Packer RMA, Hendricks A, Tivers MS, Burn CC, 2015. Impact of Facial Conformation on Canine Health: Brachycephalic Obstructive Airway Syn- While this system is not perfect, as exercise tolerance may be affected drome. PLoS ONE 10(10): e0137496. doi:10.1371/journal.pone.0137496 by ambient temperature and sometimes the animal’s fitness levels, it does expose those animals that are teetering on the edge of obstruction • Liu NC, Troconis EL, Kalmar L, Price DJ, Wright HE, Adams VJ, Sargan when calm and firmly tipped into ‘affected’ once stressed. Exercise tests DR, Ladlow JF.(2017) Conformational risk factors of brachycephalic ob- also reveal clinical signs in those dogs that only have respiratory noise structive airway syndrome (BOAS) in pugs, French bulldogs, and bulldogs. when mouth breathing (often the long but not particularly thickened soft PLoS One. Aug 1;12(8):e0181928 palates) after switching from nasal breathing in the consult room. 3. Roedler FS, Pohl S, Oechtering GU, 2013. How does severe brachyceph- We find that about 40% of dogs that show few clinical signs in the consult aly affect dog’s lives? Results of a structured preoperative owner ques- room will be classified as affected after the exercise tolerance test8. We tionnaire. Vet J. 2013 Dec;198(3):606-10. doi: 10.1016/j.tvjl.2013.09.009. consider no airway noise (grade 0) and mild airway noise (grade 1) as Epub 2013 Sep 18 clinically unaffected as in these dogs we do not detect any decrease in quality of life, with normal exercise tolerance and no other associated • Poncet CM et al. Prevalence of gastrointestinal tract lesions in brachy- clinical signs. The grade 2 and 3 dogs have airway obstruction that affects cephalic dogs with upper respiratory syndrome: clinical study in 73 cases quality of life and are regarded as clinically affected. (2000-2003) . J Small Anim Pract 2005 This grading system enables us to advise on treatment – grade 3 dogs • Packer, R., Hendricks, A. & Burn, C.C., 2012. Do Dog Owners Perceive the are surgical candidates, grade 2 dogs are likely surgical candidates but if Clinical Signs Related to Conformational Inherited Disorders as “Normal” obese, weight loss could be initiated prior to surgery. We can also monitor for the Breed? a Potential Constraint to Improving Canine Welfare. Anim dogs with the grading system and use it in addition to our objective respi- Welfare, 21(1), pp.81–93. ratory function test. • Liu NC, Troconis EL, Kalmar L, Price DJ, Wright HE, Adams VJ, Sargan In human respiratory medicine, in addition to clinical examination, DR, Ladlow JF.(2017) Conformational risk factors of brachycephalic ob- respiratory function would be tested with whole-body plethysmography structive airway syndrome (BOAS) in pugs, French bulldogs, and bulldogs. in conjunction with forced spirometry. The technique that we use for the PLoS One. Aug 1;12(8):e0181928 extreme brachycephalic breeds dogs is whole body barometric plethys- mography (WBBP) where dogs are placed in a sealed chamber with biased • Oechtering, T., Oechtering, G. & Noeller, C., 2007. Computed Tomo- 32 WSAVA GLOBAL COMMUNITY CONGRESS

graphic Imaging of the Nose in Brachycephalic Dog Breeds. Tierärztl Prax, 0012 35(K), pp.177–187. FLAT-FACED LIE OR TRUTH: BRACHYCEPHALICS • Riggs J, Liu NC, Sutton DR, Sargan D, Ladlow JF, 2019. Validation of ARE LESS HEALTHY? THE BIG DATA ANSWER exercise testing and laryngeal auscultation for grading brachycephalic obstructive airway syndrome in pugs, French bulldogs, and English bull- D. O’Neill dogs by using whole-body barometric plethysmography. Vet Surg. 2019 May;48(4):488-496. doi: 10.1111/vsu.13159. Hatfield/United Kingdom https://www.vet.cam.ac.uk/boas/about-boas Qualifications: Dan O’Neill MVB BSc(hons) GPCert(SAP) GPCert(FelP) GPCert(Derm) GPCert(B&PS) PGCertVetEd FHEA MSc(VetEpi) PhD FRCVS [email protected] Health and welfare concerns about brachycephalic dogs have become an increasingly high profile and contentious topic in veterinary medicine over recent years. Set against a backdrop of marked rises in popularity of these cherished breeds, there is evidence that brachycephalic breeds are strongly predisposed to a range of disorders intrinsically related to their conformation, including respiratory disease, eye disease, dystocia, spinal disease and heat stroke. Brachycephalic breeds are also reported with significantly shorter lifespans (median longevity: 8.6 years) than moderate and non-brachycephalic dogs (median 12.7 years) (1). Indeed, some veter- inarians now consider many popular brachycephalic breeds as simply too compromised to justify their continued existence. A recent book called Health and welfare of brachycephalic (flat-faced) companion animals: a complete guide for veterinary and animal professionals includes 20 chap- ters with many veterinary authors who present a wide range of ethical, welfare, epidemiological, social and genetic perspectives that challenge the notion that brachycephaly is conducive with good animal welfare. But, as in evidence-based world of science, what is the evidence on differenc- es in the overall health of brachycephalic compared with non-brachyce- phalic dogs in the wider dog population? A recent study has gone a long way towards filling this information gap. The VetCompass Programme collects anonymised data from primary-care veterinary practices in the UK and Australia (2, 3). Using data on a random selection of dogs from the UK VetCompass database, the study identified common disorders with predispositions and protections in the brachy- cephalic dogs compared with non-brachycephalic dogs. These results could assist veterinary practitioners with an evidence base on the health of the wider general population of brachycephalic dogs to predict, prevent and manage key health and welfare opportunities for brachycephalic dog types. The study used a cross-sectional analysis of cohort clinical data on all available dogs in the UK VetCompass Programme during 2016. Breed data were mapped to a VetCompass breed list and breeds were cate- gorised based on typical skull-shape conformation into brachycephalic and non-brachycephalic (mesocephalic, dolichocephalic and crossbred) groups. The clinical records of a randomly selected subset of animals were reviewed in detail to extract the most definitive diagnoses record- ed for all disorders with clinical evidence of existence during 2016 (4). Disorders were defined as conditions that show deviation from good health. An overall list of common disorders across both groups of dogs was generated by combining all unique disorders that were among the 20 most common disorders in either group of dogs. Multivariable risk factor analyses evaluate associations between each disorder and the brachyce- phalic/non-brachycephalic factor of main interest along with a fixed set of covariables included to account for confounding (adult bodyweight category, bodyweight relative to breed/sex mean, age category, sex, neuter and insurance). The study included a random sample of 22,333 dogs attending 784 veter- inary clinics from an overall population of 955,554 dogs under veterinary 33

13–15 NOVEMBER, 2021 care in 2016. There were 4,169 (18.74%) brachycephalic and 18,079 Health-related welfare prioritisation of canine disorders using electronic (81.26%) non-brachycephalic types. Brachycephalic dogs were younger health records in primary care practice in the UK. BMC Veterinary Re- than mesocephalics (median 5.33 years), dolichocephalics (5.07 years) search. 2019;15(1):163. and crossbreds (3.74 years). Brachycephalic dogs were also lighter than mesocephalics (median 16.98kg), dolichocephalics (25.80kg) and cross- breds (13.80kg). The brachycephalic group included 34 individual breeds compared with 169 individual breeds in the mesocephalic group and 66 individual breeds in the dolichocephalic group. Using multivariable modelling, brachycephalic dogs had 1.27 times the odds of having at least one disorder compared with crossbred types. The 95% CI for mesocephalic and dolichocephalic dogs did not overlap the 95% CI for brachycephalic dogs, indicating that brachycephalic dogs also had increased odds of having at least one disorder compared with mesocephalic and dolichocephalic dogs. The most common disorders (i.e., greatest prevalence) in the brachyce- phalic types were periodontal disease (n = 485, prevalence = 11.63%), otitis externa (303, 7.27%), obesity (266, 6.38%), anal sac impaction (249, 5.97%), overgrown nail(s) (212, 5.09%), diarrhoea (143, 3.43%) and heart murmur (3.43%). Using multivariable analysis, 8/30 disorders showed higher odds (i.e., disorder predisposition) for brachycephalic types com- pared with non-brachycephalic types: corneal ulceration (OR 8.40), heart murmur (OR 3.5), umbilical hernia (OR 3.16), pododermatitis (OR 1.66), skin cyst (OR 1.52), patellar luxation (OR 1.40), otitis externa (OR 1.29) and anal sac impaction (OR 1.24). Two disorders had reduced odds for brachycephalic types: undesirable behaviour (OR 0.52) and claw injury (OR 0.45). This study provides strong evidence that brachycephalic dogs have reduced health overall compared with non-brachycephalic dogs based. Brachycephalic dogs were more likely to have at least one disorder diagnosed compared with mesocephalic, dolichocephalic or crossbred dogs. Brachycephalic dogs showed predispositions for 8/30 disorders compared with protections for just 2/30 disorders. By focusing on com- mon problems that contribute substantially to the overall disease burden, this study also highlights disorders that should be considered as priority issues for brachycephalic dogs (5). In summary, there is now strong evidence to support the common belief that brachycephalic breeds are generally less healthy than their non-brachycephalic counterparts. As a key stakeholder in the brachyce- phalic issue, the veterinary profession must now decide how to use this new information to redress some important welfare issues related to the brachycephalic conformation. The UK Brachycephalic Working Group currently advises owners to ‘Stop and think before buying a flat-faced dog’. Veterinary professionals and organisations worldwide could adopt this reflective approach for wider dissemination to owners. This approach could help owners to reach evidence-based decisions on which dog breed to purchase after active consideration and prioritisation of the welfare needs of the dog. References 1. O’Neill DG, Church DB, McGreevy PD, Thomson PC, Brodbelt DC. Lon- gevity and mortality of owned dogs in England. The Veterinary Journal. 2013;198(3):638-43. 2. VetCompass. VetCompass Programme London: RVC Electronic Media Unit; 2021 [Available from: http://www.rvc.ac.uk/VetCOMPASS/. 3. VetCompass Australia. VetCompass Australia Sydney: The University of Sydney; 2021 [Available from: http://www.vetcompass.com.au/. 4. O’Neill DG, James H, Brodbelt DC, Church DB, Pegram C. Prevalence of commonly diagnosed disorders in UK dogs under primary veterinary care: results and applications. BMC Veterinary Research. 2021;17(1):69. 5. Summers JF, O’Neill DG, Church D, Collins L, Sargan D, Brodbelt DC. 34 WSAVA GLOBAL COMMUNITY CONGRESS

0013 • Where did the itch start, and how did it progress? Some diseases have their characteristic pattern. A dog with scabies might start scratching its DIAGNOSTIC APPROACH FOR THE ITCHY DOG AND ears, then the elbows, abdomen, and hock before becoming generalized. CAT Atopic dermatitis is often characterized by pruritus of the face, ears, an- terior flexure fold, distal limbs. Flea allergy dermatitis usually involves the M. Tunhikorn dorsolumbar region, whereas flea infestation involves more of the ventral aspect of the body. Bangkok/Thailand • Is it itch before rash VS rash before itch? Non-lesional pruritus is most Qualifications: likely due to allergies. Skin lesions (e.g., papules, pustules, crusts, excori- ations) appear later due to self-trauma or secondary infections. Psycho- Maturawan Tunhikorn genic pruritus can also start with no lesions. If the animal had lesions before becoming itchy, it is more likely from ectoparasite infestation (e.g., DVM, DipACVD scabies, cheyletiellosis) or infections. [email protected] • What is the itch level score (scale of 0-10)? Asking the owner about the Diagnostic approach for the itchy dog and cat severity of the pruritus can give an idea of the disease-causing the prob- lem. Canine scabies can be very pruritic, whereas demodicosis shows very Itch or pruritus is one of the major problems that pet owners often bring mild pruritus if no secondary infection is present. However, the severity of their animals to the veterinarian. Animals can exhibit pruritus in various the itch depends on the owner’s observations and is not always accu- ways, such as licking, scratching, biting, scooting, or rubbing. Numerous rate. The itch level score is helpful to help determine whether the animal skin diseases can cause itch, both dermatologic and nondermatologic, response to the treatment when it is back for a recheck exam. making the list of differential diagnoses very long. The most common causes of itch are from ectoparasitic infestation, allergies, and infections. • Is the problem year-round? Seasonal pruritus is frequently associated There can also be a combination of more than one disease-causing pruri- with atopic dermatitis, flea allergy dermatitis, and chigger mites, while tus in an individual animal. To identify the cause of the itch, the clinician adverse food reactions cause non-seasonal pruritus. must obtain a thorough general and dermatological history and physical examination to determine the list of differential diagnoses. Once the list • Any parasites observed on the animal and other household members? has been formed, the clinician can select the most appropriate tests and Sometimes fleas, lice, or cheyletiella can be observed with naked eyes. follow them in proper order to rule in or rule out the suspected cause. • Are other in-contact animals or humans have skin issues? If other in-con- The diagnostic approach for pruritic animals should involve the following tact animals also developed skin diseases, it is most likely from ectopara- sitic infestation, for example, scabies or cheyletiella. Dermatophytosis can 1. Acquire a detailed history both general and dermatological likewise affect both animals and humans. Other zoonotic skin diseases are scabies, cheyletiellosis, ear mites (rare). 2. Perform a thorough physical and dermatological examination • What are the current and previous diets, treats, and supplements? 3. List and prioritize the possible diagnoses Adverse food reactions can cause severe pruritus with acute onset. Based on the diet information, the clinician can formulate a diet for a food trial. 4. Perform the required tests/treatment trial, collect the information, perform further investigation (if needed) and establish a diagnosis • Are there any gastrointestinal problems (e.g., soft stool, vomiting)? Con- sider adverse food reactions in dogs or cats which have GI signs. History • What is the response to previous treatment? What was the current Obtaining a detailed and accurate history is of great importance in the medication? What is the patient’s response to glucocorticoid administra- diagnosis of pruritic skin diseases. Skipping this part could lead to misdi- tion? The information helps the clinician to learn what medication worked agnosis, waste of time and money, and cause frustration to the veterinar- and not worked. Poor response to glucocorticoid raises the suspicion of ian and owners. The clinician should develop the skill of questioning the scabies. owner. A questionnaire can be of great help, so the essential questions are not missed. Examples of questions regarding pruritus are: Physical examination • Is the animal itchy? some owners are not aware that their pet is pruritic. Thorough physical examination is essential, both general and dermatologi- Since itch can manifest in different ways, asking specific questions (e.g., cal. The clinician should assess whether there is any lesion on the animal. does your dog rub itself with furniture or does your cat lick itself) would If so, were they primary lesions or secondary lesions? What are the distri- give you more information than asking whether the dog or cat is itchy. bution and pattern? Is it symmetrical or asymmetrical? Is it generalized or Some cats are closet-licker, and the owner has no idea that the cat is localized? Lesion localization for canine scabies would be the ear margin, itchy. elbows, ventral abdomen, and hock joints. Atopic dermatitis in dogs tends to be localized at the face, ears, feet, flexure surface, and skin folds. Cats • What is the age of onset? Pruritus starting at a younger age is more are different than dogs in that they usually present with four reaction likely from ectoparasitic infestation (scabies, fleas). Allergies can develop patterns. The reaction patterns in cats include: in young to middle-aged animals with atopic dermatitis starting at around 6 months to 3 years old. Hormonal skin diseases, such as hyperadreno- Miliary dermatitis. corticism or hypothyroidism, most often develop in middle-aged to senior dogs. Self-induced alopecia. • Is it acute or chronic onset pruritus? Acute onset of pruritus is often Head and neck pruritus. seen in ectoparasitic infestations such as scabies, fleas, or food allergy. Allergies often are chronic; a dog with atopic dermatitis may lick its feet Eosinophilic granuloma complex constantly since a puppy. List and prioritize the possible diagnoses 35

13–15 NOVEMBER, 2021 After taking a good history and thorough physical examinations, the clini- 0014 cian should list and prioritize the disease in order. Common diseases do occur commonly and should be high on the list than rare ones. Diagnostic BASIC DIAGNOSTIC TESTS- PUT THE RIGHT TEST TO tests should be chosen according to the suspected diagnosis and the THE RIGHT JOB level of information they can give. M. Tunhikorn Perform the required tests/treatment trial, collect the information, perform Bangkok/Thailand further investigation (if needed) and establish a diagnosis Qualifications: Rule out common conditions such as ectoparasites and infections first. Superficial skin scrapings for scabies or surface mites can be unreward- Maturawan Tunhikorn ing. A treatment trial should be conducted to confirm the diagnosis. If the animal is still pruritic after ruling out ectoparasitic skin diseases and skin DVM, DipACVD infections, the animal likely has allergies. Food trial should be considered as the next step in the diagnosis. [email protected] Basic diagnostic tests – put the right test to the right job Various basic in-house tests are used in determining the cause of skin diseases. Choosing appropriate diagnostic tests for the suspected dis- ease will help speed the diagnostic time. Tests for suspected ectoparasite infestation include coat brushing, skin scrapings, tape preparation, tri- chogram, and ear smear for otic parasites. Test for suspected infections includes cytology, Wood’s lamp, trichogram, and fungal culture. When suspecting flea infestation and flea allergy dermatitis, the following tests can help confirm the diagnosis: · Direct examination for fleas and flea dirt · Coat brushing · Tape preparation for parasite collection · Fleas may not be present on the animal at the time of examination. To confirm the diagnosis, strict flea control is mandatory. When suspecting mite infestation, the following tests can help confirm the diagnosis: · Coat brushing: Cheyletiella, lice · Tape preparation for parasite collection: Cheyletiella, Demodex gatoi, Notoedres, cati, ectopic Otodectes, lice · Ear smear for otic parasites: Otodectes and Demodex · Superficial skin scraping: S.scabiei, Notoedres, D. gatoi, Notoedres cati,Cheyletiella, ectopic Otodectes · Deep skin scraping: Demodex canis, Demodex injai, D. cati · Trichogram: Demodex canis When suspecting infections, the following tests can help confirm the diagnosis: · Trichogram, Wood’s lamp, fungal culture: dermatophytosis · Cytology: bacterial infection, yeast infection, dermatophytosis Coat brushing: Use a flea comb to brush hair over the affected area. Comb the scales and crusts from the skin onto a white piece of paper (use black paper to check for lice). Examine the sample with the naked eye and/or a magnify- ing glass for fleas and flea dirt. The sample can later be transferred onto a glass slide with liquid paraffin and looked under the microscope at the lowest magnification to search for other ectoparasites such as lice or Cheyletiella. Sticky tape preparation: Clear adhesive tape is applied with sticky-side-down on the affected skin 36 WSAVA GLOBAL COMMUNITY CONGRESS

to collect samples. After collecting the samples, pressed the tape onto should be viewed under high magnification or oil immersion for types of the glass slide and examined it under a microscope at the lowest magnifi- organisms and types of inflammatory cells. Occasionally, acantholytic cation for fleas, lice, and surface mites. keratinocytes, neoplastic cells, and mites can be found on cytology. Ear smear for otic parasites: Reference: Use a cotton swab to collect samples from the ear canal. Rolled the swab 1. Miller WH, Griffin CE, Campbell KL. Chapter 2: Diagnostic method. In: onto the glass slide with a small amount of mineral oil, applied coverslip, Muller and Kirk’s Small Animal Dermatology 7th edition. Philadelphia, PA: and examined with a microscope under the lowest magnification for Elsevier 2013; 57-107. Otodectes cynotis and Demodex. 2. Mattia DD, Fondati A, Monaco M, et al. Comparison of two inoculation Superficial skin scraping: methods for Microsporum canisculture using the toothbrush sampling technique. Vet Dermatol 2019; 30:60-e17. Hair should be clipped before scrapings. Apply mineral oil to the skin before scraping and scrape large areas to increase the chance of finding 3. Moriello KA, Coyner K, Patrson S, Mignon B. Diagnosis and treatment of the mites. Scrape oil and debris off onto the glass slide. The finding of dermatophytosis in dogs and cats. Vet Dermatol 2017; 266-e68. one mite, egg, or fecal pellet is diagnostic. Negative results cannot rule out scabies. Clinicians may attempt to perform a pinna-pedal reflex or treatment trial on the patient. Deep skin scraping: Apply a small amount of mineral oil on the scalpel blade. Squeeze (pinch) the skin, scrape a small area in the same direction until capillary bleeding. Transfer the material onto the glass slide and cover it with a coverslip. Examine under the microscope at low magnification for Demodex mite. More than one mite is diagnostic. Trichogram: Use a simple forceps/hemostat to pluck the hairs at the base gently. Pull in the direction of hair growth, place hair on a drop of mineral oil on the glass slide. Demodex mites may be seen at the area of the root of the hairs. This method is also useful for finding parasites attached to the hairs shaft and finding dermatophyte arthrospores and hyphae along the hair shaft. This method can also help in determining if the hair loss is from pruritus. Hair infected with dermatophyte will have a swollen and irregular fuzzy looking at low magnification. Arthrospores and hyphae can be seen at high magnification. A broken or blunt hair tip will indicate external trauma. Wood’s lamp: Wood’s lamp is a screening tool for Microsporum canis infection. Hair shafts infected with M. canis should fluoresce. However, some strains will not fluoresce and will need fungal culture to confirm the disease. Many false positives can occur from medications, soaps, and bacteria. Fungal culture: Collect damaged hairs, crusts, and scales from the lesion and place them on fungal media (dermatophyte test media [DTM] or sabouraud dextrose agar). A sterile toothbrush can be used to brush the coat. This method is called the “Mackenzie brush technique” and is suitable for sampling asymptomatic carrier cats. After brushing, gently imprint the bristle on the surface of the culture medium. Do not put all the collected materials onto the culture medium; this can cause false-negative results from the overgrowth of saprophytes. Evaluate the culture daily for any change of the media color. If the color of the media changes simultaneously with the colony growth, dermatophytosis is suspected. The clinician should perform further microscopic examinations from the culture to avoid false-positive color changes and specify the fungus species. Cytology: Cytology helps identify the cause of the disease, monitor response to treatment, determine needs for culture and susceptibility tests, and inter- pret culture results. There are various techniques for obtaining the cytol- ogy sample from the skin (direct impression smear, swab collection, tape preparation, fine needle aspiration); selecting which method to collect samples depends on the nature of the lesions and the location. Samples 37

13–15 NOVEMBER, 2021 0015 - Acepromazine is often removed from the protocol THE ANAESTHESIA PLAN • Age T. Farry - Very young and older animals can have an altered ability to metabolise drug and may have decreased organ function Brisbane/Australia • Cats and small dogs are susceptible to hypothermia Qualifications: • Cats are prone to laryngospasm Trish Farry • Cats have altered ability to metabolise some drugs as they have: RVN AVN VTS (ECC) (Anaes & Analgesia) GCHEd - Reduced UDP-Glucuronosyltransferase (UGT) which is involved in the [email protected] conjugation of many substances “By failing to prepare, you are preparing to fail” Benjamin Franklin - Reduced phase I metabolism (oxidation, reduction, hydrolysis) compared The process of developing a patient specific anaesthetic plan should to other species always be a priority in managing any patient undergoing anaesthesia. An individualised plan that follows a step-by-step procedure will ensure that - Propofol is metabolised via glucuronidation and hydrolysis we can identify and assess common risk factors and safety concerns associated with anaesthesia and plan how to manage and mitigate iden- As the return to consciousness is a result of redistribution cats can be tified concerns. The anaesthesia plan should include the pre-anaesthetic induced successfully with propofol patient exam and assessment, anticipated anaesthesia and procedural considerations, drug and support therapy and monitoring along with post Constant rate infusions may result in prolonged recovery as metabolism anaesthesia and recovery plans. This may sound like a great deal of work is required for each case, but by systematically following a plan we will achieve better outcomes for our patients and allow us to be better prepared to respond History to complications that may occur during the anaesthesia period. A thorough history is vital. Attention should be paid to: How To Devise an Anaesthetic Plan • Current medications Using the acronym SHEAP (Signalment, History, Examination, Assess- ment, Plan) will aid in the preparation of a comprehensive anaesthetic - eg. NSAIDs or glucocorticoids, cardiac medications plan. • Evidence of wellness Signalment - Is the patient eating, drinking, urinating, and defecating normally? This will include species, breed, and age factors. Some examples of breed and species specific considerations for anaesthesia are: - Abnormalities in these normal bodily functions may indicate ill health and co-morbidities that can have a significant effect on anaesthesia • Greyhounds • Has the patient presented for ill health such as vomiting which may - Have the potential for prolonged recovery following anaesthesia with suggest dehydration and electrolyte abnormalities? thiopentone • Presence of previous co-morbidities and ill health - More rapid clearance of methadone so may require more frequent doses of methadone - eg. diabetes, hyperadrenocorticism, hyperthyroidism, seizures, heart disease - Susceptible to fibrinolysis and may require pre-treatment with either tranexamic acid or aminocaproic acid • Fasting status • Boxers - Anaesthesia of an animal that has eaten may predispose it to vomiting, regurgitation and aspiration - May exhibit a vasovagal response following premedication with ace- promazine • Any previous anaesthesia history - May develop arrhythmogenic right ventricular cardiomyopathy Examination • Brachycephalic breeds are prone to obstruction and increased vagal tone This is the cornerstone of planning for any anaesthetic event. Every pa- tient must be examined prior to anaesthesia and evaluated focussing on • Presence of a genetic mutation in the adenosine triphosphate driven factors that may affect the animal’s physiological homeostasis. Particular pump (ABCB1) which was formerly known as multi resistant drug 1 attention should be placed on the respiratory and cardiovascular systems. (MDR1) gene. This gene encodes a p-glycoprotein pump, present in the Examination of the cardiovascular system should include as a minimum, blood brain barrier. Provides protection from the accumulation of toxic auscultation of both sides of the heart including all heart valves and pal- levels of drugs in the CSF pation of the pulse while auscultating the heart to identify pulse deficits. Any patient with pulse deficits or an arrhythmia should have an ECG if - Breeds affected include collies, border collies (usually only a problem in one is available. The heart rate should be recorded along with rhythm and imported show dogs), Australian Shepherd and Shetland sheepdogs assessment of pulse quality, capillary refill time and mucous membrane colour. - Acepromazine and opioids (especially butorphanol) can accumulate in the CSF and their dosages should be reduced by at least 25% The respiratory system examination should include as a minimum, obser- vation of the respiratory rate and pattern prior to physical examination, noting any evidence of airway obstruction or increased respiratory effort. The nares should be examined for presence of exudate and airflow and the oral tract examined (if possible) for presence of masses or ulcers. 38 WSAVA GLOBAL COMMUNITY CONGRESS

The trachea and both sides of the thorax over the lung fields should be Part of the anaesthesia plan will be choosing the appropriate endotra- auscultated and any abnormalities noted. cheal tubes, anaesthetic circuits and calculating flow rates and choosing ventilator settings. The patient’s demeanour should be assessed and considered when de- signing a premedication plan. A relaxed animal may not require sedation Analgesia should be an integral component of the anaesthesia plan. This with a drug that causes cardiovascular side effects. will be often procedure driven, recognising the expected levels of pain. Pre-emptive and multimodal analgesia should be utilised. The body condition score should be evaluated and recorded. Obese patients can be at risk of overdose and may have compromised respira- Supportive therapy including fluid therapy, cardiovascular supportive tory function. An estimate of lean body mass should be made, and the drugs and emergency drug calculations should be prepared prior to the anaesthetic drugs calculated and administered based on this weight. induction of anaesthesia. Underweight patients may be more susceptible to hypothermia and poten- The plan should also include anaesthetic monitors specifically chosen for tially have less muscle and fat for the redistribution of injectable agents. the patient or procedure. Assessment A major part of the plan is the creation of an anticipated problem list and contingency plans. This list could include common complications of In the assessment, body systems exhibiting abnormalities should be not- anaesthesia such as hypotension, hypoventilation, bradycardia, hypother- ed. A problem list and a list of differential diagnoses should be created. mia and hypoxaemia. The anaesthetist should consider their intended The physical exam and signalment should guide the ASA status. An ASA response to complications. Complications may also be procedure specific status should be assigned which may need to be revised following results eg. haemorrhage or air embolus for a forelimb amputation or gastric of any diagnostic testing. distension for a gastroscopy procedure. Plan Checklists Diagnostic tests not requiring sedation or anaesthesia should be per- Augmenting a good patient anaesthetic plan can be checklists. In human formed first. medicine checklists have been proven to significantly decrease peri-oper- ative morbidity and mortality. The use of checklists in veterinary hospitals • Blood work can improve anaesthetic safety and decrease the severity and frequency of post-operative complications. - The extent of blood work performed on healthy animals prior to anaes- thesia is subject to debate The checklist should be signed off over three timepoints: before induction, before the first incision and before patient recovery. - For healthy patients under 7 years of age a minimum of packed cell volume, total plasma protein and creatinine should be performed To safely perform anaesthesia, the veterinary professional must have a thorough knowledge of physiology and pharmacology, and an understand- • Compromised animals should have some or all the following: ing of how the patient responds to sedation, anaesthesia, and surgery. An individual methodical plan will consider patient and procedure risk - Full blood count factors. The process of devising a plan will ensure that the anaesthetist can be well prepared to respond to changes in the patient in a timely, - Biochemical analysis considered, and calculated approach. - Blood gas analysis “There are no safe anesthetic agents, there are no safe anesthetic proce- dures. There are only safe anesthetists.” Robert Smith - Clotting profile The author would like to acknowledge and thank Dr Joanne Rainger for her • Healthy animals older than 7 years: contribution to these Proceedings. - A minimum of PCV, TPP and creatinine References available on request. - More extensive blood work may not influence anaesthetic decisions but may be extremely valuable for ongoing patient monitoring and health planning. Imaging (radiographs or ultrasound) may be indicated pre-anaesthesia as part of the patient work-up. Once additional diagnostic tests have been performed the patient should be reassessed. The ASA status should be reviewed (and modified if nec- essary), and an anaesthetic plan can now be devised. Devising an anaesthetic plan A list of potential complications relevant to the patient and the procedure should be listed. If appropriate, pre-anaesthetic stabilisation should be considered. This could include the treatment of dehydration/hypovolemia, electrolyte abnormalities and/or providing analgesia. Drug selection will be based on the patient assessment and procedure requirements. The plan should consider the most appropriate drugs for the pre-medication, induction, and maintenance period. Preparation of all equipment is essential. This involves ensuring all equipment required is tested and in a good working state. Anaesthetic machines and ventilators must be checked prior to each patient. 39

13–15 NOVEMBER, 2021 0016 the stomach and induction techniques should be aimed at rapid airway protection. Antacids and/or gastric protectants may be appropriate. CAESAREAN ANAESTHESIA Premedication/Induction T. Farry Use of premedication will be dependent on condition and demeanour of Brisbane/Australia the patient. Most agents have profound effects on the cardiorespiratory system which may compromise foetal perfusion. Qualifications: Mu opioid receptor agonists can be administered to provide sedation and Trish Farry perioperative analgesia. They have minimal cardiovascular effects but may cause maternal respiratory depression and bradycardia. Fentanyl may RVN AVN VTS (ECC) (Anesthesia and Analgesia) GCHEd be preferable due to less accumulation. If bradycardia occurs it can be treated with an anticholinergic. Glycopyrrolate does not cross the placen- [email protected] tal barrier whereas atropine does. Due to incomplete cardiac autonomic Maternal physiological changes development atropine is unlikely to influence foetal heart rate. Bradycardia in the neonate is not vagally mediated and may be a response to hypox- Cardiovascular aemia. To reverse opioid depression, naloxone can be administered to the neonate post-delivery. Increased demands on the cardiovascular system and hormonal changes result in decreased cardiac reserve. Heart rate, stroke volume and plasma Phenothiazines are not recommended, due to the inability for underde- volume all increase during pregnancy. Cardiac output and stroke volume veloped neonatal livers to metabolise most drugs. It has a long duration increase up to 50% and 35% respectively mainly in response to increased of action, causes vasodilation, and impairs thermoregulation in both plasma volume. Increases in circulating hormones cause vasodilation the mother and the neonate. If used, they should be at the lowest dose and decreases in peripheral vascular resistance. Heart rate increases as a possible. result. Increases in plasma volume(approximately 40%), lead to dilutional anaemia as red cell production is not proportional to that of the plasma. The use of alpha-2 agonists is controversial. Previous research demon- Due to decreased reserve capacity and cardiovascular responses maternal strated higher doses of alpha-2’s caused 50% reduction in uterine blood hypotension can occur rapidly. This can be exacerbated by depressant flow resulting in foetal hypoxaemia and acidosis. In 2017 a study was pub- effects of anaesthetic agents. A gravid uterus may compress the inferior lished where medetomidine(7ug/kg) was used as a premedicant, propofol vena cava and lower aorta. Compression of the vena cava reduces venous for induction, and sevoflurane as maintenance. The medetomidine was re- return resulting in decreases in preload and cardiac output. Compression versed in the puppy upon delivery and the dam post surgery. The induction of the aorta may cause decreases in uteroplacental blood flow. As pla- dose of propofol was reduced by 50% and Apgar scores and maternal and cental perfusion is directly proportional to systemic perfusion pressures, foetal survival rate compared well to other common protocols. a drop in blood pressure will affect placental perfusion and foetal oxygen delivery. Vigilant monitoring of blood pressure with early treatment of Induction agents commonly used are propofol and alfaxalone. A 2013 hypotension is essential. study demonstrated alfaxalone had similar or better outcomes for mother and offspring when compared to propofol. Using modified Apgar scoring, Respiratory vitality was found to be better within the first 60 minutes post delivery compared to propofol. Both agents had similar puppy survival rates. Oxygen consumption increases by 20% due to development of the foetus- Shorter maternal recoveries were noted in in the alfaxalone group. In a es, uterus, placenta, and mammary tissue. To meet increased O2 demand, 2016 study alfaxalone was compared as a CRI maintenance agent to iso- both tidal volume and respiratory rate increase resulting in increases in flurane. Bitches in the CRI group recovered more slowly to the isoflurane alveolar ventilation. Due to increases in minute volume, PaCO2 decreases maintenance group and puppy Apgar scores were also lower in the CRI during gestation. Functional residual capacity (FRC) decreases due to group. Induction with either propofol or alfaxalone and maintenance with displacement of the diaphragm. During labour FRC decreases further as an inhalant would be a reasonable protocol. It is optimal to wait at least pulmonary blood volume increases during uterine contraction. Pregnant 10 minutes before surgical delivery to enable foetal concentrations of patients may be more prone to atelectasis. injectable drugs to decrease. Decreased FRC increases risk of hypoventilation and hypoxaemia which Maintenance of general anesthesia is commonly achieved using inhala- may result in foetal hypoxaemia and acidosis. Hypoxaemia can occur tional agents. All inhalational agents produce dose-dependent cardio- rapidly should hypoventilation or apnoea occur. Preoxygenation is recom- vascular and respiratory depression. Isoflurane and sevoflurane are both mended prior to induction. appropriate choices. These agents require minimal hepatic metabolism and renal elimination. The lowest effective concentration should be used Pregnant patients have decreased anaesthetic requirements (25 – 40%) remembering that pregnant patients have significant decreases in MAC due to decreased FRC and the increase in progesterone and endorphin requirement(25 – 40%). levels within the CNS. Anaesthetic overdose is likely unless injectable and inhalant doses are appropriately reduced. Locoregional anaesthetic techniques can be utilised. The use of local anaesthetic techniques will enhance the anaesthesia plan, but care Gastrointestinal must be taken not to delay delivery of neonates once the animal is under anaesthesia. The epidural and CSF space are decreased by 30 - 50% due Decreased progesterone levels, gastric motility and physical displacement to venous engorgement due to increased blood flow. Volumes of drugs of the stomach may result in delayed gastric emptying. Gastric secretions injected epidurally should be decreased. The use of intraoperative opioids are more acidic and lower oesophageal sphincter tone is decreased, and is controversial due to the increased risk of respiratory depression and intragastric pressure increased. Gastric motility is further decreased bradycardia in both dam and foetuses. It is common practice to adminis- during labour. Due to the altered gastric function these patients are at ter opioids once neonates have been delivered. increased risk of regurgitation and aspiration. When undergoing anaes- thesia, the pregnant patient should always be assumed to have food in Patient monitoring should include SpO2, ABP, CO2 and ECG at regular 40 WSAVA GLOBAL COMMUNITY CONGRESS

intervals. Crystalloid fluid therapy is utilised to aid in maintenance of 0017 blood pressure. Due to physical and physiological respiratory changes as- sociated with pregnancy, assisted ventilation may be required to maintain HOW CAN LABORATORY ASSIST FOR DIAGNOSIS, normocapnia. Hypotension should be addressed immediately as it can PROGNOSIS AND MONITORING ONCOLOGIC have serious consequences for the neonate and mother. Fluid boluses, PATIENTS? decreasing inhalant and decreasing anaesthetic depth(if possible) are appropriate. If pharmacologic intervention is required, ephedrine may be S. Comazzi of benefit. Ephedrine produces an increase in venous tone. As ephedrine causes minimal arterial vasoconstriction uterine perfusion is maintained. Lodi/Italy Nor-adrenaline, dopamine or dobutamine are also reasonable choices depending on underlying causes of hypotension. Care should be taken to Qualifications: maintain temperature as hypothermia may increase coagulation time, risk of infection and delay recovery from anaesthesia. Stefano Comazzi Neonatal Resuscitation DVM PhD diplECVCP Neonates delivered by caesarean often show signs of reduced cardio- [email protected] respiratory function. Foetal hypoxia may be due to premature placental Veterinary clinical pathology is the veterinary discipline Veterinary disci- separation, impaired maternal ventilation, drug induced foetal depression, pline focused on laboratory medicine including the laboratory support to or position induced maternal hypotension. Ensuring oxygen supply is all the medical procedures for diagnosis and monitoring treatment and available for resuscitation as well as prewarmed areas to receive the neo- follow-up. The European College of Veterinary Clinical Pathology (ECVCP) nates is essential. Resuscitation of neonates should focus on oxygenation and the equivalent subspeciality of the American College of Veterinary and maintaining temperature. Membranes should be removed quickly, and Pathology (ACVP-ClinPath) identify four disciplines as part of the training fluid cleared from upper airways. Low pressure suctioning, bulb syringes of veterinary clinical pathology. These include general clinical pathology, or cotton tips may be useful for clearing mucous and fluids from the upper hematology, clinical biochemistry/urinalysis, and cytology. The laboratory respiratory tract. Vigorous body rubbing should be used to dry neonates support in the diagnosis and treatment of dogs and cats with tumors has and to stimulate spontaneous respiration. Swinging neonates is not become essential to modern veterinary oncology, similar to what happens recommended due to risk of cerebral contusion and removal of pulmonary in humans. surfactant. Flow-by oxygen should be supplied. If newborns are unrespon- sive and make no attempt to spontaneously breathe, they can be intubated Hematology may help the diagnosis of specific neoplastic diseases, and ventilated. A tight-fitting mask may also be used for positive pressure directly (such as in hematopoietic tumors) or indirectly (such as in ventilation. Naloxone can be administered to antagonise opioid induced paraneoplastic diseases). In addition, it plays an important role to frame respiratory depression(most often administered sublingually). Acupunc- health status, predict response to therapies, and monitor therapies and ture stimulation of GV 26 has also been found to be effective. A slow recurrences. heart rate is most commonly due to myocardial depression from hypoxae- mia, therefore oxygen is extremely important as treatment. If bradycardia Non-regenerative, normocytic normochromic anemia, is the most frequent is unresolved, transthoracic compressions or adrenaline may be indicated. erythrocytic abnormality in animals with cancer. Anemia may be due to Anticholinergic drugs are not recommended as drug induced tachycardia chronic disease (mostly), iron deficiency (due to malabsorption or chronic may worsen myocardial hypoxaemia. Doxapram increases myocardial blood loss), myelophtisis (mainly in leukemias), neoplastic cachexia, or and cerebral oxygen demand so may be detrimental in the presence of occasionally to myelosuppression due to chemotherapy. hypoxaemia. Neonates should always be examined for congenital abnor- malities. Once stable the newborn should be kept warm with a supply of Regenerative anemia may rarely occur as a consequence of paraneoplas- O2 and returned to the dam and encouraged to suckle as soon as possible tic hemolytic anemia (mainly in histiocytic disorders or lymphoma), micro- following delivery. angiopathic anemia (in hemangiosarcoma), or rarely acute post-hemor- rhagic anemia. Recovery In contrast, erythrocytosis is generally very rare and suggest a primary he- Post-operative monitoring should include SpO2, heart rate, respiratory matopoietic disorder (Polycythemia Vera) or secondary polycythemia due rate, and temperature. Supplemental O2 should be provided if required. to renal tumors, lymphoma, hepatic tumors, pulmonary tumors, and others Pain management must follow through the postoperative period. Left untreated, pain can cause negative changes in patient metabolism, Each of these processes shows peculiar hematologic features that may behaviour, and immune system. Failure to adequately address pain may drive the clinicians to a better framing of the clinical case. result in decreasing milk production, interfere with suckling and bonding between dam and offspring. Opioids may be administered but they will Leukogram may show several different abnormalities; among these, neu- be excreted in milk and may have effects on neonates. The practice of trophilia with lefts shift may encounter quite frequently due to inflamma- a single dose of NSAID’s is also considered appropriate. This is usually tion, necrosis, or rarely paraneoplastic neutrophilia (reported in pulmonary administered post operatively and limited to one dose due to potential carcinoma, lymphoma, transitional carcinoma, others) secretion in milk and effects on immature neonatal renal development. The goal should be to discharge these patients as soon as they are stable. Neutrophilia without lefts shift may also occur related to hyperadreno- corticism, steroids therapy (also during chemotherapy), or severe stress References available on request. related to the disease. Neutropenia is quite rare at admission and often related to myelophtysis, bone marrow suppression Immuno-mediated neutropenia. In contrast, neutropenia is an important feature during chemotherapy. It is the first sign of myelosuppression and for this reason, it is carefully evaluated to prevent adverse effects. Nadir is variable for different drugs (5 to 10 dd) followed by a rebound after 2-3 days; a Complete Blood Cell (CBC) count at day 7 is generally 41

13–15 NOVEMBER, 2021 suggested for monitoring. Some drugs (Lomustin, Carboplatin) have also laboratory approach in veterinary practice. a possible secondary nadir at 21dd Immunophenotyping plays an important role in refining the diagnosis of Different protocols have been suggested for treating neutropenia due to several neoplastic diseases by identifying the lineage of the neoplas- chemotherapy: varying from just delayed or discontinued chemotherapy tic cells. Flow cytometry (FC) is the ideal technique to identify cells in to hospitalization and antibiotics in more severe cases. Also, recombinant suspension such as in blood and other body fluids or in round cell tumors G-CSF or GM-CSF may be considered. suspended in liquid media. In comparison with immune histo/cytochem- istry FC is rapid, relatively cheap, and may test a large panel of antibodies Other leukocyte abnormalities found in patients with cancer include thus it is highly preferable in lymphohematopoietic tumors to differenti- 1) lymphocytosis (in lymphoproliferative diseases -CLL, lymphoma) or ate Acute Leukemia vs Chronic Lymphocytic leukemia, Acute Leukemia lymphopenia (due to stress leukogram or steroids administration); 2) vs stage V Lymphoma and Chronic Lymphocytic Leukemia vs reactive eosinophilia (rare – of paraneoplastic origin, reported in T lymphoma, Lymphocytosis, identify lymphoma IP and subtypes and stage canine mast cell tumor, thymoma, mammary carcinoma, transitional carcinoma lymphoma. or eosinopenia (frequent - due to stress leukogram or steroids) and 3) monocytosis (in chronic myelomonocytic leukemia or as a non-specific Other techniques such as immunocytochemistry and cytochemistry may sign in several non-hematopoietic tumors. be used in cases in which a fresh sample for FC is not possible or results are not definitive. The use of leukocyte ratios instead of single direct parameters may increase sensitivity and help to define possible cutoff values of clinical Molecular biology techniques include a wide variety of different tests and utility. However, also variability increased proportionally thus they should techniques that are currently an important part of the diagnostic pathway be used with caution to draw clinical decisions. in human medicine- However, in veterinary medicine, just a few molecular tests are standardized and useful in clinical practice for diagnostic pur- Also, platelets count and parameter, although more influenced by analyt- poses, among which PCR for antigen receptor rearrangements (PARR) and ical variability may provide interesting information: thrombocytosis may the mutation of cKIT genes. PARR may help to differentiate neoplastic vs be found in primary (essential) thrombocytosis, in reactive/Iron deficiency reactive lymphoid expansion while the evaluation of cKIT gene mutation conditions, or as a response to some chemotherapic drugs (vincristine), in mast cell tumors may help to predict more aggressive behavior and while thrombocytopenia is generally related to myelophtisis, consump- support the use of Tyrosine Kinase inhibitors. tion/DIC or myelosuppression due to chemotherapy (about at 10-12 days). Cytology is not a part of this presentation but it plays likely the most Clinical chemistry is generally associated with CBC in the standard important role as the first step to investigate masses in the laboratory approach to the oncologic patient, since it may provide two different kinds approach to veterinary patients with cancer. Diagnostic performances are of important information. The evaluation of organ profiles, although not variable among tumors and localization ranging from high accuracy for specific of neoplastic disease, may help to check health status framing round cell tumors (lymphoma, mastocytoma, plasma cell tumors, etc) to clinical conditions and predict and monitor side effects of therapy (liver low accuracy for mammary tumors, some mesenchymal tumors (osteosar- function/damage for lomustine, L-asparaginase, methotrexate azathio- coma, chondrosarcoma), cutaneous tumors, etc. prine; nephrotoxicity for cisplatin, doxorubicin; heart damage for doxo- rubicin, mitoxantrone or pancreatitis for L-asparaginase, azathioprine, In conclusion, clinical pathology may add important information for the prednisone, methotrexate). diagnosis and management of patients with cancer but a strict interaction between clinicians, clinical pathologists, and pathologists is crucial for In addition, clinical chemistry may also be used in a more specific ap- the correct managing of different neoplastic conditions. proach for the evaluation of tumor markers. These are analytes that have been demonstrated of possible diagnostic use to early detect a specific type of cancer, to monitor remission, or early predict recurrences. They could be grossly divided into 5 different groups: 1) Oncofetal proteins: alpha-fetoprotein, carcinoembryonic antigen (CEA); 2) Hormones: beta chorionic gonadotropin (HCG), parathormone related protein (PTHrp); 3) Serum enzymes: ACP, ALP, LDH; 4) Immunoglobulins; and 5) Specific tumoral antigen: CA-125, CA-15.3, prostate-specific antigen (PSA). Among these detection of hypercalcemia of malignancy (>14-15 mg/dl), due to PTHrp or other cytokines release plays an important role in veter- inary medicine for its emergency. Paraneoplastic Hypercalcemia may be found in several types of cancer among which mediastinal T cell lympho- ma and anal sac apocrine gland adenocarcinoma are the most frequent. Monoclonal hyperglobulinemia and or Bence Jones proteinuria may be important specific signs of multiple myeloma, lymphoma, or other plasma cell tumor Lactate dehydrogenase (LDH) activity is generally used in monitoring canine lymphoma as an early predictor of relapse at the end of chemo- therapy but may be also found elevated in metastatic mammary tumors and in non-neoplastic conditions such as hepatic and muscle damage and hemolysis. Other markers such as acute phase proteins, thymidine kinase, alpha-fe- toprotein, carcinoembryonic antigen, and CA-15.3 have been suggested for a possible role in monitoring lymphoma, hepatic and mammary tumors and recurrences but they have currently found a limited diffusion in the 42 WSAVA GLOBAL COMMUNITY CONGRESS

0018 non-resident cells; 7) hematological and disease diagnosis (in light of the CBC), and 8) comments on possible adjunctive tests and current literature BONE MARROW CYTOLOGY: WHY, WHEN AND references. HOW? S. Comazzi Lodi/Italy Qualifications: Stefano Comazzi DVM PhD dipl ECVCP [email protected] The evaluation of bone marrow (BM) is an important exam for clarifying hematological disorders but it should be always considered in conjunction with the results coming from the complete blood cells analysis. In fact, similar bone marrow aspects may be associated with different circulating pathways and this may drive to a different diagnosis of the disease. BM is a tissue committed to the production of all blood cells and it is composed of hematopoietic cells of different lineages supported by a stromal component that provides support and creates the microenvironment for cell growth. In young animals, the hematopoietic BM (red) is located in all bone cavities, but during growing it is slowly substituted by fat, thus trans- forming into yellow inactive BM. In adults, red BM remains in vertebral bodies, flat bones (pelvis, scapula, ribs), sternum and in the proximal parts of femur and humerus. Among these localizations, the iliac crest and the proximal part of long bones are the most diffusely used for sampling BM. Two different samples may be obtained: BM aspirate/medullary blood for cytological examination and histological (Trephine) core biopsy. BM cytol- ogy has many advantages over histology since morphology is much easier to be evaluated and sampling procedures are easier thus it rarely requires sedation. Among cytological samples, medullary blood has the advantage of providing highly cellular samples potentially also useful for further ancillary techniques such as flow cytometry and PCR tests although the abundant hemodilution may partly mask morphology of hematopoietic cells. In contrast, core biopsy is more accurate to detect cellularity and myelofibrosis. BM evaluation is suggested when some hematological abnormalities (non-regenerative anemia, cytopenias, abnormal circulating cells, or unexplained persistent thrombocytosis or leukocytosis) are de- tected or when some pathogens (Leishmania, Ehrlichia, Histoplasma, etc) are searched or when radiographic or clinical pathological signs suggest a possible medullary disease (multiple myeloma, leukemia, osteomyelitis). Finally, BM evaluation is often performed to check infiltration from tumors such as lymphoma and mast cell tumors. In contrast, BM examination should be considered with caution when severe coagulopathy or anemia are present (mainly if sedation is required) or in case of regenerative anemia or severe neutrophilia in which bone marrow will likely add just minimal information. Bone marrow examination may provide several different information and should evaluate cellularity, myeloid/erythroid ratio, maturation of 3 main lineages (granulocytes, erythrocytes, and megakaryocytes), the percent- age of blasts, signs of dysplasia, and the possible presence of other cells, including neoplastic ones. Evaluation of cellularity is better performed via histology but cytology may estimate cellularity by comparing the ratio be- tween hematopoietic and adipose tissue in marrow particles. The evalua- tion of the M/E ratio and maturation of different lineages may require well- trained clinical pathologists and a comprehensive evaluation of medullary cytology in the context of peripheral blood results. If necessary, differen- tial bone marrow count may be obtained by microscopic evaluation but it is time-consuming and should be limited to the training phases or to solve particularly challenging diseases. An adequate report should include the following information: 1) quality of the sample; 2) cellularity estimation; 3) M/E ratio; 4) description of three main lineages: presence, differentiation/ maturation, % of blasts, dysplastic signs; 5) other resident cells (macro- phages, plasma cells, osteoclasts, lymphocytes, mastocytes,…); 6) other 43

13–15 NOVEMBER, 2021 0019 Periodontium consists of alveolar bone, periodontal ligament, cementum and gingiva [2]. It surrounds and supports the tooth. Alveolar bone is the PERIODONTAL DISEASE AND THERAPY socket part of the mandible and maxilla in which the teeth are embedded. C. Wickramasinghe1,2 Cementum is a hard tissue that covers the root of the teeth. Periodontal ligament lies in between these two. The space between the tooth and 1Colombo ,/Sri Lanka, 2Colombo/Sri Lanka gingiva is gingival sulcus, of which the normal depth is less than 3 mm for dogs and less than 1 mm for cats. Qualifications: Periodontal disease Wickramasinghe Arachchige Don Chandika Hiroshan Wickramasinghe Periodontal disease is the inflammation of the structures of the periodon- tium. This is characterized by inflammation, apical migration of epithelial BVSc, MSc, MSLCVS attachment and bone loss [1]. This is an infectious disease caused by plaque bacteria and the resulting inflammatory response caused by [email protected] cytokines etc. Periodontal disease is progressive [3] if not treated, and PERIODONTAL DISEASE AND THERAPY essentially irreversible [3],[4] if guided tissue regeneration techniquehs are not used. [2] Pet Vet Animal Hospital, 155, Kirula Road, Colombo 05, Sri Lanka. As the disease process advances, gingival sulcus depth increases, and Chandika Wickramasinghe, BVSc, MSc, MSLCVS there will be permanent damages to the periodontal ligament, cementum and alveolar bones, ultimately resulting in tooth loss, and even progress- [email protected] ing to such advanced oral diseases like oronasal fistula, mandibular frac- tures etc. Bacterimia leads to disease processes in vital organs like liver, Introduction heart, kidneys etc. Chronic pain is also an important factor affecting the quality of life. Periodontal disease can also lead to endodontic disease Historically, veterinary dental issues were considered an old or senior pa- when periodontitis reaches the apex of the root of a tooth [5]. Indices tient disease. However, oral issues are one of the most under diagnosed like gingivitis index, furcation index, probe depth, mobility index, plaque conditions in pet animals. Chronic periodontitis is an extremely common index, calculus index etc. are useful in establishing the overall periodontal problem in dogs and cats [2]. The majority of animals over the age of disease grade of a patient. three years have a degree of periodontal disease that warrants treatment [1]. By the age of 3 years, 90% of dogs and 70% cats suffer from some Clinical Manifestations sort of oral issues. Dental issues can be more prominent in small breed and brachycephalic dogs due to crowding of teeth. Clinical features of periodontal disease include gingivitis, gingival bleed- ing, halitosis, drooling, plaque and calculus, gingival recession, furcation Food particles get mixed with bacteria and salivary components to form exposure etc. These can lead to behavioral manifestations like acting the plaque on teeth. These bacteria are one of the main causes of oral withdrawn or aggressive, chewing differently, reluctance to play with health issues; particularly periodontal disease. Plaque gets stabilized, chew-toys, not allowing brushing teeth or toughing lips/teeth etc. due to usually within 3-5 days. Once stabilized, this is called tartar/cement and it pain [4]. cannot be removed by regular brushing. That is why daily tooth-brushing is of paramount importance to maintain the optimal oral health. Periodontium: Anatomy Diagnosis Signalment and proper history/complaint will provide very useful infor- mation. Then, external orofacial examination and conscious oral cavity examination needs to be performed. Finally, under anesthesia visual examination, probing and dental radiographs have to be done. Diagnosis must be established using a combination of oral examination under anes- thesia and dental radiography [3]. Table 01: Grading of Periodontitis Grade Plaque and Gum Health Radiologic Other Calculus Changes No Furcation/ I Mild amount of Mild Redness No Change Mobility, Estab- Plaque lished Gingivitis, Reversible II Subgingival Redness and Upto 25% Support Early Periodonti- Plaque Oedema Loss tis, Irreversible III Subgingival Redness, Oedema, 25 to 50% support Established Calculus Gums bleed with loss Periodontitis, gentle probing, Irreversible, Furca- Gum recession or tion II/III hyperplasia 44 WSAVA GLOBAL COMMUNITY CONGRESS

Severe inflamma- 0020 tion, Gum reces- IV Large amounts sion, Pus, Gums Over 50% support Severe, advanced PAIN MANAGEMENT FOR CANINE AND FELINE of subingival bleed easily, Deep loss Periodontitis, DENTAL PATIENTS calculus pockets Irreverble, Furca- tion III B. Ong Treatment Serdang/Malaysia Treatment depends on the periodontal disease grade and the specific Qualifications: findings. For initial stages, supra-gingival scaling (removal of plaque and calculus above the gingival margin [1]) and polishing (smoothing the Full name: Benedict Ong Huai Ern roughness caused by scaling and removing any remaining plaque and Qualifications: Doctor of Veterinary Medicine (DVM), Master of Veterinary stained particles [1]) under GA would be sufficient. Moderate periodon- Medicine (MVM), Doctor of Philosophy (Ph.D.) titis needs sub-gingival scaling and root planning (SRP), together with Email: [email protected] long acting topical antibiotic preparations to stop further damage. Root planning is the removal of the superficial layer of toxin laden cementum- WHY PAIN MANAGEMENT IS RELEVANT IN EVERY PRACTICE? from the root surface [1]. This produces smooth root surface, reducing accumulation of plaque, and also increasing epithelial re-attachment. Dental pain can be excruciating especially when it is undertreated in Shallow periodontal pockets are treated in a closed fashion, but pockets > canine and feline patients. As many of the patients who undergo the 6 mm deep require flap surgery to expose root surface to ensure adequate dental procedure are geriatric patients, they often have other co-existing cleaning.[2][5] Guided tissue regeneration techniques/bone grafts etc. can diseases such as renal and cardiac diseases and have high anesthetic reverse the bone loss at moderate levels of periodontitis. Advanced peri- risk. With proper pain management, the requirement of general anesthesia odontal disease stages with > 50% attachment loss needs extraction of could be reduced, which minimizes the cardiovascular and respiratory the affected teeth as corrective measures. Systemic antibiotics (that act depression secondary to general anesthesia. Post-operatively, the patients against Gram negative anaerobic bacteria) such as clindamycin, Augmen- with less general anesthesia requirement will have a shorter recovery time tin, metronidazole, doxycycline, azithromycin etc. may also be used when from general anesthesia. As the dental pain is alleviated, they will have a necessary. Moreover, complicated pathology like mandibular fractures, better appetite and smoother recovery. oronasal fistulae etc. need their specific corrective surgical procedures. Prevention/Management MULTIMODAL ANALGESIA FOR DENTAL PATIENT Prevention of supra-gingival and sub-gingival plaque accumulation is The mainstay of dental pain management for the canine and feline the baseline [5]. The benefit of any professional periodontal therapy is species is opioid, dental nerve block, and non-steroidal anti-inflamma- short-lived unless maintained by effective homecare [1]. This will also tory drugs (NSAIDs). The multimodal analgesia approach is preferably reduce the need for frequent professional scaling and polishing. Proper employed because it requires a lower dosage of multiple analgesic drugs, client education is a key factor here. Education of all the staff members of which results in fewer adverse effects. Different analgesic agents act at veterinary practices too is of paramount importance. the different sites of the pain transmission pathway. For example, NSAIDs reduce nociceptor sensitization during dental extraction by reducing References inflammation around the affected areas; regional anesthesia blocks the transmission of pain impulses along the nerves from the nociceptor to the • Crossley DA, Penman S. BSAVA Manual of Small Animal Dentistry. brain stem; whereas a full mu-opioid agonist binds to the receptor at the 2nd Edition. BSAVA, UK. 1995. spinal cord and brain which inhibits pain modulation and perception. • Niemiec BA. Small Animal Dental, Oral and Maxillofacial Disease. Taylor OPIOID & NON-STEROIDAL ANTI-INFLAMMATORY DRUGS & Francis Group, Boca Raton, FL. 2012. In dogs, full mu-opioid agonists (for example, morphine and fentanyl) are • Perry R, Tutt C. Periodontal disease in cats: Back to basics--with an eye commonly used for moderate to severe pain such as dental pain. The pos- on the future. J. Feline Med. Surg. 2015. PubMed. sible adverse effects of administrating morphine before the anesthesia induction is nausea and vomiting in dogs. Therefore, it is recommended 4. https://www.smalldoorvet.com/learning-center/medical/periodon- to administer morphine intramuscularly after induction and intubation, tal-disease-in-dogs before the dental procedure in dogs. A full mu-opioid agonist may cause dysphoria and hyperthermia in cats. However, such concern should not 5. https://www.msdvetmanual.com/digestive-system/dentistry/periodon- impede the use of opioids in the pain management of the feline species, tal-disease-in-small-animals#v3261247 because the high effectiveness of opioids outweighs the adverse effect of poor pain management. Non-steroidal inflammatory drugs (NSAIDs) are added to complement the pain management quality for a dental procedure and have anti-inflamma- tory properties. However, it is important to assess the patient’s condition before administering NSAIDs to ensure the patient is well-hydrated, normotensive, has no coagulopathy, and has no unstable kidney disease. If it is administered pre-operatively, blood pressure must be monitored throughout the anesthesia procedure to ensure that it is normotensive. For patients that are prone to hypotension secondary to general anesthesia, the author prefers to administer NSAIDs after the general anesthesia is discontinued. 45

13–15 NOVEMBER, 2021 DENTAL NERVE BLOCK the nerves supplying to the ipsilateral lower incisor and canine teeth. The whole length of the 26 G IV catheter should be inserted caudally at the The dental nerve block is the most important and effective element in pain ventral one-third of the lower gum. The mental nerve block can block the management for canine and feline dental patients. The most efficient and incisor tooth and canine teeth of the ipsilateral mandible side. easiest dental nerve blocks are the infraorbital nerve block and mental nerve block. This is because the targetted nerves for these two dental Fig 2: Mental nerve block in dogs: The tip of the lower canine tooth root blocks run through the canal of the foramen which is easily located. By (dotted line) points to the mental foramen. inserting a needle and administering the local anesthetic agent into the foramen, these nerves will be blocked completely by the spread of the CAUDAL MANDIBULAR NERVE BLOCK local anesthetic agent in the canal. To ease the effort of performing dental The caudal mandibular nerve block is relatively difficult to locate the nerve nerve blocks among the general practitioners, the author recommends as the nerve is running between the soft tissue/muscle and bone. First, some landmarks that are easy to recognize and can be applied in the extra-orally, use a finger to feel the angular process of the mandible (the same way in canine and feline patients. Aspiration should be made before ventral angle of the mandible). Then, intraorally, use another finger to feel injection to ensure the local anesthetic agent does not enter the blood- the dorsal angle of the mandible, caudal to the last molar teeth. Subse- stream, and injection should be smooth to ensure the local anesthetic quently, insert a 22 G intravenous catheter stylet (in dogs) or 24 G hypo- solution is not injected into the nerve. The author prefers to use bupiva- dermic needle (in cats) extra-orally from the angular process (blue cross) caine 0.5% because the duration of analgesia of bupivacaine can last up to the dorsal angle(yellow cross) (Fig 3). The needle should be aimed to 4-6 hours. towards the medial side of the mandible. The target of the block is at the midpoint of the imaginary line drawn between the angular process and the INFRAORBITAL NERVE BLOCK dorsal angle. Slowly withdraw the needle back to the angular process from the dorsal angle of the mandible, and make a line block from the dorsal The infraorbital nerve block is the easiest to be performed as the foramen angle to the angular process. This nerve block can block all teeth at the is relatively larger compared to the mental foramen. The author prefers to ipsilateral mandibular side. use a 24 G intravenous (IV) catheter to insert into the infraorbital foramen, as the tip of the catheter is blunt and can reach the caudal end of the in- fraorbital canal, allowing it to block teeth at the caudal maxillary region. In dolichocephalic and mesocephalic dog breeds, the infraorbital nerve block can block the nerve supply to the incisor, canine, and first, second, and third premolar teeth. In brachycephalic dog breeds and cats, infraorbital nerve block using an IV catheter can block the nerve supply to all teeth at the ipsilateral side of the maxilla. The landmark of the infraorbital foramen is between the smaller maxillary premolar teeth (third premolar teeth) and the larger maxillary premolar teeth (fourth premolar teeth). The needle should be directed parallel to the maxilla and inserted at the dorsal one- third of the gum. Once the whole length of 24 G IV catheter is inserted into the foramen, the foramen should be pressed with a finger during injection to ensure the local anesthetic solution can spread to the caudal site of the infraorbital canal. Fig 3: Caudal mandibular nerve block in dogs: make a line block from the dorsal angle (yellow cross) to the angular process (blue cross). Fig 1: Infraorbital nerve block in dogs: 24 G IV catheter is inserted into the POST-OPERATIVE PAIN ASSESSMENT infraorbital foramen located dorsal to the intersection between smaller pre-molar teeth (red outline) and larger pre-molar teeth (purple outline). Post-operatively, pain assessment should be conducted to assess the adequacy of the pain management. The Feline Grimace Scale is a simple MENTAL NERVE BLOCK and practical tool to assess pain in a cat. The assessment of the pain score is based on five action units of the facial expression of the cat: The mental nerve block is the second easiest nerve block to be per- ear position, orbital tightening, muzzle tension, whiskers change, and formed. However, the diameter of the mental foramen is much smaller head position. The assessment has been validated to be used for pain than the infraorbital foramen. Therefore, the author prefers to insert a assessment in cat patients undergoing dental procedures. In dog patients, 26 G hypodermic needle into the cat’s mental foramen or a 24 G intrave- Glasglow Composite Pain Scale and Colorado Canine Acute Pain Scales nous (IV) catheter into the dog’s mental foramen. The landmark to locate can be used to assess the patient after the dental procedure. These tools the mental foramen is to locate the tip of the canine tooth root which is assess pain based on the changes in the behavior of the dog patient after pointing towards the mental foramen. The mental nerve block can block the procedure. Good pre-operative and intra-operative pain management is more effective in treating pain when compared to relying on post-opera- tive pain management alone. In conclusion, effective pain management for dental patients will provide better hemodynamic stability during general anesthesia, promote better appetite after the procedure, and attain smoother recovery. 46 WSAVA GLOBAL COMMUNITY CONGRESS

References: 0021 Rochette J. (2001). Local Anesthetic Nerve Blocks and Oral Analgesia. THE CRITICAL ROLE OF PRIVATE AND PUBLIC World Small Animal Veterinary Association World Congress Proceedings. VETERINARIANS IN RABIES ELIMINATION Niemiec B., Gawor J., Nemec A., Clarke D., McLeod K., Tutt C., Gioso M., T. Scott1, A. Coetzer2, L. Nel2 Steagall P. V., Chandler M., Morgenegg G., Jouppi R. (2020). World Small Animal Veterinary Association Global Dental Guidelines. Journal of Small 1Luxembourg/Luxembourg, 2Pretoria/South Africa Animal Practice 61 (7): 395-403. Qualifications: O’ Morrow C. (2010). Advanced Dental Local Nerve Block Anesthesia. Veterinary Dentistry. 51: 1411- 1415. Dr. Terence Peter Scott Woodward T. M. (2008). Pain Management and Regional Anesthesia for PhD Microbiology (Virology; Rabies) the Dental Patient. Top Companion Anim. Med.23 (2): 106-114. [email protected] Considering the zoonotic nature of rabies – a fatal encephalitic disease affecting all mammals – the role of the veterinary and animal health sector in controlling and eliminating the disease is critical. It is widely accepted that the only practical and feasible means to achieve dog rabies elimination is through targeted and sustained mass dog vaccination of at-risk dog populations. While the global goal for the elimination of dog-mediated human rabies cases by 2030 - accounting for 99% of all human rabies deaths globally – focuses on the human aspect of rabies, this goal remains an intermediary target towards the eventual elimination of dog-mediated rabies globally. While the public health impact of rabies is typically used to advocate for support – in particular to political stake- holders and communities – the challenge lies primarily with the control and elimination of the disease in animal populations. Thus, the role of both private and government veterinary practitioners is key to achieving rabies elimination. To achieve success, a combined approach towards controlling and eliminating rabies is required. Such an approach requires the combination of efforts towards vaccinating the at-risk dog population, educating com- munities and professionals about the dangers of the disease, preventative measures and responsible dog ownership, surveillance, and the provision of pre- and post-exposure prophylactic treatment to at-risk individuals, including veterinary practitioners. While many of these activities should be shared among sectors and stakeholders, veterinarians and their colleagues working in animal health are typically expected to contribute to many of these aspects. Of these various activities, the vaccination of dogs against rabies is the principal, and most important, role of veterinarians towards achieving rabies elimination. Considering the differing roles between private and government veterinarians, this role usually differs slightly with some overlap being evident. The roles of the private and government veterinar- ians also have more impact and influence on rabies control, elimination, or prevention, depending on whether the country in which they practice is dog-rabies endemic or dog-rabies free. For those dog-rabies free countries, the private practitioners typically play an important role in terms of ensuring the maintenance of a suitable vaccination coverage in the owned, confined dog population, considering that confined dog populations are more prevalent in dog-rabies free countries. Government veterinarians respond to potential outbreaks from re-introductions or spillover events and maintain vigilance at borders and ports of entry to en- sure that any animals entering from rabies-endemic countries are healthy and have adhered to the appropriate regulations, including vaccination against rabies1. Mass dog vaccination (MDV) campaigns are not required in dog-rabies free countries as the focus lies with the maintenance of the rabies-free status through the prevention of re-introduction, and the rapid response to introduced rabies cases to eliminate any potential infection and spread in the local population. This is also applicable to the introduc- tion of rabies from wildlife reservoirs, including both terrestrial reservoirs such as Raccoon dogs (as is the present concern in eastern Europe), raccoons and skunks in North America and the introduction of rabies or 47

13–15 NOVEMBER, 2021 rabies-related lyssaviruses from bats. Conversely, in dog-rabies endemic for rabies surveillance to ensure that an adequate surveillance network is countries government veterinarians have the responsibility to organize, established and functioning. direct, and implement MDV programs aimed at achieving a 70% vaccina- tion coverage in the at-risk dog population. This at-risk target population While the primary role of both private and government veterinarians re- is typically free roaming dogs, and thus, not the target market for private mains clear – the need for continued and sustained vaccination of at-risk veterinarians. However, by engaging the community and vaccinating/ dog populations – there are multiple other critical activities that these pro- sterilizing free roaming dogs (some being owned and others ownerless) fessionals play in the efforts to control and eliminate rabies. While these community trust can be built, and a better understanding of the benefits of activities contribute to an increased workload on an already overburdened veterinary intervention can be developed. By building trust and concurrent- profession, the benefits – both in terms of reducing future workload, as ly educating the community about aspects of responsible dog ownership, well as the financial benefits - of these activities outweigh the demands, owners who left their dogs to roam may become more engaged with as countries progress towards achieving dog rabies elimination. their dog and confine, or partially confine, their animal to their property. With this improved community trust and responsible dog ownership, dog References: owners are more likely to consent to medical advice and examination from veterinary practitioners and be more likely to bring their pets for future 1. Vega S, Lorenzo-Rebenaque L, Marin C, Domingo R, Fariñas F. consultation – particularly in those areas where there may be miscon- Tackling the Threat of Rabies Reintroduction in Europe. Front Vet Sci. ceptions about veterinary practice or animal diseases like rabies, canine 2021;7:613712. doi:10.3389/fvets.2020.613712 distemper, and others. Furthermore, owners may be more likely to be able to handle their animal after building a relationship with their dog, based on the education and awareness information shared by the veterinarian. This has a knock-on benefit, by reducing the number of free roaming dogs (thus reducing the workload for government veterinarians) and building a customer-base for private practitioners. Thus, while there is often friction between government veterinarians and private practitioners, the goal to eliminate dog-mediated rabies should remain the same, as this is clearly beneficial to both parties. While MDV remains critical to the success of rabies elimination and is the most important role of both private and government veterinarians in rabies endemic countries, education, community sensitization, and awareness are all essential aspects that support, and contribute towards, the success of MDV campaigns. In dog rabies-free countries, community sensitization and awareness remain essential to maintaining vigilance and freedom from the disease, especially in those countries where wildlife vectors (including rabies-related lyssaviruses in bats) exist. It is essential that the public are aware of the steps needed in the case of an exposure, that they continue to ensure that their dogs are vaccinated, and that dog adoptions and rescues from other countries must adhere to the appro- priate regulations before import. Maintaining a herd immunity in the dog population is challenging when the risk appears insignificant but is es- sential to ensure the continued safety of both the local human and animal populations, including wildlife and endangered species that may be placed at-risk with the re-introduction of the disease. Education helps communities to better understand the disease, the risks that it poses, the means of disease transmission, and the means by which the disease can be prevented. Therefore, education helps to address vaccination hesitancy and myths and misconceptions about both the disease and the preventative measures. Thus, education is required in both rabies-free and rabies-endemic countries to ensure that a suitable protective vaccination coverage is achieved and that owners are guided towards best practice and responsible dog ownership. The devastating ef- fects of fake news, myths, and vaccine hesitancy have been evident in the current COVID-19 pandemic and have also resulted in the re-emergence of preventable diseases such as measles. Similarly, for rabies, vaccine hesitancy arises due to various myths and misconceptions and need to be addressed through effective education interventions. Lastly, veterinarians must contribute to reliable rabies surveillance to en- sure that cases are detected and reported, and that adequate vaccination coverage is achieved or maintained. This includes reporting of suspect and probable cases of rabies, as well as the submission of samples to lab- oratories for diagnosis. In particular, the adequate tracking and reporting of vaccinations is often neglected, resulting in a lack of understanding of areas requiring further vaccination to achieve the required coverage for rabies elimination. Both private and government veterinarians are critical 48 WSAVA GLOBAL COMMUNITY CONGRESS

0022 collecting and sharing data with stakeholders outside of a specific sector is essential. While many countries have surveillance systems that collect RABIES AND MHEALTH: YOUR ROLE IN RABIES rabies data (to varying degrees of complexity and completeness) within SURVEILLANCE both the human health and animal health sectors, it is often the case that this data is not shared. As a result, the information relating to the T. Scott1, A. Coetzer2, L. Nel2 burden of the disease and progress made towards elimination can be incongruent or inconsistent, especially when analyzing data reported to 1Luxembourg/Luxembourg, 2Pretoria/South Africa international agencies such as the OIE and WHO3. Therefore, for rabies, there is a clear need for coordinated One Health surveillance systems that Qualifications: use robust data capture methods, real-time analysis, and have easy and reliable means to share or report data. These surveillance systems should Dr. Terence Peter Scott not only include data collection from governmental efforts but should also include data from the non-governmental partners who may contrib- PhD Microbiology (Virology; Rabies) ute towards rabies elimination efforts, including civil society and private practice veterinarians. [email protected] Rabies is a disease that is fatal, yet entirely preventable. Despite the In response to this need, the Global Alliance for Rabies Control (GARC) ability and knowledge to control and eliminate the disease through the developed the Rabies Epidemiological Bulletin (REB) in 20164. The REB availability of effective vaccines for both human and animals, the disease is a health information system that coordinates and integrates data continues to kill tens of thousands of individuals every year. Only recently from both the human and animal health sectors into a single system for has rabies been recognized by the World Health Organization as a Ne- accurate, timely, and meaningful rabies surveillance. It is based on the glected Tropical Disease (NTD) and is also the only vaccine-preventable DHIS2 (District Health Information System 2) platform, an open-source NTD. Thus, the case for the elimination of rabies should be strong, as program that is widely used in developing countries globally. The REB is elimination is possible and has been demonstrated in both the developed an overarching rabies surveillance system that is comprised of multiple and developing world. Therefore, it begs the questions as to why rabies tools for high-resolution data collection and automatic analysis. These has not been prioritized by governments and stakeholders for elimination. individual tools within the system are specialized for particular tasks and surveillance needs but all contribute to data collection and analysis in the The perpetuation of neglect for rabies can be traced back to various system as a whole. The creation of multiple specialized tools ensures that factors, including a lack of advocacy and political will to drive rabies data collection remains simple and rapid, removing the need for the user elimination efforts. However, the lack of awareness is not based on in the field to filter or sort through multiple datasets. apathy towards a fatal, yet preventable zoonotic disease, but can rather be attributed to the lack of evidence towards the seriousness and burden that The REB presently comprises of 6 individual tools. Importantly, these the disease presents to both human and animal health. With unreliable tools work synchronously, ensuring that the data collected using one or limited burden data, the true disease situation remains unclear, and tool contributes to the data analysis from another tool. Furthermore, the the seriousness of the disease is not conveyed to the relevant stake- tools also increase in complexity, and can be implemented based on the holders. Due to the lack of data, the case cannot effectively be made available capacity within the country or project site. Therefore, in areas at to stakeholders who control the access to the funding and resources early stages of rabies elimination interventions, or those with extremely needed for the elimination of the disease. Finally, because of the lack of limited resources and capacity, the foundational surveillance tools can funding and resources, programmatic implementation (including effective be implemented, such as tracking mass dog vaccinations. Once capacity data collection and analysis) remains poor. This perpetuates the cycle builds and more resources become available, more complex surveillance of neglect, ensuring that NTDs like rabies remain under-prioritized and methodologies can be implemented through their supporting tool, such under-resourced 1,2. as the more resource-intensive Integrated Bite Case Management. Most critically, the data collected using the foundational tools is the same data As improved programmatic implementation is challenging without used in the more complex programs, resulting in a graduated approach to additional resources and funding, coupled with the fact that resourcing a compatible and comprehensive rabies surveillance system. programs is typically based on results and impact, the most feasible means to break this perpetuating cycle of neglect is through improved One of the foundational, yet most important, tools available on the REB data collection, analysis, and reporting. While data collection is under- is the Rabies Vaccination Tracker (RVT)5,6. This tool facilitates data taken in many countries and in many programs, it is often the case that collection through a mobile phone application, ensuring that every dog the analysis and use of the data remains lacking. This can be attributed vaccinated against rabies is tracked and the pertinent data collected. to various challenges or limitations within the program, including a lack Importantly, the tool has been developed so that data collection is rapid of skilled personnel capable of analyzing the data, limited capacity of the and simple, resulting in the user (the vaccinator) being able to collect the personnel or department responsible for data analysis (considering that data during the vaccination process. Data collection takes no more than these departments are typically responsible for the analysis of multiple 5-7 seconds per animal, thus not hindering the vaccinator’s capacity to health datasets), and poor/inconsistent data collection. In addition, in vaccinate more animals. The critical impact of this vaccination tracker those instances where the data is captured and analyzed, the time taken app ensures that vaccination coverage can be determined and missed ar- to complete this process and share the results with the relevant author- eas - or those where vaccination coverage is insufficient - can be identified ities is often too lengthy for stakeholders to make any informed deci- and targeted. Because data analysis is near real-time, analyses can be sions, thus hindering the potential for any outbreak response or reactive undertaken hourly or daily, ensuring that mass dog vaccination campaigns measures to control and eliminate rabies. Therefore, there is a need for remain targeted and efficient. improved mechanisms for data collection, analysis, and timely reporting that ensures that decision-makers have the most up-to-date data available The capture, analysis and sharing of dog vaccination data is important in an easily understandable and usable format that allows them to effec- for all partners involved in rabies control and elimination. Government tively react to the programmatic needs for rabies elimination. veterinarians and those working in mass dog vaccination campaigns in dog-rabies endemic countries clearly benefit from the use of this tool Considering the zoonotic nature of rabies and the need for a concerted as they typically focus on free-roaming dogs that are often ownerless. One Health approach to achieve rabies elimination, the importance of On the other hand, private veterinarians typically contribute towards 49

13–15 NOVEMBER, 2021 the vaccination of owned (and mostly confined) animals, yet this data 0023 is seldom collected and rarely contributes to the overall vaccination coverage achieved, despite the number of animals vaccinated often being E-LEARNING FOR PROFESSIONALS: RABIES of significant proportion. Therefore, GARC has made the mobile phone ap- CERTIFICATION COURSES plication and vaccination tracking tool available to any interested person, free of charge. The aim is to encourage improved data collection across A. Coetzer1, T. Scott2, L. Nel1 sectors, including the private sector and civil society, and to use the data to generate a clear and complete analysis of the true rabies situation and 1Pretoria/South Africa, 2Luxembourg/Luxembourg intervention efforts in the country, from both confined and free-roaming animals. Qualifications: With accurate data collected in a cohesive and comprehensive manner, Andre Coetzer the cycle of neglect can be broken, ensuring that rabies control and elimination efforts are well resourced and prioritized. To achieve this, PhD, Microbiology we encourage the use of the free mobile phone application and tools avail- able through the Rabies Epidemiological Bulletin for any person interested [email protected] in supporting rabies surveillance efforts in their country – whether as a Enhanced public awareness and responsible pet ownership has been private practitioner or during a mass dog vaccination campaign. identified as two of the key factors that need to be addressed in order to successfully control and eliminate rabies1. Published literature focusing References: on the benefit of increased public awareness with regards to rabies and its prevention has showcased the benefit of these educational activities, with 1. Nel LH. Factors Impacting the Control of Rabies. Microbiol Spectr. studies reporting on increased animal welfare2, increased post-exposure 2013;1(2):1-12. doi:10.1128/microbiolspec.OH-0006-2012.f1 prophylaxis (PEP) compliance3, decreased bite cases4, and increased vaccination coverage5. 2. Minghui R, Stone M, Semedo MH, Nel L. New global strategic plan to eliminate dog-mediated rabies by 2030. Lancet Glob Heal. Despite the clear benefit associated with increased public awareness, 2018;6(8):e828-e829. doi:10.1016/S2214-109X(18)30302-4 global educational initiatives are often not comprehensive enough, with various Knowledge, Attitude, and Practices (KAP) studies reporting on 3. Nel LH. Discrepancies in data reporting for rabies, Africa. Emerg Infect people with a sub-optimal level of understanding about rabies and its Dis. 2013;19(4):529-533. prevention6,7. In response, the Global Alliance for Rabies Control, in collaboration with the Partners of Rabies Prevention (PRP), developed an 4. Scott TP, Coetzer A, Fahrion AS, Nel LH. Addressing the disconnect be- online education platform (termed the GARC Education Platform (GEP)) tween the estimated, reported, and true rabies data: The development of a where interested parties could gain free access to the most up-to-date regional African Rabies Bulletin. Front Vet Sci. 2017;4(FEB). doi:10.3389/ and correct information about rabies and its prevention through four fvets.2017.00018 established essential courses – each addressing a specific educational need in the realm of rabies control8 (Figure 1). The courses are structured 5. Coetzer A, Scott TP, Noor K, Gwenhure LF, Nel LH. A Novel Integrated as dynamic step by step self-learning programs and each course has a and Labile eHealth System for Monitoring Dog Rabies Vaccination Cam- final assessment which, upon mastering, the participant is rewarded with paigns. Vaccines. 2019;7(3):108. doi:10.3390/vaccines7030108 an official certificate as evidence of the specific achievement. 6. Athingo R, Tenzin T, Coetzer A, et al. Application of the GARC Data Logger—a custom-developed data collection device—to capture and monitor mass dog vaccination campaigns in Namibia. PLoS Negl Trop Dis. 2020;14(12):e0008948. doi:10.1371/journal.pntd.0008948 Figure 1. Overview of the courses available on the GARC Education Platform The first essential course of the GEP is the Rabies Educator Certificate (REC), which was developed to help meet the need to effectively dissemi- nate accurate, life-saving information about rabies to at-risk communities throughout the world. The REC course is open to any interested partic- ipant, but is aimed specifically at people who work regularly in at-risk 50 WSAVA GLOBAL COMMUNITY CONGRESS