WSAVA Nov 2021 Proceedings

VetStarchÔ. When dealing with normovolemic hypotensive patients colloid illness. When a sick patient arrives to the hospital, consider not only their therapy becomes more common. Patients that are hypoproteinemic may time in the hospital, but how long the patient has gone without proper also be on colloid therapy as a way to decrease edema. Colloids are not nutrition before arriving to veterinary care. All body systems rely on nutri- a benign drug, and research from human medicine has introduced doubt tion to function, and more importantly to heal, leading to the conclusion into their use in critically ill patients as their use has been linked to kidney that nutrition is a vital parameter that should be monitored and addressed injury. They still have a place in veterinary critical care medicine, but with each patient. Feeding the gut is vital. Without food in the gut, the should not be introduced without appropriate thought. top layers of epithelial cells, as well as the microvilli, will begin to die off. Enterocytes need food in order to maintain the tight junctions between With some patients, their hypotension is not caused by a loss of fluid or each cell, thus keeping gut bacteria where it belongs. Without food, per- blood, but by systemic illness. Inflammation causes hormone release that meability increases, bacterial translocation may occur, and inflammation leads to vasodilation and hypotension. Septic patients can be hypotensive occurs. Providing enteral nutrition is more cost effective, less technically and normovolemic, and correcting their hypotension with fluid challeng- challenging, and better overall for the health of the intestines. es can be detrimental to their recovery. SIRS, anaphylaxis, and cardiac disease patients can present the same challenge when treating their hypo- Veterinary technicians must also be comfortable caring for various tubes tension. Continue to treat the underlying disease cause, but fluid therapy such as multi-lumen central lines, nasogastric feeding tubes, nasal oxygen alone will not correct hypotension in these patients. In these situations, cannulas, urinary catheters, and Jackson-Pratt drains. If they are not yet drug therapy is necessary to restore and maintain perfusion. present, hospitals should create protocols for the use and care of special drains and catheters to ensure that everyone is caring for them appro- Dopamine: Administration of this drug will cause an increase in car- priately. Surgical incisions must be checked frequently and cleaned or diac contractility as well as arterial constriction (in higher doses) and covered as needed to protect them from urine and feces. Gloves should increased blood pressure. Due to increased norepinephrine release, dopa- be worn to prevent surgical site infections. mine at doses higher than 10mcg/kg/min should not be used in patients suffering from severe cardiac disease as it will increase cardiac afterload. In any hospital treating critical patients, the nursing team must be actively The effects are dose dependent with higher doses risking arrhythmias, engaged in each case; not just checking boxes on the treatment sheets to extreme tachycardia, and hypoxia due to elevated myocardial needs for move on to the next case. Each disease process must be considered and oxygen. Dopamine has a very short half-life and so it must be adminis- the veterinary technicians should look for relationships between diseases tered as a CRI and the dose changed according to patient response. Most so as not to be caught by surprise when the patient status changes. Close, patients will receive a dose range of 5-10mcg/kg/min but can go >10mcg/ careful monitoring can lead to successful recovery. kg/min. References Available Upon Request Dobutamine: Dobutamine is a positive inotrope that only acts on Beta 1 receptors and does not cause arterial constriction. Because of this, dobutamine can be used in patients with severe cardiac disease to increase blood pressure and peripheral perfusion. It works by increasing cardiac contractility and can lead to an almost immediate increase in blood pressure once the constant rate infusion is started. Dobutamine has a very short half-life and must be administered as a CRI at a dose range of 5-20mcg/kg/min (dogs). Norepinephrine: When administered IV, it acts on alpha receptors causing potent vasoconstriction without significantly affecting cardiac output and heart rate. Because of this, it is best to use norepinephrine when the patient’s cardiac function is known to be normal (absence of structural cardiac disease), as heart disease can be exacerbated by norepinephrine administration. Norepinephrine is the first-line choice for treating hypoten- sion related to sepsis as it will not affect cardiac output or heart rate. It is only given as a CRI and the effects are dose dependent and titrated until the desired outcome is reached. The dose is started at 0.1mcg/kg/min. Hypothermia is a common complication encountered with critical illness. Hypothermia can cause ECG abnormalities, decrease coagulation, inhibit platelet function, and eventually can be the cause of death. Prevention is the best medicine for hypothermia and should remain on the list for the cause of intraoperative and post-operative anesthetic complications. Us- ing cage warmers and warm forced air can be utilized to maintain normal body temperature. In trauma patients, active warming should be a priority and technicians responsible for frequently checking body temperature until it remains normal without heat support. Pain management must be part of any critical patient care protocol and tailored for the specific patient’s needs. In post-operative, trauma, or critical disease patients, pain management is necessary for healing. Full mu agonist opioids (morphine, methadone, hydromorphone, oxymorphone, and fentanyl) are the strongest analgesic drugs available. Opioids have minimal effect on the cardiovascular status of the patient making them safe to use even in the most critical patients. Nutrition in hospitalized patients is often overlooked in the early hours of 101

13–15 NOVEMBER, 2021 0056 other instances co-infection reflects frequent tick exposure and multiple independently obtained chronic infections. EHRLICHIOSIS - MORE THAN ONE DISEASE Laboratory Findings R. Lobetti Thrombocytopenia is the most frequent haematological abnormality Johannesburg / South Africa occurring in more than 90% of cases. Anaemia, usually non-regenerative normocytic and normochromic, is another common finding. In addition, Qualifications: mild to severe leukopenia is a frequent abnormality. Dogs in the chronic stage of the disease may develop severe pancytopenia, as their bone Remo Lobetti marrow becomes hypocellular, which carries a grave prognosis. BVSc, MMedVet (Med), PhD, Dipl. ECVIM-CA (Internal Medicine) Hyperglobulinaemia, hypoalbuminaemia, elevation of ALP and ALT activity, azotaemia, and hyperbilirubinaemia are reported in ehrlichiosis. Hyper- [email protected] globulinaemia is characterized by increased beta or gamma globulins Ehrlichial organisms are tick-borne obligatory intracellular bacteria of the (or both), with either a polyclonal or monoclonal gammopathy evident on Anaplasmataceae family, which include Ehrlichia, Anaplasma, Neorickett- serum protein electrophoresis. A monoclonal gammopathy, in association sia, and Rickettsia. Previously ehrlichial infection was subdivided into E. with severe bone marrow plasmacytosis, could be easily misdiagnosed as canis, E. chaffeensis, E. ewingii, E. equi, E. platys, and E. risticii. Currently, a plasma cell myeloma or, when found in association with lymphocytosis, however, the ehrlichial infection can be from E. canis, E. chaffeensis, and misdiagnosed as lymphocytic leukaemia. Hypoalbuminaemia occurs E. ewingii. Ehrlichia risticii is now classified as Neorickettsia ristici and in association with protein-losing nephropathy (PLN) or a reciprocal E. platys as A. platys. Ehrlichia equi and E. phagocytophila are the same decrease in albumin associated with hyperglobulinaemia. Experimentally, species as A. phagocytophila. Ehrlichia canis and E. chaffeensis infect a transient, spontaneously reversible PLN associated with ultrastructur- monocytes, A. phagocytophilum and E. ewingii infect granulocytes, and A. al glomerular damage occurs 2-5 weeks post infection. In the chronic platys infect thrombocytes. disease phase, E. canis can induce a severe PLN most likely related to immune complex glomerulonephritis. The significance of ehrlichiosis has been highlighted since the discovery and emergence of the human ehrlichiosis caused by E. chaffeensis, E. Immune-mediated responses can play a major role in the pathogenesis of ewingii, and A. phagocytophilum. E. canis infection. Anti-platelet antibodies have been demonstrated less than a week after experimental infection. Platelet aggregation abnor- CANINE MONOCYTIC EHRLICHIOSIS (E. canis) malities, anti-nuclear antibodies, erythrocyte auto-agglutination, positive Coombs’ test, and circulating immune-complexes have been shown in Ehrlichia canis morulae are found in monocytes and macrophages as a dogs with ehrlichiosis. “micro-colony” of bacteria surrounded by a membranous vacuole. Morulae may contain 100 or more ehrlichial organisms resembling elementary The thrombocytopenia in canine ehrlichiosis is probably a result of several bodies of chlamydiae. Ehrlichia canis is transmitted by Rhipicephalus mechanisms, including: increased consumption with vascular endothelial sanguineus. changes, thrombocyte sequestration and pooling in the spleen, throm- bophagocytosis with immunological destruction, a decrease in the half Ehrlichia canis was not well described until the Vietnam war when military life time of circulating thrombocytes possibly due to opsonization with German shepherd dogs in the war zone began dying in large numbers from antibodies, and production impairment due to bone marrow destruction an infection that appeared to wipe out all their blood cells, and subse- and hypocellularity. In addition to the decrease in circulating platelet num- quently named tropical canine pancytopenia. In the 1980s, the disease ber, thrombocytopathy has also been implicating as an additional factor was reported in people but with a different Ehrlichia that affected dogs. contributing to lack of thrombocyte function in monocytic ehrlichiosis. When the human disease was recognized, research intensified. CANINE GRANULOCYTIC EHRLICHIOSIS (E. ewingii) The pathogenesis of the disease involves an incubation period of 8-20 days, followed by 3 consecutive phases: an acute phase which lasts 1-4 The causative organism of canine granulocytic ehrlichiosis is E. ewingii, weeks, a sub-clinical phase which may last from months to years, and a which is responsible for the disease in people. Transmission is by Ambly- chronic phase. Not all infected dogs develop the chronic severe form of omma americanum. the disease and the conditions that lead to the development of this stage are currently undetermined. Clinical Findings Clinical Findings Dogs present with polyarthritis and/or nonspecific clinical signs including fever, lethargy, anorexia, vomiting, or diarrhoea. Clinical signs develop The clinical presentation of the disease may vary, and the clinical signs 7-21 days after being bitten by the tick. most frequently reported are lethargy, anorexia, pyrexia, lymphadenomeg- aly, splenomegaly, and haemorrhages ranging from petechiae, ecchy- Laboratory Findings moses and epistaxis. Ocular manifestations include uveitis, keratocon- junctivitis, hyphaema, glaucoma, chorioretinitis and retinal detachment. Laboratory abnormalities include nonregenerative anaemia, thrombocyto- Other clinical signs are polyarthritis, polymyositis, and neurological penia, lymphopenia, and eosinopenia. abnormalities, the latter associated with vasculitis, meningoencephalitis, lymphocytic infiltration of the central and peripheral nervous system or HUMAN MONOCYTIC EHRLICHIOSIS (E. chaffeensis) haemorrhages. Renal pathology has been associated with glomerulone- phritis. Although E. chaffeensis is the causative agent of human ehrlichiosis it can also infect dogs. Transmission is by Amblyomma americanum. Ehrlichia canis infections can occur in dogs with a concurrent infection with A. platys, Babesia canis, Hepatozoon canis, and Bartonella vinsonii or in conjunction with E. chaffeensis or E. ewingii. In some instances, simul- taneous transmission of organisms from vector ticks occurs, whereas in 102 WSAVA GLOBAL COMMUNITY CONGRESS

Clinical Findings disease. Following treatment, rapid clinical improvement is frequently noted in chronically infected dogs; however, periods up to a year may be Clinical manifestations of this disease in dogs are not completely defined. necessary for complete haematological recovery. The long-term prognosis Dogs may present with nonspecific clinical signs of anorexia, fever, leth- is variable, potentially related to failure to diagnose concurrent infec- argy or lymphadenopathy and is generally indistinguishable from E. canis. tions. Haemorrhage or concurrent infection may contribute to death of The majority of cases has been with experimentally infected animals chronically infected dogs, despite the initiation of therapy. The duration of doxycycline treatment for chronically affected dogs or those with severe Incubation period is similar to the other Ehrlichia’s, namely 7-21 days after pancytopenia or aplastic anaemia remains controversial. been bitten by a tick. Supportive therapy, including fluids, blood transfusion, vitamins, and Laboratory Findings anabolic steroids is required in some dogs. Long-term tetracycline prophy- laxis (6.6 mg/kg once daily), repositol oxytetracycline (200 mg intramus- Thrombocytopenia has been documented in experimentally infected dogs. cularly twice weekly), and topically applied acaracides have been used in military working dogs to prevent E. canis infection in highly endemic DIAGNOSIS regions. This approach may be appropriate for recurrent infections in kennels if tick control measures are of limited effectiveness. Because of Monocytic morula in peripheral blood smears is consistent with a diagno- extensive dog transport and chronic asymptomatic E. canis infection, the sis of E. canis or E. chaffeensis, whereas neutrophilic morulae are consis- establishment of new endemic foci in previously naive regions is possible. tent with a diagnosis of E. ewingii. The detection of morulae, however, is Tick control measures are very important but may not always provide an rare and cannot serve as a main diagnostic option. effective means to prevent infection with an Ehrlichia spp. The in-house ELISA assay (SNAP 4Dx Plus) is a point-of-care test and detect antibodies to E. canis, E. chaffeensisand E. ewingii. As the test is a qualitative assay further quantification of antibody levels can be done using an IFA technique, dot enzyme-linked immunosorbent assay (ELISA) test, or recombinant ELISA test. Due to cross-reactivity to immunoreactive proteins, most dogs infected with E. canis or E. chaffeensis will have a positive IFA or ELISA test, whereas less than half of the dogs infected with E. ewingii will have measurable cross-reacting antibodies. Serologic cross-reaction has not been reported in association with R. rickettsii, B. canis, A. platys, or A. phagocytophilum. A positive titre is considered in- dicative of prior exposure, although experimentally infected dogs become seronegative within 6-9 months after effective treatment, whereas untreat- ed dogs remain seropositive. However, in clinical cases, despite antibiotic treatment some dogs become asymptomatic but maintain antibody titres for years. Infection with E. canis does not infer protective immunity; therefore, subsequent exposure to infected ticks after treatment will result in disease recurrence, generally of decreased severity. Clinically, dogs are assumed to have eliminated the infection with an Ehrlichiaspp. if hyper- globulinaemia resolves progressively after treatment or if PCR is negative. Infrequently, a dog maintains a high antibody titre or a haematological abnormality such as thrombocytopenia persists for years after antibiotic therapy. Although it is unclear whether these dogs are chronically infected with E. canis, infected with other pathogens, or if the persistent haema- tological abnormalities are mediated through altered immunoregulation induced by the organism, little evidence exists to support antimicrobial resistance among Ehrlichia spp. that leads to persistent infection. Detection of the presence of Ehrlichia spp DNA by PCR is highly sensitive and specific and has become a popular assay in both research and in clin- ical diagnosis. In addition, it can also be used to differentiate the infecting Ehrlichia spp. and to determine if treatment has effectively eliminated the infection. In dogs with persistently high antibody titres, PCR testing is indicated, preferably when antibiotics are not being administered. THERAPY Doxycycline at 10 mg/kg oid for 28 days is the currently recommended therapy. Enrofloxacin will suppress the infection and may result in clinical and haematological improvement but does not eliminate the infection. Although imidocarb dipropionate has gained clinical acceptance in some endemic regions for treating severe, chronic, or presumed refractory cases of ehrlichiosis, lack of efficacy has been demonstrated in treating some dogs. The short-term prognosis for canine ehrlichiosis is generally good. Dramatic clinical improvement usually occurs within 24-48 hours after initiation of doxycycline in dogs with acute-phase or mild chronic-phase 103

13–15 NOVEMBER, 2021 0057 mammary tumours IS THIS MASTITIS OR INFLAMMATORY MAMMARY IMC characteristic features can be easily confused with skin infections CARCINOMA? (such as mastitis) and improperly treated with antibiotics, which delays the definitive diagnosis F. Queiroga It can occur in female dogs or cats, but recently it was described in a male Vila Real/Portugal dog Qualifications: The definitive diagnosis is made by skin biopsy, which reveals tumour emboli in dermal lymphatics (the hallmark of this tumour) Felisbina Luísa Queiroga Surgery is contraindicated for the majority of the cases due to post-surgi- DVM, MSc, PhD cal complications and extremely high rates of local recurrence. [email protected] Early neoadjuvant treatment is indicated with a multimodal approach Mammary tumours are one of the neoplasms that most frequently whenever possible (Radiotherapy/Chemotherapy/Tyrosine Kinase Inhibi- affect females of the canine and feline species. On the majority of the tors/Cox-2 inhibitors) occasions, the diagnosis is simple, as the clinical presentation is typical (a mass occurring near or in the mammary gland). However, in some situa- References: tions, doubts can occur mostly if a local inflammation is present, which can difficult the diagnosis. Clemente M, Pérez-Alenza MD, Peña L. Metastasis of canine inflammatory versus non-inflammatory mammary tumours. J Comp Pathol. 2010 Aug- The inflammatory mammary tumour is a special malignant tumour, with Oct;143(2-3):157-63. one of the most aggressive clinical behaviours. The aim is to provide information that allows a proper diagnosis ruling out other differential de M Souza CH, Toledo-Piza E, Amorin R, Barboza A, Tobias KM. Inflam- diagnoses, such as benign conditions associated with inflammation (for matory mammary carcinoma in 12 dogs: clinical features, cyclooxygen- example mastitis, dermatitis, ulcerated mammary tumour and fibroadeno- ase-2 expression, and response to piroxicam treatment. Can Vet J. 2009 matous hyperplasia of the mammary gland in the female cat). May;50(5):506-10. Inflammatory mammary carcinoma (IMC) is the most aggressive type of Marconato L, Romanelli G, Stefanello D, Giacoboni C, Bonfanti U, Bettini G, mammary cancer with short survival times after diagnosis. Inflammatory Finotello R, Verganti S, Valenti P, Ciaramella L, Zini E. Prognostic factors mammary carcinoma has unique histopathologic and clinical features for dogs with mammary inflammatory carcinoma: 43 cases (2003-2008). J (generalized edema, redness, severe swelling, warmth, erythema, pain Am Vet Med Assoc. 2009 Oct 15;235(8):967-72. of the mammary gland) associated with edema of the thoracic or pelvic members (depending on the IMC location in the mammary chain). Millanta F, Verin R, Asproni P, Giannetti G, Poli A. A case of feline primary inflammatory mammary carcinoma: clinicopathological and immunohisto- Two distinct clinical presentations were described: chemical findings. J Feline Med Surg. 2012 Jun;14(6):420-423. Primary form – arising in the mammary chain without a previous history of Pérez Alenza MD, Tabanera E, Peña L. Inflammatory mammary carci- mammary nodules noma in dogs: 33 cases (1995-1999). J Am Vet Med Assoc. 2001 Oct 15;219(8):1110-1114. Secondary form – arising in the mammary chain in an animal who already had mammary nodules, or some days or weeks after surgery of a mamma- Pérez-Alenza MD, Jiménez A, Nieto AI, Peña L. First description of feline ry tumour inflammatory mammary carcinoma: clinicopathological and immu- nohistochemical characteristics of three cases. Breast Cancer Res. The definitive diagnosis is obtained throughout an incisional biopsy. The 2004;6(4):R300-7. histological hallmark is the formation of tumour emboli in dermal lymphat- ics resulting in profuse edema secondarily to obstruction of lymphatic Queiroga FL, Perez-Alenza MD, Silvan G, Peña L, Lopes C, Illera JC. Cox-2 drainage. levels in canine mammary tumors, including inflammatory mammary carcinoma: clinicopathological features and prognostic significance. It is noteworthy that for a correct diagnosis, the histological diagnosis Anticancer Res. 2005 Nov-Dec;25(6B):4269-75. must be combined with the observation of clinical signs related to exuber- ant inflammation. Raposo TP, Arias-Pulido H, Chaher N, Fiering SN, Argyle DJ, Prada J, Pires I, Queiroga FL. Comparative aspects of canine and human inflammatory Surgery is the first-line treatment option for the majority of canine and breast cancer. Semin Oncol. 2017 Aug;44(4):288-300. feline mammary tumours, but for IMC cases, neoadjuvant chemotherapy and/or palliative treatment are preferable and surgery is not even indicat- Rossi F, Sabattini S, Vascellari M, Marconato L. The impact of toceranib, ed. The reason for this difference has to do with the diffuse presentation piroxicam and thalidomide with or without hypofractionated radiation ther- and extensive inflammation of inflammatory carcinomas, as well as the apy on clinical outcome in dogs with inflammatory mammary carcinoma. difficulty of defining surgical margins. Vet Comp Oncol. 2018 Dec;16(4):497-504. There is no consensus for neoadjuvant treatment but a multimodal Silva DMD, Kluthcovsky LC, Jensen de Morais H, Pallú GM, Dos Santos GC, approach (Radiotherapy, Chemotherapy, Cox-2 inhibitors, Tyrosine Kinase Costa Castro JL, Engracia Filho JR. Inflammatory Mammary Carcinoma in inhibitors) has been proposed. a Male Dog-Case Report. Top Companion Anim Med. 2019 Dec;37:100357. doi: 10.1016/j.tcam.2019.100357. Key points: Two distinct clinical presentations (primary and secondary forms) Characteristic clinical signs that are not the typical presentation of other 104 WSAVA GLOBAL COMMUNITY CONGRESS

0058 when they are given. Core vaccination may be started earlier, but never earlier than 4 weeks of age with MLV products. For puppies a product con- CPV& CDV IMMUNIZATION FAILURES: WHY THEY taining high-titer CDV and CPV2 may be used at 4 to 6 weeks (if available) STILL OCCUR? before switching to trivalent core vaccine at 8 weeks or older. For adult dogs there is ample evidence supporting revaccination with MLV core M. Marcondes vaccines no more frequently than every 3 years. Increasing the frequency of vaccination with MLV core vaccines does not confer greater protection São Paulo/Brazil to a dog. Increasing the number of dogs that are properly vaccinated is much more important to ensure protection through population or “herd” Qualifications: immunity than vaccinating each animal more often. Vaccination against CPV and CDV is not performed extensively in many parts of the world, Mary Marcondes especially in developing countries. DVM, MSc, PhD There is no evidence that any canine breed or breed group requires any specific vaccination protocol. There are some breeds (e.g., Rottweiler, [email protected] Dobermann) that have a greater risk of being genetic low responders and Vaccination is the most effective measure to control the spread of canine non-responders to CPV2. However, there is no reason to vaccinate those distemper virus (CDV) and canine parvovirus (CPV) infection in dogs and dogs more frequently than other breeds. If they are of this genetic type, to prevent the development of both distemper and parvovirosis. However, that means that the lack the immunological ability to ever respond to the despite the existence of vaccines, these diseases are still commonly particular antigen (e.g., CPV2); that means that no matter how frequently observed in dogs. There are many causes for immunization failures. No they are vaccinated, they will not respond to vaccination. This situation vaccine immunizes 100% of vaccinated animals. This simply reflects the is one in which serological testing is of practical benefit. Test kits will be biological variation within the population of vaccinated animals. There able to determine whether a dog is seronegative to CPV2 after vaccina- are unresponsive or “poorly responsive” animals that, often due to genetic tion. factors, are not able to develop an adequate immune response. In these cases, the immune response is independent of the number of vacci- Over the decades since the first identification of CPV2 in 1978 new vari- nations. As a biological process, the immune response never provides ants of the virus (CPV2a, CPV2b and CPV2c) have emerged in many parts absolute protection and is never equal in all members of a vaccinated of the world. Most vaccines contain either CPV2 or CPV2b and questions population. As immunity is influenced by many genetic and environmental have been raised as to whether these provide adequate cross-protection factors, the range of immune responses in a large population of animals against new virus variants (specifically CPV2c). There are numerous follows a normal distribution. This means that most animals respond to studies that show such cross-protection occurs and that all current CPV vaccines by developing a medium and adequate immune response, while vaccines remain efficacious in the field. Occasional reports of clinical some generate an excellent response, and a few generate a weak immune parvovirosis in vaccinated dogs still occur, but this generally relates to response. Those who respond poorly may not be protected against failure to vaccinate according to guidelines recommendations, with the infection, despite having received an effective vaccine, within a correct last vaccine given at 12 weeks of age, according to manufacturer’s rec- protocol. ommendations, when puppies may still have MDA that can interfere with immunization. Apart from this, among the causes of vaccine failures, maternally derived antibody (MDA) interference in early life is the most common one. Regarding distemper, while most of the cases of immunization failure are Although antibodies acquired by colostrum are important to protect the related to interference of MDA by the time of the last puppy vaccine, there offspring in the first weeks of life, they also block the immune response is also a concern related to antigenic differences between the vaccine when vaccines are administered. Dogs are only able to produce their own strains and the circulating wild type strains. Outbreaks of distemper in immune response to vaccination when maternally derived antibodies are wildlife can cause a potential risk for CDV infection in domestic dogs with almost completely degraded. In most puppies MDA decline to a level at access to wildlife species that are reservoirs of CDV. According to some which a response to vaccination is possible at around 12 weeks. Pups studies, if the neutralizing antibody titer produced after vaccination is not with poor MDA may be vulnerable (and capable of responding to vacci- robust, the crossreacting antibodies against heterologous strains may not nation) at an earlier age, while others may possess MDA at such high be adequate to be fully protective. Also, as for CPV2, in many parts of the titers that they are incapable of responding to vaccination until 16 weeks world there is still a lack of herd immunity against CDV. of age. Because of this, the recommendation of the WSAVA Vaccination Guidelines Group (VGG) guidelines is for initial core vaccination (CDV, References: CPV2 and CAV2), preferably as modified live vaccine (MLV), at 8 - 9 weeks of age followed by a second vaccination 3 to 4 weeks later, and a third 1.Altman KD, Kelman M, Ward MP. Are vaccine strain, type or adminis- vaccination given at 16 weeks of age or older. When the last vaccine dose tration protocol risk factors for canine parvovirus vaccine failure? Vet is given at 16 weeks of age or older, MDA should have decreased to a low Microbiol. 2017 Oct; 210:8-16. level, and active immunization will succeed in most puppies. MDA inter- feres with active immunization for varying periods of time in the puppy, 2.Anis E, Holford AL, Galyon GD, Wilkes RP. Antigenic analysis of genetic depending on the titer of colostral antibody and the amount of antibody variants of Canine distemper virus. Vet Microbiol. 2018 Jun;219:154-160. absorbed after birth, as well as the specific vaccine. VGG guidelines also recommend that a final MLV core vaccine (CDV, CPV and CAV) is given 3. Day MJ, Horzinek MC, Schultz RD, Squires RA; Vaccination Guidelines between 6 months to 1 year of age (preferably at 6 months) to ensure that Group (VGG) of the World Small Animal Veterinary Association (WSAVA). all puppies receive at least one dose of vaccine that can confer immunity WSAVA Guidelines for the vaccination of dogs and cats. J Small Anim in the absence of MDA. By contrast, many vaccine data sheets recom- Pract. 2016 Jan;57(1):E1-E45. mend a last dose given at 12 weeks of age, when some dogs may not be immunized because of the presence of MDA. 4. Day MJ, Crawford C, Marcondes M, Squires M. Recommendations on vaccination for Latin America small animal practitioners: a report of the Development of protective immunity is not dependent on the number of WSAVA Vaccination Guidelines Group. J Samll Anim Pract. 2020; E1-35 MLV core vaccines given during the puppy vaccination series, but rather 5.Decaro N, Buonavoglia C, Barrs VR. Canine parvovirus vaccination and 105

13–15 NOVEMBER, 2021 immunisation failures: Are we far from disease eradication? Vet Microbiol. 0059 2020 Aug;247:108760. MINIMALLY INVASIVE SURGERY FOR THE 6.Larson LJ, Schultz RD. Do two current canine parvovirus type 2 and 2b TREATMENT OF HIATAL HERNIA vaccines provide protection against the new type 2c variant? Vet Ther. 2008 Summer;9(2):94-101. A. Singh 7.Mitchell SA, Zwijnenberg RJ, Huang J, Hodge A, Day MJ. Duration of Guelph/Canada serological response to canine parvovirus-type 2, canine distemper virus, canine adenovirus type 1 and canine parainfluenza virus in client-owned Qualifications: dogs in Australia. Aust Vet J. 2012 Dec;90(12):468-73. Ameet Singh 8.Siedek EM, Schmidt H, Sture GH, Raue R. Vaccination with canine par- vovirus type 2 (CPV-2) protects against challenge with virulent CPV-2b and DVM, DVSc, DACVS, ACVS Founding Fellow, Minimally Invasive Surgery CPV-2c. Berl Munch Tierarztl Wochenschr. 2011 Jan-Feb;124(1-2):58-64. [email protected] 9.Spibey N, Greenwood NM, Sutton D, Chalmers WS, Tarpey I. Canine Hiatal herniation is a relatively uncommon but increasingly recognized parvovirus type 2 vaccine protects against virulent challenge with type 2c problem in dogs causing regurgitation of food and water, discomfort and virus. Vet Microbiol. 2008 Apr 1;128(1-2):48-55. the potential for the development of esophageal inflammation, esoph- ageal stricture and aspiration pneumonia. In veterinary medicine there is a relatively rudimentary understanding of the function of the canine gas- tro-esophageal junction (GEJ), which forms the natural barrier for reflux of food, water and stomach acid back up into the esophagus. The lower esophageal sphincter (LES) is created by the muscular tone within the circular smooth muscle of the muscularis mucosa of the distal esophagus as well as the mechanical support provided by the attachments of the esophagus to the diaphragm as it passes from the chest into the abdomi- nal cavity. Surgical techniques for the treatment of hiatal herniation (HH) in people have been extensively studied and have received rigorous evaluation over the years in the scientific literature. The same cannot be said for HH in dogs. Of the group of gastroesophageal junction (GEJ) anomalies that are seen in the dog (which includes sliding hiatal hernia, paraesopha- geal hernia and gastroesophageal intussusception) sliding hiatal hernia is by far the most common. This condition can arise as a congenital anomaly and has been reported most commonly in this form in young Shar Peis.1,2 Acquired HH can be seen secondary to airway obstructive disease or neuromuscular disorders affecting the diaphragm.3 In brachy- cephalic breeds it is thought that increased inspiratory effort leads to a reduction in intra-esophageal and intrapleural pressures possibly leading to the distal esophagus and stomach being pulled into the thoracic cavity during inspiration.4 Clinical observations have been made to substantiate this proposed pathophysiology where a population of bulldogs with HH were shown to exhibit the more severe manifestations of brachycephalic syndrome compared to Bulldogs without HH.3 A multitude of treatment recommendations for HH have been made in the literature over the years. Medical management has been aimed at inhibition of normal gastric acid secretion to reduce its ulcerogenic effects on the esophagus when GERD occurs and is centered around the administration of antacids or proton pump inhibitors. Mucosal protectants such as sucralfate have been recommended in slurry form to coat and protect the distal esophagus from the effects of reflux. Some studies have suggested that medical management is often unsuccessful in controlling clinical signs1 whereas others have suggested that medical management should always be attempted as it alone can be successful in over 50% of cases.5 These discrepant results may be partially attributable to differing case populations or to the lack of standardized reporting of outcomes for this condition. However, it is safe to say that there is an important role for surgery in the treatment of HH as treatment failures following medical management occur with some frequency. Furthermore, some authors believe that if there is a deficiency in barrier function of the GEJ that can be surgically treated this may be a better approach to management than attempts at medically alleviating the consequences of GERD. To that end several surgical therapies have been in common usage for many years for treatment of HH in dogs. The most common approach is a combina- 106 WSAVA GLOBAL COMMUNITY CONGRESS

tion of treatments using diaphragmatic hiatal reduction (phrenoplasty or 0060 crural apposition), esophagopexy and left-sided gastropexy.1,2,5,6 Out- come data for this combination of therapies is quite variable and the PERSPECTIVES ON FELINE HEARTWORM DISEASE ability to formally evaluate the procedure is adversely affected by small case numbers, combination therapies and inconsistent outcome mea- M. Cousins sures.1,2,5,6 Fundoplication procedures, often used in humans with GERD have also been reported for use in dogs with less encouraging results and New Orleans/United States of America a possibly higher incidence of complications.5 Qualifications: Minimally invasive surgery is the standard of care for treatment of hiatal hernia and GERD in humans and development of these techniques for W. Mark Cousins dogs with these conditions should be advanced. A description of the MIS management of hiatal hernia in the dog will be provided in this lecture. Doctor of Veterinary Medicine (DVM) References Diplomate, American Board of Veterinary Practitioners, (Feline Medicine) 1) Callan MB, Washabau RJ, Saunders HM, et al. Congenital esophageal Certified Veterinary Pain Practitioner hiatal hernia in the Chinese Shar-Pei dog. J Vet Intern Med 1993;7:210-215 Certified Veterinary Acupuncturistn (IVAS) 2) Guiot LP, Lansdowne JL, Rouppert P, et al. Hiatal hernia in the dog: Feline Heartworm Disease: an Overview A clinical report of four Chinese Shar-Peis. J Am Anim Hosp Assoc 2008;44:335-341 W. Mark Cousins, DVM 3) Hardie EM, Ramirez O, Clary EM, et al. Abnormalities of the thoracic Dipl. American Board of Veterinary Practitioners (feline medicine) bellows: Stress fractures of the ribs and hiatal hernia J Vet Intern Med 1998;12:279-287 Certified Veterinary Pain Practitioner 4) Stalcup SA, Mellins RB. Mechanical forces producing pulmonary edema Certified Veterinary Acupuncturist in acute asthma. N Eng J Med 1997;297:592-596 Feline heartworm disease is discussed in detail. The epidemiologic rates 5) Lorinson D, Bright RM. Long-term outcome of medical and surgical of infection in cats are dependent on mosquito (the vector of Dirofilaria treatment of hiatal hernias in dogs and cats: 27 cases (1978-1996). J Am immitis) pressure in different areas; but, are generally considered to be Vet Med Assoc 1998;213:381-384 underestimated by veterinary practitioners. Additionally, microenviron- mental conditions in different locals can often belie the prevalence of 6) Prymak C, Saunders HM, Washabau RJ. Hiatal hernia repair by resto- this disease due to their support of the mosquito. Differences in diag- ration and stabilization of normal anatomy. An evaluation in four dogs and nostic methods of D. immitis (including their indication, strengths, and one cat. Vet Surg1989;18:386-391 limitations) will be examined. Newer methods of diagnosis will also be discussed. Newer diagnostic techniques will be presented and may make detection of feline heartworm disease more accurate, allowing veterinar- ians to understand the true prevalence of this disease in their geographic locales. The pathogenesis of adult D. immitis in the feline cardiovascular/pulmo- nary system can lead to a complex of well described clinical signs such as chronic vomiting, coughing, acute respiratory disease complex, and sud- den death. Most commonly, these infections by adult D. immitis are as- ymptomatic. Additionally, and more ominously, new research has shown reasons why damage done by feline heartworms may be more pervasive than previously believed. Data suggests that immature D. immitis larvae migrating in the cat’s pulmonary parenchyma may be culpable for clinical disease as well, whether or not these larvae actually mature to adults. This is due to the fact that pulmonary damage happens from migrating sub-adult phases of heartworms that may be killed by host immunoge- nicity before adult worms establish a presence in the heart of infected cats. This would make the prevalence of this disease much higher than originally thought. Diagnosis of this syndrome is difficult. However, re- search has shown that the pulmonary pathology (and subsequent clinical signs) of this larval syndrome is equal to that of the pathology caused by the presence of adults in the pulmonary system; and, it is probably, more prevalent. This new information makes the recommendation for feline heartworm disease more medically significant. A brief synopsis of feline heartworm prevention available and the concept of D. immitis resistance to macrocyclic lactones will also be examined as well. 107

13–15 NOVEMBER, 2021 0061 to avoid causing iatrogenic trauma in the event of instrument slippage or encountering diseased bone. In addition, the jaw should be gently held EXTRACTIONS MADE EASIER with the opposite hand to provide stability and avoid mandibular fracture. B. Niemiec First, select an instrument which matches the curvature and size of the root. There are numerous instruments available including the classic San Diego/United States of America elevator, the luxating elevator, and the winged elevators. Classic elevators and winged elevators are used in an “insert and twist” motion to tear Qualifications: the periodontal ligament, whereas luxators are used in a rocking motion during insertion to fatigue as well as cut the periodontal ligament. Lux- Brook A. Niemiec DVM ators can be GENTLY twisted for elevation, but they are not designed for this and can be easily damaged when used in this manner. Diplomate, American Veterinary Dental College Elevation is initiated by inserting the elevator or luxator firmly yet gently Diplomate, European Veterinary Dental College into the periodontal space. The insertion should be performed while keeping the instrument at about a 10 to 20 degree angle toward the tooth, Fellow, Academy of Veterinary Dentistry to avoid slippage. Once in the space between the bone and the tooth, the Extractions are surgery, and therefore need to be treated with appropriate instrument is gently twisted with two-finger pressure. This is not to say respect. Patience and gentle technique is the best way to achieve a suc- that the instrument should be held with two fingers, rather the entire hand cessful outcome. All extractions can be broken down into simple, single should be used to hold the instrument. Twist only with the force that you rooted extractions. Therefore proper elevation and extraction techniques could generate when holding with two fingers. Hold the position for 10-30 learned and performed on incisor teeth will make all extractions easier. seconds to fatigue and tear the periodontal ligament. Proper and well maintained equipment is critical for successful ex- It is important to note that the periodontal ligament is very effective in tractions. This author prefers luxating elevators to standard or winged resisting intense, short forces. It is only by the exertion of prolonged elevators. Small extraction forceps and needle holders will also benefit the force (i.e. 10-30 seconds) that the ligament will become weakened. Heavy surgeon. stresses only serve to put pressure on the alveolar bone and tooth which can result in the fracture of one of these structures, so it is important not Step 2: DENTAL RADIOGRAPHS to use too much force. Dental radiographs should be exposed on all teeth prior to extraction. Den- After holding for 10 to 30 seconds, reposition the instrument about 1/8 tal radiographs are invaluable resources for the practiconer. Radiographs of the way around the tooth and repeat the above step. Continue this allow the practitioner to determine the amount of disease present, any procedure 360 degrees around the tooth, each time moving the elevator root abnormalities or ankylosis. apically as much as possible. Depending on the level of disease and the size of the tooth, a few to several rotations of the tooth may be necessary. Step 4: PAIN MANAGEMENT The key point to successful elevation is PATIENCE. Only by slow, consis- tent elevation will the root loosen without breaking. It is always easier to Extractions are surgical procedures and are moderately to severely painful extract an intact root than to remove fractured root tips. for the patient. Depending on patient health, a multimodal approach (com- bination of opioids, NSAIDs, local anesthetics, and dissociative) should be Step 7: EXTRACT THE TOOTH: employed, as this provides superior analgesia. Removing the tooth should only be attempted after the tooth is very SINGLE ROOT EXTRACTIONS mobile and loose. This is accomplished by grasping the tooth with the extraction forceps and gently pulling the tooth from the socket. Do NOT Step 5: INCISE THE GINGIVAL ATTACHMENT apply undue pressure as this may result in root fracture. In many cases, especially with premolars, the roots are round in shape and will respond This is accomplished with a scalpel blade (number 11 or 15), elevator, or favorably to gentle twisting and holding of the tooth while applying luxator. The selected instrument is placed into the gingival sulcus with the traction. This should not be performed if there are root abnormalities tip of the blade angled toward the tooth (this will help avoid going outside (significant curves, weakening) seen on the pre-operative radiograph. It is the bone and creating a defect or cutting through the gingiva). The blade helpful to think of the extraction forceps as an extension of your fingers. is then advanced apically to the level of the alveolar bone, and the instru- Undue pressure should not be applied. If the tooth does not come out ment is carefully worked around the entire tooth circumference. easily, more elevation is necessary. Start elevation again until the tooth is loose enough to be easily removed from the alveolus. This step is very helpful as the gingival attachment contributes approxi- mately15% of the retentive strength of the periodontal apparatus. More Step 8: AVELOPLASTY importantly, however, this procedure will keep the gingiva from tearing during the extraction procedure. This is most important with mobile teeth This step is performed to remove diseased tissue or bone, as well as where little elevation is needed, but one edge is still attached. Gingival rough boney edges that could irritate the gingiva and delay healing. tearing can cause defects that require closure or can make a planned Diseased tissue can be removed by hand with a curette. Bone removal closure more difficult. and smoothing is best performed with a carbide, or preferably a coarse diamond bur on a water-cooled high-speed air driven hand-piece. Alter- Step 6: ELEVATE THE TOOTH natively, ronguers or bone files may be used if a high-speed dental unit is unavailable. Next, the alveolus should be gently flushed with a 0.12% Elevation is the most dangerous step in the extraction procedure. Remem- chlorhexidine solution to decrease bacterial contamination. After the ber that you are holding a sharp surgical instrument and working in an alveolus is cleaned, it may be packed with an osseopromotive substance. area of numerous critical and delicate structures. There have been many reports of eyes that have been gouged and lost by extraction instruments as well as at least one confirmed fatality due to an elevator puncturing a patient’s brain. The index finger is placed near the tip of the instrument 108 WSAVA GLOBAL COMMUNITY CONGRESS

Step 9: CLOSURE OF THE EXTRACTION SITE: 0062 This is a controversial subject among veterinary dentists, and thus some DIAGNOSIS AND MANAGEMENT OF IMMUNE- texts recommend suturing only in large extractions, other authors (includ- MEDIATED THROMBOCYTOPENIA ing this one) recommend suturing almost all extraction sites. Closure of the extraction site promotes hemostasis and improve post-operative N. Whitley discomfort and aesthetics. It is always indicated in cases of larger teeth (e.g. canines, carnassials), or any time that a gingival flap is created to Hertfordshire/United Kingdom allow for easier extraction. This is best accomplished with size 3/0 to 5/0 absorbable sutures on a reverse cutting needle. Closure is performed with Qualifications: a simple interrupted pattern with sutures placed 2 to 3 mm apart. It is further recommended to utilize one additional throw over manufacturer’s Nathaniel T Whitley recommendations to counteract tongue action. BVMS, PhD, CertVC, DACVIM, DECVIM-CA, FRCVS EXTRACTION OF MULTI ROOTED TEETH: Member of the WSAVA Vaccination Gudelines Group Section all multi-rooted teeth into single rooted pieces. The roots of almost all multi-rooted teeth are divergent and this will cause the root tips E-mail: [email protected] to break off if extractions are attempted in one piece. Root fracture can Presentation and Diagnosis occur even if a tooth is relatively mobile to start with. With mobile teeth, the sectioning step alone often allows for simple extraction. Immune-mediated Thrombocytopenia (IMT) is one of the more common canine immune-mediated diseases, resulting from IgG formation against The best tool for sectioning teeth is a bur on a high-speed air driven hand platelet membrane antigens GPIIb and IIIA (rarely against megakaryo- piece. Besides being the quickest and most efficient tool for the job, it cytes). Cocker spaniels and some other breeds are predisposed. IMT also has air and water coolant that will avoid overheating the tooth. Many is rare in cats. Canine IMT is considered a good model for human IMT, different styles of burs are available, however this author prefers a cross- although the latter is heterogeneous, with diagnosis often defined by cut taper fissure bur (699 for cats and small dogs, 701 for medium dogs treatment response, and complicated by existence of several inherited and 702 for large breeds). thrombocytopenias. Presentation is variable, depending on extent and location of any bleeding. Unusually for an immune-disease, some patients The best way to section the teeth is to start at the furcation and work to- are asymptomatic, with the thrombocytopenia an incidental discovery on wards the crown of the tooth. This method is used for two major reasons. bloodwork performed for another reason. Bleeding (typically cutaneous First, it avoids the possibility of missing the furcation and cutting down or mucosal) is much more likely with platelet counts <30,000/uL. IMT into a root, which subsequently weakens the root and increases the risk patients may have concurrent, previous or subsequent immune-mediate of root fracture. In addition, this method avoids the possibility of cutting haemolytic anemia (IMHA). When the problems occur at the same time through the tooth and inadvertently damaging the gingiva or alveolar this is referred to as Evan’s syndrome. Patterns of bleeding may overlap bone. with those present due to platelet dysfunction, Von-Willebrand’s disease or vasculitis. The DOGiBAT scoring system is sometimes used as a measure After the tooth has been properly sectioned, follow the above steps for of IMT severity in clinical studies. each single rooted piece. In some cases, the individual tooth pieces can be carefully elevated against each other to gain purchase. IMT is nearly always a diagnosis of exclusion, supported by experi- ence and pattern recognition. The major differential for platelet counts Key Points: <50,000/uL is the consumptive coagulopathy present in DIC, where typically other abnormalities are present on a coagulation profile and Proper preparation and mindset are crucial other clinical derangements may elude to what is driving the DIC. Rarely, anticoagulant rodenticide may also cause very low counts (mechanisms Small/sharp instruments are the most effective choice incompletely understood). Beware spurious (false) thrombocytopenias caused by platelet clumping in the collection tube or syringe, or failure of Gentle elevation and patience are necessary for successful outcomes automated analysers to count macrothrombocytes. Cavalier King Charles Spaniels and some other breeds share a mutation in their beta-1-tubulin All teeth can be broken down into simple single root extractions gene – affected individuals have fewer, larger platelets of a characteristic appearance, but do not bleed, purportedly due to having a normal and Dental radiographs are an invaluable resource functional total platelet mass. This is a breed anomaly not IMT. Other mechanisms that should be considered for mild to moderate thrombocy- Further reading: topenia include defective platelet production (bone marrow disease, in- cluding drug toxicity) and platelet sequestration (such as splenic disease, Niemiec BA: Dental Extractions Made Easier. Practical Veterinary Publish- including torsion). ing. Tustin CA The diagnostic approach to severe thrombocytopenia must address not only differentials for thrombocytopenia (and anemia if present) but also aim to rule out presence of “trigger” factors that could have disrupted im- mune homeostasis and triggered attack on the platelets. Triggers may be considered under the categories of drugs (including vaccines), infection, inflammatory, infectious and neoplastic disease. Previous IMHA would increase suspicion for IMT. Vector borne disease is the major concern (particularly Babsesia and Rickettsial infections) and may cause throm- bocytopenia with or without an immune-mediated component. However, theoretically any infection (including wounds, abscesses, severe dental or biliary infections) could be a trigger – the more severe the infection, 109

13–15 NOVEMBER, 2021 the more plausible. This means that the initial workup for IMT general- patients with documented active bleeding or transfusion dependence, a ly consists of haematology, biochemistry, urinalysis (mid-stream free single intravenous dose of vincristine (0.02mg/kg) shortens the time for catch), chest and abdominal imaging, and any infectious disease testing recovery of a “safe” platelet count with an associated reduction in hos- deemed appropriate to the individual patient’s lifestyle. Although IMT is pitalisation time and costs. This should be considered standard of care. an antibody-mediated disease, measuring antiplatelet antibody is often Vincristine induced neutropenia is rare at this dose unless the patient is technically challenging, rarely commercially available and although it can receiving ciclosporin, which increases the risk. Intravenous human immu- be a specific test, it is insensitive and still does not distinguish primary noglobulin has roughly the same efficacy as vincristine when used in the from secondary IMT. same context, but is very expensive and often hard to source. It is some- times used to help achieve initial remission. For glucocorticoids, I use Anaemia in IMT may be caused by the following, in isolation or combina- injectable dexamethasone at 0.25mg/kg q 24 hr until I am confident that tion: the patient will absorb oral medications, and then prednisolone at 1-2mg/ kg q 24 hr. In dogs >20mg prednisolone is dosed at 50mg/M2 q 24 hr. Blood loss from bleeding due to thrombocytopenia – this is common and can be anywhere, but most often is gastrointestinal Lack of consensus surrounds indications for, timing and choice of “second line” immunosuppressants, if it is considered that steroids (+ Concurrent or sequential IMHA (uncommon) vincristine) alone are unsatisfactory or inadequate. The most robust argu- ment for early use of a second agent is to enable accelerated weaning of Comorbidities, implying potential presence of a trigger for secondary IMT steroid dose in a patient likely to be poorly tolerant of them (due to side (such as bone marrow neoplasia) effects or comorbidity). More often there is fear that the patient may not be responding to or will not respond to steroids/vincristine alone. Choice Some immunosuppressants (e.g. steroid induced GI ulceration, or azathio- of second-line agent is currently informed by retrospective studies and prine induced suppression of haematopoiesis) varied expert opinion. Note that an ACVIM consensus statement on diag- nosis and management of IMT is in preparation. Second line agents that In trying to establish the dominant cause of anaemia, keep in mind that could be considered (listed according to my order of preference) include spherocytes, ghost cells, agglutination or icterus point towards IMHA, ciclosporin (veterinary licensed preparations available in many countries), whereas blood loss may cause signs of hypovolemia in the acute phases, leflunomide, mycophenolate mofetil, chlorambucil (cats) and azathioprine with hypoproteinemia often manifesting following fluid therapy/fluid (dogs). With the exception of ciclosporin, these preparations are cytotoxic shifts. and appropriate handling precautions and haematological monitoring are indicated. Clinicians should familiarise themselves with common Management side effects and additional monitoring specific to each agent. Pertinent publications include: There are three components to managing IMT patients, which may need to be addressed simultaneously, depending on the patient: A retrospective study on prednisolone and ciclosporin versus predniso- lone and mycophenolate in canine IMT. Hospitalisation and survival times Remove and/or treat trigger factors that may be driving the IMT, where were similar between groups but both costs and side effects were lower in possible. Concurrent immunosuppressive therapy may be required after the mycophenolate group (Cummings and Rizzo 2017) a few days if the thrombocytopenia is not improving, particularly in cases where antimicrobial therapy is already in place to address an infectious A case series on 5 dogs treated with mycophenolate alone (steroids were trigger. contraindicated due to recent therapy with non-steroidal anti-inflammatory drugs). All dogs achieved rapid and durable remission (Yau and Bianco Transfusion therapy. Blood products to manage anaemia are often re- 2014) quired. Blood products to improve thrombocytopenia are harder to source and rarely required. Adjunctive therapies have been described including splenectomy (effec- tive in some cases) and anecdotally melatonin (unproven and mecha- Anaemia – the primary goal is to provide additional oxygen carrying ca- nisms unknown). Several thrombopoietin receptor agonists are used for pacity. If component therapy is available, packed red cell transfusions are various thrombocytopenias in human medicine. Of these, Romiplostim has indicated and often the most convenient. Fresh whole blood could also been described for canine IMT that had been refractory to other immuno- be used – it may go some way towards replacing lost/consumed plasma suppressants. proteins and clotting factors and arguably could be viewed as a superior product. In deciding whether to transfuse, clinicians are encouraged Weaning immunosuppressants: once platelet count has been at or above where possible to base their decision on rate of decline of PCV and trends normal for at least 2 weeks, total immunosuppressant dose should not on physical examination (heart rate, pulse strength etc.) rather than use normally be reduced by more than 25-33% every 2-3 weeks, with platelet an absolute cut off value for packed cell volume. count checked before each dose reduction. Hence most patients receive 12-16 weeks of immunosuppressants for their first bout of disease. Thrombocytopenia – it has been uncommon for dogs and cats to receive platelet transfusions due to the belief that platelets administered are Prognosis rapidly consumed/destroyed, as well as lack of available products. For most vets, fresh whole blood is the most readily available product for A small recent study showed relapses tended to be early on whilst still patients with life threatening bleeding (for example into the lungs or CNS). receiving immunosuppressants (31% of dogs relapsed after discharge, Platelet-rich plasma or platelet concentrate may be prepared freshly and 50% of these had subsequent relapse). However, after 6 months, only on an individual patient basis for immediate administration for those 11% of dogs went on to have a relapse. practices with an on-site or very local animal blood bank. DMSO stabilised cryopreserved platelets have recently been available in USA and trials are Full references on request underway on lyophyilised canine platelets (StablePlate RX). Immunosuppressive therapy. Most IMT patients need and respond to immunosuppressive glucocorticoid (“steroid”) treatment within 7 days. Patients are typically discharged on treatment when the risk of bleeding is much reduced and weaning of glucocorticoid dose is commenced once platelet count has been at or above normal for at least 2 weeks. For 110 WSAVA GLOBAL COMMUNITY CONGRESS

0063 0064 CUTANEOUS LESIONS IN KOI - A CLINICAL REVIEW ARTIFICIAL INTELLIGENCE FOR CLINICAL DECISION MAKING AND EARLY DISEASE DETECTION, J. Tepper K. Reagan Manorville/United States of America Davis/United States of America Qualifications: Qualifications: Julius M. Tepper, DVM, CertAqV Krystle Reagan, DVM, PhD, DACVIM (SAIM) [email protected] In koi, one of the most common complaints for which the pet fish prac- [email protected] titioner is called upon are cutaneous changes that are visibly evident to Artificial Intelligence in Veterinary Medicine the owner. The majority of these lesions are cutaneous ulcers. Along with “mouth rot’ and “fin rot”, these form the complex described as koi ulcer Krystle Reagan, DVM, PhD, DACVIM(SAIM) disease. Treatment protocols will vary depending on whether the lesions are of the trunk, the mouth or the fins or in combination. It will also be Advances in computational power have led to an explosion of artificial dependent on the extent of the lesion(s), the stage of degeneration/regen- intelligence (AI) applications impacting our daily lives. This can be seen eration and the treatment options available. It is important to determine when you ask Google Maps to predict the fastest route home, watch a the stage in the development and healing as local debridement will be show that Netflix has recommended for you, or if you have ever asked useful in the degenerative phase, but counterproductive during healing. Alexa to play some music. We have become comfortable with the This would limit the use of topical treatment to only the first few days af- integration of AI into our daily lives, but many of us have not considered ter ulceration. Determination of stressors in the aquasystem leading up to how this technology could impact how medical care is administered. AI the outbreak should be identified where present. Systemic antibiotics are techniques have the potential to impact nearly every aspect of the health often indicated, especially with multiple and/or extensive lesions. Addi- care industry from the identification of at-risk populations, prediction of tional considerations are maintenance of ideal water quality, especially if disease states, intercepting medical errors, augmenting clinical decision treating in a quarantine system and stabilized water temperature at 75 °F making, monitoring treatment regimens, and more. Collaborative research (24°C), the preferred optimum temperature for koi. Additional conditions efforts between clinician-scientists, data scientists, and engineers have that may be seen on the integument are saprolegniasis, koi herpesvirus just started shining the light on how AI may impact our clinical deci- (CyHV-3), edema (“Pine cone disease”), macroscopic parasites (lernea, sion-making in the future. Having awareness of how AI powered solutions argulus, ich), neoplasia (carp pox, papilloma, squamous cell carcinoma), may transform how we practice medicine will equip you to responsibly trauma (heron attack), special conditions of butterfly koi fins, special con- deploy these techniques. ditions of doitsu koi, and finally, clinically significant non-lesions (narial folds of showa, narial folds of butterfly koi, shimmies). What is artificial intelligence? Artificial intelligence refers to the engineering of machines to mimic human intelligence. “Algorithms” are often referred to when referencing AI, and they are defined as a set of instructions that tells a computer what to do. All algorithms have an input and an output. AI is a broad umbrella term that encompasses more specific techniques. Machine learning (ML) refers to techniques that utilize statistical meth- ods and algorithms that learn from experience to improve the ability to complete a task correctly. These statistical methods are based in if-then decision trees, regression analysis, and Bayesian inference. Another sub- set of AI, within machine learning, is deep learning. These methods use a series of algorithms that mimic the way the human brain works through a process called neural networks. Neural networks receive an input, and each artificial neuron creates an output which can be communicated to other neurons to achieve an overall output. What can AI accomplish? Machine learning algorithms (MLAs) can be trained to identify complex and subtle patterns within data, and in turn complete a task on new data point. Some of the common uses of this technology is determining a classification (disease present or absent) or identify an image. In the human health care field applications of MLA have included identification of cancerous tumors on mammograms, identification of skin lesions that are malignant, identification of diabetic retinopathy lesions on fundic examination, and prediction of severe COVID-19 disease. Processes that are standardized and produce large volumes of high-quality data are well suited to benefit from the application of AI or ML. This creates a challenge in veterinary medicine where diagnostic assays may not be applied in a standardized manner and data sets are much smaller than those available for human medicine. Despite these limitations, promising use cases have 111

13–15 NOVEMBER, 2021 been developed that can provide objective analysis on patient data. - Prediction of hypoadrenocorticism in dogs from CBC and serum chemis- try data1 - Prediction of development of chronic kidney disease in cats from patient data, serum chemistry and urinalysis values2 - Identification of enlarged left atrium on thoracic radiographs of dogs3 - Syndromic surveillance of pathology reports4 How are MLA’s trained? References: Training of MLA’s requires data of interest that you suspect may have 1. Reagan KL, Reagan BA and Gilor C. Machine learning algorithm patterns that correlate with the question of interest. For example, a ques- as a diagnostic tool for hypoadrenocorticism in dogs. Domestic Ani- tion may be “Can a MLA be training to recognize a picture of a duck?”. mal Endocrinology 2020; 72: 106396. DOI: https://doi.org/10.1016/j. To determine this, a large dataset of animal pictures should be collected. domaniend.2019.106396. Two types of learning are utilized to classify the data. The first is super- vised learning, where each piece of training data is labeled with the output 2. Bradley R, Tagkopoulos I, Kim M, et al. Predicting early risk of chronic category of interest (not a duck or duck). The second type of learning is kidney disease in cats using routine clinical laboratory tests and machine unsupervised learning, where the input data is not labeled, but instead the learning. Journal of Veterinary Internal Medicine 2019; 33: 2644-2656. MLA clusters like data points together. DOI: 10.1111/jvim.15623. 3. Li S, Wang Z, Visser LC, et al. Pilot study: Application of artificial intelli- gence for detecting left atrial enlargement on canine thoracic radiographs. Veterinary Radiology & Ultrasound 2020; 61: 611-618. DOI: https://doi. org/10.1111/vru.12901. 4. Bollig N, Clarke L, Elsmo E, et al. Machine learning for syndromic sur- veillance using veterinary necropsy reports. PloS one 2020; 15: e0228105. Once the MLA is trained, it must be tested on data points that were not utilized in the training process to establish the performance of the MLA. This is can be accomplished by using 80% of the original data set to train the MLA and reserving 20% of the data to test performance. The perfor- mance of the MLA can be reported similar to other diagnostic tests with accuracy, sensitivity, and specificity. 112 WSAVA GLOBAL COMMUNITY CONGRESS

0066 III JOINING FORCES VETERINARIANS, BREEDERS AND KENNEL CLUBS BOAS: A CHALLENGE REQUIRING COOPERATION BETWEEN VETERINARIANS, BREEDERS AND Polarisation is gaining ground between and within stakeholders, which AUTHORITIES does not help the dogs involved. To move towards a sustainable solution, and if we really are willing to put these dogs’ health and welfare first, we Å. Hedhammar1, M. Megens2 need to collaborate. 1Uppsala/Sweden, 2Den Bosch/Netherlands Veterinarians are best suited to handle and advise on recognizing the clin- ical effects of exaggerated anatomical features. However, to impact these Qualifications: anatomical features, we need to involve those who advise on “desired anatomical features” from other perspectives than health and well-being. Åke Hedhammar In some countries, the veterinarians and breeders and the Kennel Club already started to join forces to move away from exaggerated anatomical Prof em. traits. [email protected] Examples on collaborative action nationally (in Sweden as of below ) and internationally. http://www.ukbwg.org.uk/ Monique Megens 1960th DVM Attention to the effects of exaggerated anatomical features on Canine [email protected] Health by Nordic Vets and Kennel Clubs (Bonnett, Megens, O’Neil and As both veterinarians, but with somewhat different experiences from Hedhammar 2021) collaborative efforts to “combat” negative effects by extreme conforma- tion, we will share our concerns and proposals to handle the current BOAS 1980th situation with you. A video production on the same issue featuring Harold Spira - veterinarian I Introduction and All breed show judge that “toured “to many countries during the 80th with examples on how “wordings in breed standards” had resulted in exag- Many different stakeholders are involved in breeding dogs for various gerations. functions. Each of these stakeholders can influence the demand and selection of breeding stock for a specific type of dogs and breeds. They 2000th may also handle the problematic conformations differently. At both national and international levels, many stakeholders, including regulatory First Swedish version Breed specific instructions (BSI) based on a report bodies, have taken actions to improve the health and welfare of dogs by all breed show judges, a survey to small animal vets and Insurance with extreme conformations. However, these actions have not proven to data. be enough, and there is much left to achieve to substantially improve the current welfare crisis related to extreme conformation in dogs. Current version now spread internationally Dog breeding is truly international and involves many stakeholders. https://www.skk.se/globalassets/dokument/utstallning/breed-special- (Hedhammar 2011 a,b) Therefore, there is no quick and easy solution per- specific-instructions---bsi-a8.pdf formed by one stakeholder in just one country. We should acknowledge the complexity and therefore, it is crucial that all relevant stakeholders Production of an accompanying Video production on assessment of join forces and work collaboratively across borders. breathing featuring vets and a show judge https://www.youtube.com/ watch?v=kQ_3f4bLkME When conformation adversely affects the health and welfare of a dog, particularly when selecting for unhealthy exaggeration of certain traits, we First dog Health workshop arranged in Stockholm 2012 to bring stakehold- talk about extreme conformation. Some types of dogs and breeds show ers together. Based on that the Establishment of International Partnership more extremes of conformation that impact their health and welfare than for Dogs (IPFD) and launching of DogWellNet https://dogwellnet.com/ others. The brachycephalic dogs are well known for their extreme con- formation, but we should also acknowledge major differences between Currently ongoing: brachycephalic breeds. Inventory on phenotypic and genotypic variation in English and French In this lecture we will focus on the role of the veterinarians and emphasise Bulldogs, Pugs and Boston terrier with veterinarians and show judges on the need to collaborate with cynological organisations and authorities. examining all dogs Survey to owners, breeders, show judges and veterinarians on their experi- ence and views on BOAS (n- 18 000) II VETERINARIANS IV AUTHORITIES – WHAT HAPPENED IN THE NETHERLANDS As companion animal veterinarians, we are increasingly faced with health In many countries, the legislation and regulation on animal welfare focus and welfare problems in patients related to extreme conformation. How on large animals. Where it includes any animal welfare of companion do we deal with the fact that we see more and more compromised dogs? animals, the text of the law is often very broad and open to interpretation. Are we part of the problem by facilitating the breeding of these dogs by For example, the Dutch legislation states ‘that it is prohibited to breed performing artificial insemination or elective caesarean sections? Do we companion animals in a manner that is detrimental to the welfare and maintain the status quo by performing conformation-altering surgery? Let health of the parent animal or its offspring’. However, what is great in the us acknowledge that we are part of the problem, but for sure we can play case of the Dutch Government, they did not leave it like that. They took a a major role in moving forward towards the solution. Veterinarians are the major step forward to be able to enforce the legislation when ’a breeder experts in animal health and welfare. has made insufficient effort to prevent harmful conformational features, serious diseases or behavioural abnormalities from being passed on to 113

13–15 NOVEMBER, 2021 offspring’. Aug 189(2)141-146 https://pubmed.ncbi.nlm.nih.gov/21757380/ The focus was first on brachycephalic dogs, and the Minister asked the Hedhammar ÅA, Malm S, Bonnett B. 2011b veterinary faculty to come up with criteria. Unfortunately, in 2020, when the criteria were implemented, none of the dogs from breeds like Pugs, International and collaborative strategies to enhance genetic health in French Bulldogs, and Bulldogs could meet these criteria; therefore, it indi- purebred dogs. Vet J. Aug; 189(2):189-96. https://doi.org/10.1016/j. rectly led to a ban of breeding these dogs in The Netherlands. But did that tvjl.2011.06.018 solve the issue? The reality is that those breeds are now imported. And, not including the Kennel Club, relevant breed clubs or breeders increased O’Neill DG, Keijser SFA, Hedhammar Å, Kisko C, Leroy G, Llewellyn-Zaidi A, the polarisation between and within stakeholders. Malm S, Olson PN, Packer RMA, Rousselot JF, Seath IJ, Stull JW, Bonnett BN. 2017 V INTERNATIONAL MULTISTAKEHOLDER APPROACH Moving from information and collaboration to action: report from the 3rd Since the 1st Dog Health workshop in Stockholm, each subsequent Work- International Dog Health Workshop, Paris in April 2017. Canine Genet shops of The International Partnership for Dogs (IPFD) in Dortmund, Paris, Epidemiology. dec 7; 4:16. https://doi.org/10.1186/s40575-017-0054-4 and Windsor all have had sessions on extreme Conformation (O’Neill DG, Keijser SFA, Hedhammar Å, et al. 2017,Pegram, C.L., Bonnett, B.N., Skarp, Pegram C.L., Bonnett, B.N., Skarp, H. et al. 2020 H. et al. 2019) Moving from information and collaboration to action: report from the 4th In Windsor (UK) in June 2019, at the 4th International Dog Health Work- international dog health workshop, Windsor in May 2019. Canine Genet shop, one session was entirely focused on branchy issues, especially Epidemiol 7, 4. BOAS. At the meeting, it was suggested it would be helpful to start a multi-stakeholder International Brachycephalic Working Group. Although https://doi.org/10.1186/s40575-020-00083-x the early focus was on brachycephalic dogs, the group soon decided to broaden the scope and include all extreme conformations in dogs. Bonnett B, Megens M, O’Neil D and Hedhammar Å 2021 It was renamed: the International Collaborative on Extreme Conforma- tion in Dogs (ICECDogs). Currently, the group exist of stakeholders and International and National Approaches to Brachycephalic Breed Health multi-stakeholder groups from seven countries and is growing. Reforms in Dogs For further info about aim and scope of international and some national In Health and Welfare of Brachycephalic (Flat-faced) Companion Animals activities in i.e. UK , please visit https://dogwellnet.com/icecdogs/ http:// A Complete Guide for Veterinary and Animal Professionals 1st Edition www.ukbwg.org.uk/ Edited By Rowena Packer, Dan O’Neill VI Further actions and strategies needed https://www.routledge.com/Health-and-Welfare-of-Brachycephal- Despite having achieved great attention by stakeholders as well as media, ic-Flat-faced-Companion-Animals-A-Complete/Packer-ONeill/p/ and despite the already created awareness of most of the negative effects book/9780367207243 of exaggerated anatomical features, we have NOT achieved a significant impact on the prevalence and severity of health problems related to BOAS. Partly by a simultaneous dramatic rise in popularity of the type of dogs of concern. Partly by not having been able to influence the perception by the public of a “desired” individual of brachycephalic dog with less exaggerat- ed features. It is crucial to change the perception of what a healthy dog is. We need to urge the judges to promote the less exaggerated individuals at shows and breeders to use them to produce the next generation. And we veterinarians should not only treat dogs with clinical symptoms, but also assist in the selection of healthy breeding stock and be stronger involved in the selection for favourable and less exaggerated breed-specif- ic anatomical features. Let us change our focus from banning and avoiding the worst, to promot- ing the desired individuals to be used for breeding. That calls for an ex- tended involvement in information and educations of the public in general, as well as breeders and judges at dog shows. Veterinarians are a key stakeholder, and we should take our responsibility. But we should also acknowledge that we cannot solve such a complex issue alone and therefore we should join forces to the benefit of the dogs involved. References Hedhammar ÅA, Indrebø A 2011a Rules, regulations, strategies and activities within the Fédération Cy- nologique Internationale (FCI) to promote canine genetic health, Vet J. 114 WSAVA GLOBAL COMMUNITY CONGRESS

0067 be verified by CT/MRI of the pituitary gland. SCIENTIFIC ACHIEVEMENT AWARD LECTURE: Treatment options FELINE DIABETES MELLITUS: CHALLENGES IN DIAGNOSIS, THERAPY AND MONITORING Treatment consists of drug therapy, dietary therapy and weight manage- ment. Various classes of drugs are available for the treatment of diabetes C. Reusch in humans, only very few of them have either been evaluated in larger groups of cats or have been found to be of minor effectiveness. SGT-2 Zürich/Switzerland inhibitors, which are given orally are currently under investigation seem to be quite promising. However, there is the potential risk of diabetic Qualifications: ketoacidosis in cats which have a complete lack of endogenous insulin production. Another promising class of drugs are the incretin-related Claudia E. Reusch therapeutics (e.g. GLP-1 agonists). They may not be sufficiently effective to use them as monotherapy, however, they seem to be able to significant- Prof. Dr. ly reduce glycemic variability in diabetic cats when given additionally to insulin3. Dipl ECVIM-CA So far, insulin is the mainstay of therapy. All available insulins are [email protected] generally effective in cats, however, duration of effect as well as action Feline diabetes mellitus: challenges in diagnosis, therapy and monitoring profiles vary substantially. Insulins which come as a suspension need mixing before use, creating an important potential source of error. Insulin Diagnosis and characterization of type of diabetes analogues come as clear solutions and mixing is not needed. They should render insulin absorption more predictable. Additionally, duration of effect Cats have the potential to develop stress hyperglycemia which may have of Caninsulin/Vetsulin in cats often times is too short (< 9 hours)4. In the same magnitude as hyperglycemia due to diabetes. Therefore, diagno- Zurich our insulin of first choice in cats is Lantus with a starting dose of sis of diabetes warrants caution and may pose a challenge in some cases. 1-2 U/cat BID. The ESVE started the ALIVE project several years ago, with the aim to create agreement over the definitions of diseases and diagnostic criteria. Application of small insulin doses with syringes may be associated with The ALIVE criteria for the diagnosis of feline diabetes are: large error, usually the delivered dose is substantially higher than the intended dose5,6. We therefore recommend to deliver small doses of 1. In a cat with a random blood glucose > 270 mg/dl (15 mmol/l) with Lantus in cats with the JuniorStar pen. If good glycemic control cannot be classical clinical signs of hyperglycemia or hyperglycemic crisis AND at reached, in particular when the cats shows high glycemic variability (see least one of the following criteria: below) we switch to Toujeo insulin, a novel glargine formulation with 300 - increased glycated proteins U/ml (instead of 100 U/ml) glargine with an improved pharmacokinetic profile. - glucosuria on more than one occasion on a naturally voided sample at home at least 2 days after any stressfull events. Diabetic cats should be fed a diet low in carbohydrate (< 15% ME). The exception are cats with another disease, in those cases other diets may 2. In a cat with a random blood glucose > 126 mg/dl (7 mmol/l) and < 270 have priority. Cats with diabetes often times are obese, which is associ- mg/dl (15 mmol/l) and at least 2 of the following criteria: ated with insulin resistance. Initially cats with diabetes lose weight which puts them at risk for hepatic lipidosis. At this stage additional weight loss - classic clinical signs of hyperglycemia or hyperglycemic crisis by weight loss programs should be avoided. The first action should be to start therapy and to stop weight loss triggered by insulin deficiency. Only - increased glycated proteins thereafter a weight loss program should be started. - glucosuria on more than one occasion on a naturally voided sample at Monitoring and glycemic variability home at least 2 days after any stressfull events. A diabetic cat in which pu/pd and polyphagia has resolved and body Situation 2 often times is challenging as none of the additional criteria weight stays in the desired range is usually well controlled. As well may be met. controlled cats, well controlled cats with short phases of hypoglycemia and cats in diabetic remission look the same clinically, further monitoring Up to 80% of cats may suffer a type 2-like diabetes, which is a combi- with blood glucose measurements is advisable. Persistence of clinical nation of impaired insulin action and β-cell dysfunction. A substantial signs and undesired weight loss is suggestive for poor glycemic control percentage of cats with this type will experience diabetic remission. or the presence of another disease. Blood glucose measurements (not Although it would be most desirable to be able to predict remission at the fructosamine or glycated hemoglobin) will help to identify the problem time of diagnosis, unfortunately none of the tests evaluated so far allow (e.g. short duration of insulin effect, high glycemic variability). Monitoring discrimination between cats with and without remission1. should either be done by blood glucose curves with a portable glucose meter (PBGM) or continuous glucose monitoring systems. A huge number The remaining cats develop diabetes as a consequence of another of PBGMs are available, most of them are made for use in humans. The disease. The most relevant of those are pancreatitis and hypersomatot- latter tend to underestimate the true blood glucose concentration in cats. ropism. The cause and effect of pancreatitis and diabetes however is It is therefore advisable to use a PBGM which has been designed for use very difficult to define and largely unknown. Hypersomatotropisms has in cats and has been validated in an independent study. For continuous gained a lot of attention during the last decade. In our clinic approxi- glucose monitoring a new technology called flash glucose monitoring mately 15% of cats with diabetes suffer from hypersomatotropism. IGF-1 (FreeStyle Libre) has recently become available. In cats the sensor is usu- is a valuable screening test, however its use is associated with some ally placed in the dorsal/dorsolateral neck area. When the reader device pitfalls. Some cats with diabetes and hypersomatotropism have low IGF-1 is swiped close to the sensor in current interstitial glucose concentration concentrations before starting insulin therapy, however, intensive insulin appears on the display as well as an 8-hour trend graph. The system has therapy may lead to a false increase in IGF-1. Additionally, in some assays removal of interfering binding proteins is incomplete leading to a false increase in IGF-1 concentration2. Therefore, the diagnosis should always 115

13–15 NOVEMBER, 2021 several advantages: small size, easy to use, intuitive computer software, 0068 affordabilitiy. The disadvantage is a high rate of sensor failures7. In the study by Shea and Hess7 correlation between the FreeStyle Libre and an THRIVING, NOT JUST SURVIVING IN VETERINARY automated biochemical analyzer was good. However, correlation was poor MEDICINE in case of hypoglycemia. We have had variable results with the FreeStyle Libre with regard to accuracy. In some cats glucose concentrations are M. Brashear close to the gold standard method, in others large discrepancies are found. West Lafayette/United States of America In cats in which measurement of blood glucose is impossible, monitoring Qualifications: clinical signs and urine glucose may be used as an alternative. It is im- portant to inform the owner about the limitations and the potential risks of Megan Brashear, BS, RVT, VTS (ECC) misinterpretation. Fructosamine also has substantial limitations: marked hyperglycemia is needed to increase fructosamine above the upper limit [email protected] of the reference interval; its concentration is influenced by various other For those who work full time, we find ourselves spending more quality diseases (e.g. hyperthyroidism); there are large individual differences with time with our coworkers than those people who we chose to marry or regard to glycation. share our homes with. 40 hours a week in a small treatment area with peo- ple we are forced to interact with is not always a pleasant experience. Add Glycemic variability (GV) refers to glycemic excursions, including episodes the stress of a hospital, money, clients, time constraints, and a barking of hypo- and hyperglycemia, during the course of a day or on different dog or two and we can quickly see how communication breakdowns hap- days8. GV may pose a huge challenge for both the veterinarian and the pens within veterinary teams. If we are lucky we have the support of our owner. A systematic approach is important in order to decide if the GV has team and we work through problems together. Unfortunately, competition a treatable reason or not. and lack of communication skills lead to a breakdown within veterinary teams. By learning good communication skills, we can elevate not only Treatable reasons are: technical problems with the insulin and its our teamwork with each other, but we can see our clients as team mem- application, suboptimal action profile of the insulin, wrong diet, stress, bers as well. The first step to dealing with issues among team members is diabetogenic drugs, other diseases. Reasons which are difficult to diag- to actually deal with the problem. Issues that start small can blow up into nose and/or treat are: abnormal insulin absorption or insulin metabolism, big problems if they are left to fester. Managers and leaders need to en- variable insulin sensitivity, disturbed counter regulation, disturbed gastric courage employees to manage small problems amongst themselves, and emptying. We recently demonstrated that GV declines when cats were employees need to feel empowered to generate difficult conversations in given a GLP-1 analogue once a week additionally to their standard insulin order to move past disagreements. Have these conversations outside of therapy3. work if at all possible – at least begin them on a break away from the front desk. Admit some fault to the misunderstanding and ask what can be References done to move past the issue. By confronting problems early in the process we can hopefully avoid a large-scale issue months down the road. 1 Tschuor F et al: Remission of Diabetes Mellitus in Cats Cannot be Pre- dicted by the Arginine Stimulation Test. JVIM 2011;25:83-89 The first step to developing good communication skills is to make sure that we understand ourselves. When we know how we communicate, how 2 Tschuor F et al: Evaluation of four methods used to measure plasma we prefer to be communicated with, and know what our stressors are, we insulin-like growth factor 1 concentrations in healthy cats and cats with are more aware of ourselves and how we react to others. The purpose of diabetes mellitus or other diseases. AJVR 2012; 73,1925-1931 understanding people and their personality characteristics is not to label and discredit people, but to see strengths and play to those strengths. 3 Kraemer AL et al: Glycemic variability in newly diagnosed diabetic cats Practice members need to place a premium on helping each other. While treated with the glucagon-like peptide-1 analogue exenatide extended it is beneficial to foster comradery among small groups working together, release. JVIM 2020;34:2287-2295 do not let it turn into hostility for other teams. This can happen between shifts as well as between varying roles. Challenge employees to see 4 Gostelow R et al: Prospective evaluation of a protocol for transitioning each other as internal customers. Treat coworkers with as much respect porcine lente insulin-treated diabetic cats to human recombinant prota- as a client deserves. Encourage employees to participate in the training mine zinc insulin. JFMS 2018; 20: 114-121 process. If a technician is having problems with a process that involves the front desk, a customer service representative can step in and help 5 Casella SJ et al: Accuracy and Precision of Low-Dose Insulin Administra- with the training process rather than waiting for the technician manager to tion. Pediatrics 1993;91:1155-1157 respond. The technician team, rather than complain that the check in pro- cess is taking too long, can offer to help by taking phone calls or entering 6 Malerba E et al: The accuracy and precision of insulin administration information into the computer. using human and veterinary pen-injectors and syringes for administration of insulin. JVIM 2021;35:1255-1264 Euthanasia can be a major trigger to feeling fed up and burned out. Depending on the patient population, some veterinary professionals are 7 Shea EK et al: Validation of a flash glucose monitoring system in outpa- involved with euthanasia (many times multiple) every single shift. While tient diabetic cats. JVIM 2021;1-10 euthanasia can be a great gift for suffering animals, the grieving client also requires compassion. Sometimes an animal is euthanized for a 8 Suh S et al: Glycemic Variability: How Do We Measure It and Why Is It correctable medical problem but the client lacks the funds. Other times, Important? Diabetes Metab J 2015;39:273-282 euthanasia is the appropriate choice but the client cannot bring them- selves to authorize it. Animals are removed from the hospital to “die in peace” at home, leaving the staff in frustration. Even if a visit does not end in euthanasia some animals return home with minimal treatment due to the financial position of owners. In these types of situations, the vet- erinary team must train themselves to look for the good in the client and 116 WSAVA GLOBAL COMMUNITY CONGRESS

resist the urge to judge. By giving in and judging that client, we take on Feelings of burnout do not have to be a permanent situation. With that responsibility for the patient and the end result can never be positive. recognition, self-care, and time it is possible to return to loving your job, Our role is not to judge the decisions made by others. Our role as veteri- your patients, and your clients. Evaluate yourself every few months and nary professionals is to provide the best possible care for the pet and to be honest with where you are in your career. What can you do to remain educate the owner with empathy and decency. When we are able to look happy and ensure mental health in the future? Rely on your coworkers for for and focus on the client experience, we are better able to understand support, and be a support to them. Take time to take care of yourself so their decisions and focus more on making the pet’s life the best we can that you can take care of others. with what we are given. Many veterinary hospitals operate in a guilt culture, where staff members work long hours and extra shifts out of guilt to their coworkers and other patients. Lunch and breaks are not taken because there is always more work to do and more patients to care for. Staff members work through colds and fevers because staying home sick means your team has to work twice as hard. It is up to all of us to take responsibility for ourselves and do what is best by us to keep our longevity in the profession. Make a meal break a priority and communicate with your team when you plan to take a break. Put pressure on teammates to take a minute to eat. Discuss the possibility of a hospital budget for healthy snacks close to the treatment area. While easy to place blame when triage lists are high and staffing is low, it is up to us to empower ourselves and each other to take care of ourselves. While impossible to banish guilt completely, work on becoming self-aware and fight the urge to give in every time. The tools to combat compassion fatigue and burnout are within us. First is to recognize chang- es in our attitude and outlook. Quick to anger, apathy, sadness, trouble sleeping, forced isolation, crying at work (or at the thought of work), and lack of hobbies outside of work are all danger signs of burnout. Are you simply going through the motions at work? Do you find yourself treating patients without caring who they are or why they are in your hospital? Do you lack empathy for your coworkers? Recognizing negative trends in your own behavior and thoughts can mean that you are suffering. Recovering from that “crispy” burned out feeling is possible but it requires self-care and self-inventory. Taking time away from work, whether it be a few days at home watching movies, taking appropriate breaks, or leaving town for a few days can help to reset. Discover hobbies and have something to look forward to outside of work. Eating better is necessary, and means that you have to take breaks at work to eat home cooked food. Exercise, as simple as walking your dog every night after work, can help ease anxiety and bad feelings. Many veterinary practices, invested in the long term health of their employees, are implementing self-care ideas in the practice. Working to change the guilt culture takes work and a progres- sive manager, but should be a goal in every hospital. Even if you do not have symptoms of compassion fatigue, look out for problems in your coworkers. Look out for each other by ensuring everyone has appropriate breaks. Make it okay for everyone to discuss their feel- ings after a tough euthanasia. Plan activities outside of work for everyone to bond together in a non-stressful situation. Discuss the possibility of a wellness program at work. Reward healthy behavior, or have a central location for listing positive changes and encourage discussion. Create a small budget for buying healthy snacks for the team. Even small changes from leadership can show to the staff that mental and physical health is important. It is also important to resist the urge to complain about clients in front of coworkers. Clients can be a major source of stress due to decisions they make that are outside of our control. It is easy to place our own knowl- edge and desires onto clients and then experience crushing defeat when decisions are made outside of what we expect. It is easy to slip into anger when we think animals have waited too long for care, or when they are kept alive when we perceive suffering. It is easy to complain when a client over the phone asks “dumb” questions. Take a step back and assume the best from each interaction with a client. They want the best for their pet, and they are doing the best that they can do. Complaining, making fun of client questions, and placing blame will only serve to bring you down and by verbalizing your complaints you will also bring down your team. 117

13–15 NOVEMBER, 2021 0069 Caloric restriction ANTI-AGING CONCEPTS FOR GERIATRIC PETS Calorie restriction acts, in part, by inhibition of mTOR. When no protein is coming in, mTOR shuts off, and autophagy (clean up, recycle) begins. This M. Mcmichael allows removal of damaged organelles, cleaning up debris, and removal of damaged DNA. Calorie restriction (fasting) reverses chemotherapy in- Auburn/United States of America duced DNA damage. Cycles of fasting delay progression of melanoma, gli- oma, breast cancer and improve effectiveness of chemotherapy. In 2006 Qualifications: researchers published findings from a study in dogs. There were 48 Labra- dor Retriever puppies from 7 litters that were split into pairs (matched for Maureen A. McMichael, DVM, M.Ed., Diplomate ACVECC sex and weight). All were fed the exact same diet but the calorie restricted Title: UPDATE ON ANTI-AGING CONCEPTS FOR PETS group were fed 25% less than the control group starting at 8 weeks of age. The calorie restricted group lived 1.8 years longer, and, importantly had Author: Maureen A. McMichael, DVM, M.Ed., DACVECC a significant delay in age related diseases such as osteoarthritis. Newer research using this study suggests that signals from the microbiome of Institution Address: College of Veterinary Medicine, Auburn University, the calorie restricted group may be involved in the longevity and health of Auburn, AL the dogs. https://pubmed.ncbi.nlm.nih.gov/18062831/ [email protected] Studies in humans are a bit more difficult and the CALERIE study attempt- ed to mimic the dog study. The humans, however only cut down their Introduction intake by 11.9% in the calorie restriction group. Despite this, after 2 years there was a decrease in cholesterol, systolic and diastolic blood pressure, There has been a plethora of anti-aging research in the last few years, insulin sensitivity, metabolic syndrome score and C-reactive protein. some of which is applicable to our veterinary patients. The main benefits of these strategies are their ability to halt the negative effects associated Promising Therapies with aging such as arthritis, cognitive decline, frailty, sensory loss (e.g., hearing, vision loss), and energy level. The area that has received the most Diet attention is caloric restriction which has very promising results. Caloric restriction has the most solid research behind it. Cutting calories Review of Essential Repair Mechanisms by slowly decreasing the amount fed over time to ~20% less calories is likely to be very helpful over the course of the dog’s life. The gut is the Autophagy workhorse of the body, and likely where health or disease begins. Inflam- mation that begins in the gut spreads to all areas of the body leading to Autophagy is the body’s ability to clear damaged organelles and dam- pain and dysfunction. There is a delicate balance between health produc- aged DNA by clearing excised genomic fragments. When an organelle ing microbes and disease producing microbes that is easily disrupted is targeted for recycling (e.g., mitochondria) the organelle is isolated leading to disease. All of these conditions are significantly worsened within a vesicle called an autophagosome which subsequently fuses with as dogs age and many of them can be addressed with simple and safe a lysosome. The new, autolysosome, is then degraded and the organelle strategies. Essentials of a healthy microbiome start with high quality fiber. parts are recycled. This essential mechanism allows the body to maintain The best sources of beneficial fiber are often lacking in many K9 diets. healthy cells. Autophagy is inhibited in early stage cancer, allowing tumor These include asparagus, Jerusalem artichoke, dandelion greens, banana, formation and growth and occurs during periods of low to no energy input leeks and garlic and onions. These last two (garlic and onions) can cause (e.g., fasting, low protein ingestion). problems in dogs if ingested in large amounts so it is best to limit these to small amounts or skip them. Intestinal gas (flatulence) can occur if the Sirtuin Signaling fiber is increased too quickly. It is best to go slow and build up. Sirtuins (SIRTs) are a family of NAD+ dependent deacylases that prevent Fermented foods such as pickled veggies, miso, sauerkraut, and kom- disease and may reverse some aspects of aging. Sirtuins delay cellular bucha are very helpful in replacing some of the good microbes that may senescence and extend lifespan through age related telomere attrition. have been lost due to antibiotic administration, illness, or from chlorinated Sirtuins regulate DNA repair, fat differentiation, glucose output, insulin water. Chlorinated water is one reason to continue to supplement the diet sensitivity, fatty acid oxidation, inflammation and aging. There are differ- with fermented food. Many dogs love fermented veggies and these make ent SIRTs in the cytoplasm, mitochondria, nucleus of each cell. There is a wonderful snack. The absorption of fats, fat soluble vitamins, and some an association between loss of SIRTs in cancer cells and accumulation of B vitamins diminishes in dogs with age. Supplementation with select vita- mutations and genomic instability. mins that are difficult for the gut to absorb in older dogs (e.g., B12) should be considered. Not having enough B12 can lead to decreased absorption mTOR of nutrients from food, low RBC counts (and low energy), difficulty fighting off infections (e.g., immune function compromise), mental decline (e.g., The mammalian (or mechanistic) target of rapamycin (mTOR) are kinases forgetting or not responding to commands, acting confused), decreased that play important roles in autophagy, protein synthesis, mitochondri- energy, balance problems (seem wobbly or unstable), difficulty sleeping al biogenesis, cell growth & proliferation, cell survival & motility, and at night, and many other issues. In order to get around the difficulty of transcription. Decreased mTOR is associated with increased life span in absorbing this orally in older dogs many veterinarians prescribe injections mice and worms. A simplified description is that when mTOR is turned on of B12. The Texas A&M GI Lab has published dosages for dogs on their mammals are in growth mode (e.g., cells divide, all energy goes towards website along with testing options. https://vetmed.tamu.edu/gilab/re- growing) and when mTOR is turned off we are in preservation and clean up search/cobalamin-information/#dosing mode (e.g., autophagy). Amino acids, particularly methionine and leucine, are potent activators of mTOR and this “abundant energy” signal tells the Gastric Acid body to grow. When mTOR is off (no energy or amino acids coming in) it tells the body to switch to quiescent mode. In quiescent mode, the body Gastric acid and prostaglandins in the stomach decrease with age, making switches to autophagy and the clean up begins. 118 WSAVA GLOBAL COMMUNITY CONGRESS

digesting food take longer and will increase the chance of ulcers in the 0070 stomach if the dog is on any anti-inflammatory medications (e.g., NSAIDs, Rimadyl®, Ibuprofen, etc.). Alternative options for inflammation include NEW PRACTICE TOOLS FOR RECOGNITION OF turmeric, ginger, Epsom salt soaks, cold laser therapy, and acupuncture. LEPTOSPIROSIS In older humans (and likely dogs and cats) the taste buds decrease. It is likely that this contributes to a diminished appetite. The combination J. Sykes of nasal changes (decrease in olfactory receptors, drying out of nasal mucous) and decreased taste buds likely contributes to appetite changes. Davis/United States of America A simple vaporizer may help improve both taste and smell function. There is decreased movement of food through the GI Tract due to lower gastric Qualifications: acid, lower numbers of neurons and decreased blood flow to the gut. This slows the movement of the intestines so that it takes food longer to move Jane Emily Sykes through the GI tract. Allowing older dogs more time to digest (e.g., before vigorous exercise) may be helpful. Constipation should be considered a BVSc(Hons) PhD MBA DipACVIM (Small Animal Internal Medicine) serious condition as it is related to cognitive decline in humans (and likely dogs). There is a clear association between constipation and onset of [email protected] Parkinson’s in humans. Interestingly, the only substance that is associated Leptospirosis is caused by infection with various serovars of Leptospira with absence of Parkinson’s is coffee consumption, which has a benefi- interrogans sensu lato. Organisms are transmitted by direct contact with cial effect on constipation. Decreased movement of the GI tract leads to infected urine, bite wounds or ingestion of infected tissues, or indirectly, constipation, which is quite common in older dogs. Two issues that can through contact with infected water, soil, food or bedding. Survival of lep- worsen constipation are dehydration and lack of fiber. Older dogs have tospires is promoted by stagnant warm water, a neutral or slightly alkaline less efficient kidneys (they cannot optimally dilute or concentrate urine) pH, and temperatures between 0 and 25°C. and are predisposed to dehydration. In addition, the thirst response is diminished in older dogs so they will often become dehydrated before they There are over 200 pathogenic serovars, which are grouped into anti- become thirsty and have a hard time catching up. genically-related serogroups. Classification of leptospires is gradually moving from predominantly serovar-based classification to that based on Energy Requirements sequence typing (sequence type [ST]-based classification). Each serovar (and more accurately, each ST) is adapted to a one or more mammalian In dogs a 20% decrease in energy requirements was documented to occur host species (maintenance hosts). Other hosts act as incidental hosts. after the age of 7 years. It is likely that in dogs decreased activity (e.g., Disease in incidental hosts tends to be more severe and the duration of partially from arthritis) contributes to lack of exercise and this contributes shedding is generally shorter. Maintenance hosts include dogs (Canicola); to decreased food requirements. Aging is associated with decreased mus- rats (Icterohaemorrhagiae); small wildlife mammalian species such as cle mass (sarcopenia). The loss in muscle leads to a host of problems voles, skunks, and raccoons (Grippotyphosa); cattle and pigs (Pomona); including instability in the joints (progressing to arthritis), weakness, and pigs (Bratislava); cattle (Hardjo); and mice (Ballum). The prevalence of lack of desire for exercise. The vicious cycle then leads to more muscle infection with a serovar/ST in dogs depends on the degree of contact loss (from lack of activity). between the dog population and the maintenance host for that serovar/ST. Melatonin The most common serovars thought to infect dogs before the introduction of the Leptospira vaccines several decades ago were Icterohaemorrhagiae Melatonin, a hormone that is essential for sleep, is produced in the brain and Canicola. After the introduction of bivalent bacterins containing these with decrease in melatonin with age in people. Keeping the gut healthy two serovars, in North America and Europe, there were decreasing reports may help keep melatonin levels normal but supplementing with melatonin of disease associated with seroconversion to Canicola and Icterohaemor- (3-6 mg/dog given 30 minutes before bed) may help older dogs sleep. rhagiae, and increasing reports of disease associated with seroconversion Since the detrimental solutes in the brain are cleared by the glymphatic to serovars Pomona, Grippotyphosa, Autumnalis and Bratislava (in North system during the deep phase of sleep, melatonin may help prevent America) and Sejroe, Australis and Grippotyphosa (in Europe). Vaccine cognitive decline. pressure, increasing contact between dogs and certain wildlife reservoir hosts and increased testing have been suggested as reasons for this References change. In truth, the actual serovars causing disease in dogs worldwide still remain poorly characterized because the disease is diagnosed by se- Lawler DF, et al. Diet restriction and Ageing in dogs. Br J Nutr 2008 rology, and serologic test results cannot be used to identify the infecting Apr;99(4):793-805 serovar. Recent studies using culture and sequence typing have begun to shed more light on the true infecting serovars. https://pubmed.ncbi.nlm.nih.gov/18062831/ Pathogenic leptospires penetrate abraded skin or mucus membranes and multiply rapidly in the bloodstream and tissues, causing renal failure, hepatic injury (usually not hepatic failure) and vasculitis. The disease is multisystemic and may also involve the pancreas (pancreatitis), gas- trointestinal tract (gastroenteritis), eye (uveitis) and lungs (leptospiral pulmonary hemorrhage syndrome, or LPHS). In humans, Leptospira can also cause meningitis, which is most commonly manifest as a severe headache. Clinical manifestations may also depend on the age of the host, the infectious dose, and the strain of Leptospira involved. Leptospirosis is a critical illness that requires immediate antimicrobial therapy. Because there is a lack of widely-available, rapid, point-of-care organism-detection tests, and multiple tests may be required to confirm the diagnosis, presumptive diagnosis requires a high index of clinical sus- picion and initiation of antimicrobial therapy while awaiting all diagnostic 119

13–15 NOVEMBER, 2021 test results. sensitive than other assays early in the course of illness.2 Positive results may occur as a result of very recent vaccination or exposure; in one Euro- Leukocytosis, thrombocytopenia, azotemia, increased CK activity, pean study, 19/25 dogs were seronegative using the WITNESS Lepto by hypoalbuminemia and mild to moderately elevated liver enzyme activities 12 weeks after vaccination.3 Clinicians should consider reflex testing with (especially ALT) are common. Although hyperkalemia has been reported, MAT in order to obtain a quantitative titer if positive results occur using normokalemia or hypokalemia are more common because of the effect of in-clinic serologic tests, followed by convalescent serology 1-2 weeks Leptospira on the renal medullary thick ascending limb tubular Na+-K+-Cl- later in order to document a change in titer. Additional clinical validation cotransporter. Urinalysis may reveal isosthenuria, proteinuria, glucosuria of these assays in different regions of the United States would be helpful and casts. Although it occurs with other causes of renal tubular damage, to confirm their sensitivity and specificity. glucosuria in addition to azotemia can be a “red flag” for a diagnosis of leptospirosis. Proteinuria is typically low-level (urine protein:creatinine Darkfield microscopy of the urine is not recommended as sole test for ratio < 5), which helps differentiate leptospirosis (interstitial nephritis) diagnosis because of the large number of false positives and false neg- from Lyme nephritis (which involves the glomerulus). Thoracic radiogra- atives. Culture is difficult because of the fastidious growth requirements phy may reveal a focal or diffuse interstitial to bronchointerstitial pattern; of leptospires and the need for specialized media, may be the only way to alveolar patterns may represent pulmonary hemorrhage. Occasionally properly identify infecting serovars and serotypes. The sensitivity of PCR mild pleural effusion is evident. Hepatomegaly, splenomegaly, renomegaly assays is still not well established, and they do not provide information and/or peritoneal effusion may be evident from abdominal radiography. about the infecting serovar, although they have been used to provide Hyperechoic renal cortices and mild renal pelvis dilation are occasionally information on ST. The sensitivity of PCR may also be higher very early seen with abdominal ultrasound. in the course of illness and in dogs that have not received any treatment with antimicrobials. PCR assays are best performed on blood AND urine A machine learning algorithm has shown promise for early diagnosis of concurrently because urinary shedding begins 10 days after the onset of leptospirosis in dogs based on initial laboratory findings, and was more infection. Because organisms can be detected in the urine of dogs that do sensitive than acute serology using the microscopic agglutination test. not have leptospirosis, any positive PCR result on urine should be inter- preted in light of clinical signs. One recent study showed good agreement Currently available diagnostic tests include PCR, serology using the between PCR and culture in experimentally infected dogs.4 microscopic agglutination test (MAT), and in-clinic serologic assays that detect IgG/IgM (SNAP Lepto, IDEXX Laboratories; ImmunoComb Lepto- Selected References: spira Antibody Detection Kit, Biogal), or IgM (WITNESS Lepto, Zoetis). A point-of-care isothermal PCR assay is also available in some countries • Miller MD, Annis KM, Lappin MR, et al. Variability in results of the (PCRun, Biogal). microscopic agglutination test in dogs with clinical leptospirosis and dogs vaccinated against leptospirosis. J Vet Intern Med 2011;25(3):426-432, In the MAT, respective titers are provided for each of several different serovars in order to increase the chance of antibody detection. Studies in • Lizer J, Velineni S, Weber A, et al. Evaluation of 3 serological tests for humans and dogs have shown that the serovar with the highest titer can early detection of Leptospira-specific antibodies in experimentally-infect- vary over time and that paradoxical cross-reactivity to multiple serovars ed dogs. J Vet Intern Med 2017a; Nov 13 [Epub]. occurs after exposure to a single serovar. In addition, the panel used in veterinary medicine is limited when compared with 20+ serovar panels • Lizer J, Grahlmann M, Hapke H, et al. Evaluation of a rapid IgM used in human diagnosis. Thus, the MAT should not be used to try to iden- detection test for diagnosis of acute leptospirosis in dogs. Vet Rec tify the infecting serovar. Titers with any serologic test may be negative 2017b;180(21):517. in the first week of illness because of the short incubation period and delay in antibody production. Low positive or negative titers after at least • Blanchard S, Cariou C, Bouyet J, et al. Quantitative real-time PCR assays one week of illness suggest leptospirosis is not present. Overdiagnosis for the detection of pathogenic Leptospira species in urine and blood results from misinterpretation of positive serologic test results. Positive samples titers early in the course of an illness may reflect residual post-vaccination titers or prior subclinical infection, and are not diagnostic for the disease. Demonstration of a fourfold rise in titer is required over a 1-2 week inter- val. In acutely ill dogs (< 1 week of illness), it is the author’s opinion that leptospirosis serology should only be performed in a paired fashion or not at all, because of the limited utility of a single positive titer, regardless of its magnitude. Postvaccinal titers against Icterohaemorrhagiae, Canicola, Grippotyphosa and Pomona occasionally rise as high as 1:6400 for a few months after vaccination, and these can interfere with interpretation. The results can also vary dramatically between laboratories.1 Use of a labo- ratory with a high level of quality control is recommended, or a laboratory that participates in the International Leptospirosis Society’s proficiency testing scheme. In-clinic serologic assays yield qualitative (positive or negative) results, and are useful for screening dogs for the presence or absence of anti- bodies. Should these kits yield negative results, then the clinician should consider whether it may be too early for the animal to have developed antibodies (as can occur with the MAT). Another test should be performed one week later to see if the animal seroconverts. The IDEXX assay detects IgG and IgM, and should these kits yield positive results, then the clinician should consider whether previous vaccination has occurred. Previous exposure without clinical disease should also be considered as a reason for positive results. The Zoetis assay detects IgM, and appears to be more 120 WSAVA GLOBAL COMMUNITY CONGRESS

0071 Nutritional assessment in practice HOW TO USE NUTRITIONAL ASSESSMENT IN Every patient should have a physical examination (PE) (including pain PRACTICE assessment) and a nutritional assessment. A detailed nutritional history M. Rinkinen should be obtained as part of the medical history. Both body condition score (BCS) and muscle condition score (MCS) evaluations are included Vantaa/Finland in the PE and recorded. For BCS, a 9-point scale is advised (Freeman et al, 2001). Qualifications: Minna Rinkinen The nutritional assessment is a two-part process: DVM, PhD Adjunct professor • Screening evaluation. If the animal is found to be in good health and has [email protected] no diet-related risk factors, there is no need for further actions • Extended evaluation is performed if PE or dietary history reveal possible nutrition-related risk factors NUTRITIONAL ASSESMENT IN PRACTICE Nutritional risk factors necessitating more thorough evaluation Minna Rinkinen, DVM, PhD Dietary and medical history Adjunct professor Unconventional diet (e.g., home-made, raw, vegetarian); more than 10 % of daily calories origination from snacks or table scraps. Evidensia Veterinary Hospital Tammisto, Vantaa, Finland Gastrointestinal symptoms: vomiting, diarrhoea, anorexia, constipation, “Every patient, every time” nausea etc A physical examination should always include the evaluation of the five Medications and supplements vital signs: Physical examination • Temperature Unexplained weight change • Pulse Dental disorders • Respiration Poor hair coat, skin, or ear disease • Pain assessment Any medical condition identified • Nutritional assessment BCS and MCS To help practitioners with the 5th vital sign assessment WSAVA Global Nu- trition Committee (GNC) published the Nutritional Assessment Guidelines Ideal BCS for most pets is 4 or 5 out of 9. Any BCS lower or higher needs in 2011 as a tool for veterinarians (Freeman et al, 2011). additional scrutiny, as well as any sing of muscle wasting. The impact of nutrition on health and disease is well established. Ap- Extended evaluation propriate diet can help to maintain well-being and to prevent diet-related problems, whereas inadequate diet can cause substantial health issues. When nutrition-related risk factors are identified in the screening eval- In addition, dietary modification plays an important role in the manage- uation a thorough assessment of the animal, its diet, feeding, possible ment of certain medical conditions, e.g., chronic kidney disease or food medications and environmental factors is indicated. allergies. The pet parent is interviewed more detailed about any changes in food Currently, there are many feeding options available for dogs and cats, intake or behaviour (e.g., poor appetite, vomiting, problems in chewing). and some practices may possess a potential health risk for the pet. For Diagnostic work-up is planned individually and may include laboratory example, the pet parent may have chosen to feed their pet a home-made tests or diagnostic imaging. diet or have opted for a raw-food or vegetarian diet. These unconventional feeding practices have become more and more popular during the last The diet should be evaluated in detail: type of food the animal is eating decade (Dodd et al, 2020). (commercial, home-made), calorie and nutrition content, any treats, sup- Not all diets are created equal Every pet should be fed a balanced diet that meets its needs. Those needs vary depending on the animal species and physiological status. Poor or unbalanced diet may be the sole reason for the animal having clinical symptoms that have prompted the owner to seek veterinary medical help. Therefore, taking a proper nutritional history and assessing the nutritional status of the patient on every appointment is vital. Especially any unconventional diet should be scrutinized and considered a possible etiological factor. 121

13–15 NOVEMBER, 2021 plements, table scrap, bones, rawhide, dental chews etc. Is it possible the 0072 food the animal is fed may be tainted or spoiled? ALTERNATIVE DIETS (RAW, GRAIN FREE, Environmental factors and feeding practices need to be assessed, too. VEGETARIAN) Especially with cats the environment may have a big impact on nutrition (e.g., competition or conflicts in multicat household, other environmental C. Villaverde stressors). Amount of physical activity is important when estimating the energy needs of the patient. Fermoy/Ireland Interpretation, analysis, and actions Qualifications: First, animal’s condition is evaluated in relation to the current feeding. Is Cecilia Villaverde the caloric content right? Is the animal fed a proper diet considering its current life stage and other needs? Is there a medical condition requiring BVSc, PhD, DACVIM (Nutrition), DECVCN a dietary intervention? [email protected] If the current diet is not appropriate, then a better option should be sug- Commercial pet food started at the end of the 19th century and is now gested. If needed, a board-certified nutrition specialist may be consulted, a big industry all over the world. Currently, there are hundreds of pet especially if a home-prepared diet is required. As most of the caregivers food manufacturers and thousands of foods for healthy dogs and cats wish to give their pets treats it is advisable, in addition to the dietary available. Pet foods can be classified according to their moisture content recommendations, to list suitable treats and chews, too. & processing, target species, life stage, lifestyle, sensitivities, etc. Com- pared to more conventional diets (extruded or wet, meat and cereal- con- Why is nutritional assessment needed? taining diets) there are also alternative diets that are marketed as more natural (e.g., raw, grain free) or following human trends (such as plant- Every pet eats every day (with some exceptions). What they eat may have based/vegetarian). The veterinary team should be knowledgeable about a big impact on their wellbeing. Anorexia and hyporexia may be harmful alternative diet trends to better advice their clients on how to choose an even in a couple of days. adequate food for their pets. According to a recent study (Dodd et al 2020) more than 50 % of care- Vegetarian givers are feeding their pets home-made and/or raw food in addition to conventional diet. This feeding trend possesses a risk for health prob- Plant based diets for pets have been in the market for a few years. One lems. It is very likely that every small animal practitioner will see patients study (surveying English speaker pet owners) identified that mainly vegan that need an extended nutritional evaluation daily. Overlooking nutritional people fed exclusively plant-based diets to their pets1. Whereas owners assessment may lead to missing important patient information. who feed these diets overall may perceive their pets to be healthy2, some case reports have reported issues with these diets and laboratory analysis References available upon request studies have also identified potential problems, associated for exam- ple to amino acid concentrations3,4. Plant based diets for cats are not recommended, due to their carnivorous nature. They can be complete and balanced for dogs but, given the issues reported, it is important to use a product from a reputable manufacturer with good quality control (https:// wsava.org/global-guidelines/global-nutrition-guidelines/). Grain free Grain free diets are those formulated without cereals. These diets are no homogeneous, and their nutritional profile (similar to grain containing diets) is highly variable, and there is no evidence that these diets are supe- rior (nutritionally or in any other way) to cereal containing diets. Therefore, the term grain free is purely a marketing one. While they are commonly recommended for allergies, cereals are not a commonly reported allergen in the literature5, compared to animal meats. Grain free diets are not starch free, they use other sources of carbohy- drates such as pulses and root vegetables. While these ingredients have been long used in pet food, their inclusion in high amount is more typical of grain free diets. While these diets can be complete and balanced, an association between some brands of grain free diets (especially those high in pulses like peas and lentils) and dilated cardiomyopathy in dogs has been reported in the United States (https://www.fda.gov/animal-veterinary/animal-health-liter- acy/questions-answers-fdas-work-potential-causes-non-hereditary-dcm- dogs). Currently, the reason for this association is unknown and the FDA has not recommended a recall of these diets, and several research groups are actively investigating this topic6,7. 122 WSAVA GLOBAL COMMUNITY CONGRESS

Raw 0073 Raw meat based diets (RMBD) are increasing in popularity and their mar- TRANSITIONING TO PRACTICE - IF ONLY SOMEONE keting is heavily based on them being purportedly more “natural” for dogs HAD TOLD ME THIS BEFORE I GRADUATED! and cats, as in less processed and closer to the diet these species have evolved eating. This is debatable (evidence8 supports dogs have evolved B. Mcerlean eating starch and the typical prey of cat9 is not what is usually included in commercial RMBD) and, moreover, such a diet has not been shown to be Belhus/Australia associated with a longer, healthier life. Qualifications: These RMBD10 have well described risks, including nutritional issues, problems with bones and microbiological safety (https://wsava.org/ Brian Anthony Mc Erlean wp-content/uploads/2021/04/Raw-Meat-Based-Diets-for-Pets_WSA- MVB VA-Global-Nutrition-Toolkit.pdf). Publications have described both pets [email protected] and humans handling the food can get sick with pathogenic microorgan- If only someone had told me this before I graduated! isms. While the risk is not well quantified, it is present, and caretakers need to be aware of those before deciding on using RMBD for their pets. Brian Mc Erlean MVB Veterinary clinics should have a policy in place on how to handle these pets both as outpatients and during hospitalization, to ensure other AVA Benevolent Fund Trustee patients and staff are as safe as possible. If I could summarise the number one requirement for success in anything 1. Dodd SAS, Cave NJ, Adolphe JL, Shoveller AK, Verbrugghe A. Plant- it’s GRIT and I can refer you to Angela Lee Duckworth’s Ted talks on the based (vegan) diets for pets: A survey of pet owner attitudes and feeding topic1 . Grit is that courage and determination to stick at it which drives practices. PLoS One. 2019 Jan 15;14(1):e0210806. accomplishment. 2. Dodd SAS, Dewey C, Khosa D, Verbrugghe A. A cross-sectional study of If you can marry GRIT to SUPPORT you will go a long way in your profes- owner-reported health in Canadian and American cats fed meat- and plant- sional and personal life. based diets. BMC Vet Res. 2021 Jan 28;17(1):53. Your first job is unlikely to be your last so you have to keep going until 3. Dodd SAS, Shoveller AK, Fascetti AJ, Yu ZZ, Ma DWL, Verbrugghe A. you find your niche. It took me four jobs before I found my niche and then A Comparison of Key Essential Nutrients in Commercial Plant-Based it was a real push to get ownership of a practice. Remember you will be Pet Foods Sold in Canada to American and European Canine and Feline working most of your life so you should put a lot of effort into finding Dietary Recommendations. Animals (Basel). 2021 Aug 9;11(8):2348. satisfaction at work. Try not to accept a job without doing a background check especially if it is your first job where you will need support and 4. Kanakubo K, Fascetti AJ, Larsen JA. Assessment of protein and amino collegiality. Remember you are never trapped within your current job or acid concentrations and labeling adequacy of commercial vegetarian in the profession. I have known veterinarians become science teachers, diets formulated for dogs and cats. J Am Vet Med Assoc. 2015 Aug politicians, TV personalities, winemakers and billionaires. 15;247(4):385-92. Support. 5. Mueller RS, Olivry T, Prélaud P. Critically appraised topic on adverse food reactions of companion animals (2): common food allergen sources You need to build support structures and work on them long before you in dogs and cats. BMC Vet Res. 2016 Jan 12;12:9. may need them. The toughest time to build any kind of support structures is when it goes wrong. According to Prof. Robin Dunbar you can only have 6. Freeman LM, Stern JA, Fries R, Adin DB, Rush JE. Diet-associated dilat- five close friends because of the social investment time. ed cardiomyopathy in dogs: what do we know? J Am Vet Med Assoc. 2018 Examples of support structures are your family friends and colleagues. Dec 1;253(11):1390-1394. In Australia we have mentors, an AVA Benevolent Fund and counselling which is free initially to members. 7. Adin D, DeFrancesco TC, Keene B, Tou S, Meurs K, Atkins C, Aona B, You need support structures to get through your personal and profes- Kurtz K, Barron L, Saker K. Echocardiographic phenotype of canine dilated sional life. A life partner and close family are amongst the best support cardiomyopathy differs based on diet type. J Vet Cardiol. 2019 Feb;21:1-9. structures you can have on the corrugated road of life. We evolved in small inclusive social tribes of approximately 150 people known as Dun- 8. Axelsson E, Ratnakumar A, Arendt ML, Maqbool K, Webster MT, Perloski bar’s number. Tribal life is written large in our genes which explains why M, Liberg O, Arnemo JM, Hedhammar A, Lindblad-Toh K. The genomic loneliness is so devastating. signature of dog domestication reveals adaptation to a starch-rich diet. Nature. 2013 Mar 21;495(7441):360-4. Experience 9. Plantinga EA, Bosch G, Hendriks WH. Estimation of the dietary nutrient It is great if you can join a practice where the principal (s) is supportive profile of free-roaming feral cats: possible implications for nutrition of and will teach you. It is a great idea to find someone who is working or domestic cats. Br J Nutr. 2011 Oct;106 Suppl 1:S35-48. has worked at that practice and speak to them before you join. A little homework can be of huge benefit. Try and learn one new skill set every 10. Freeman LM, Chandler ML, Hamper BA, Weeth LP. Current knowledge month for life. about the risks and benefits of raw meat-based diets for dogs and cats. J Am Vet Med Assoc. 2013 Dec 1;243(11):1549-58. Stay Positive Many veterinarians, being the perfectionists we are, struggle with failure. Yet failure comes with the job. You do not have control over how long that mare/cow has been in labour before you get there. Similarly that dog or cat may have been obstructed for 24 hrs before it was presented. 123

13–15 NOVEMBER, 2021 One good approach is to have a client in the computer database called Mr Develop distractive techniques and Mrs Success and when clients bring gifts or write letters or compli- ment you, put the information in there so you can access it on the rare Book your next holiday or book dinner out with friends after you have occasions the going gets tough. Keep dwelling on the successes. Put something go wrong or an abusive client. Exercise with a friend. Learn to failure behind. switch off the bad stuff really quickly. Mentors It will very occasionally go wrong. In Australia new graduates are entitled to mentors who have undergone a Not every case works out and not every client is supportive. Veterinary mentor training course. Mentoring is a service which benefits both men- Boards protect the public not veterinarians. If you drive a car you will tors and mentees. Your mentor should be outside the practice you work get dents and speeding fines. If you become a veterinarian you will get in. No one will understand your veterinary problem better than another unexpected outcomes, deaths and complaints and some complaints may veterinarian. A good mentor is a good listener. even go to the Boards. Just treat complaints as a fact of life and deal with them quickly by listening first and coming back later with the response, Geographical Isolation provided it is not an emergency. I can thoroughly recommend golf and gardening if you want to understand If you work in a remote location or feel isolated it can be good to join failure. some entity in the local community or learn a new skill removed from practice. Sport is a great way to integrate but there are volunteer groups Time everywhere. Volunteering is very good mental health. It is easy to make friend with people who have similar interests. Where do I find the time to write up my cases, do my shopping and laun- In Australia we established the Australian Veterinary Orchestra. Veterinar- dry, exercise, socialise and volunteer? The answer is time management ians in remote areas can stay connected for life and play at the confer- and one of the most important things in time management is learning the ences. In Western Australia we have a golf group who play four times ability to say NO. a year with the help of sponsorship. Many members play golf amongst themselves outside of fixtures. Golf is a great sport for veterinarians. You Refine your skills. have to switch your phone off, you can play in your rostered time off and you get exercise. I was in practice for 33 years and another 10 years in part time work. It is a marathon and not a sprint. The most skilful hard working veterinarians Relationships I know were always in great demand from clients and other practices! I wish someone had told me before I graduated that a veterinary career is Personal relationships often suffer if they become long distance or you all about GRIT and SUPPORT. have unsociable hours. It is very important to put a lot of effort in. Com- munication is very important especially if you are tired or have had enough 1 The Strongest Predictor of Success. Angela Lee Duckworth YouTube of people and their problems. One of the most important supports you can 30/4/21 Ted have in veterinary practice is an understanding partner in life. Relationship 2Assessment of Bidirectional Relationships Between Physical Activity and breakdown can be devastating for veterinarians especially with children Depression Among AdultsA 2-Sample Mendelian Randomization Study involved, so learn to put a lot of time into developing quality relationships Karmel W. Choi, PhD1,2,3,4; Chia-Yen Chen, PhD3,4,5; Murray B. Stein, in your life. Your career isn’t everything. MD, MPH6,7; et al Yann C. Klimentidis, PhD8,9; Min-Jung Wang, MSc2; Karestan C. Koenen, PhD1,2,3,4; Jordan W. Smoller, MD, ScD1,2,3,4; for How to win friends and influence people. the Major Depressive Disorder Working Group of the Psychiatric Genom- ics Consortium JAMA Psychiatry. Published online January 23, 2019. There is a famous book of that name by Dale Carnegie4. He discovered doi:10.1001/jamapsychiatry.2018.4175 that we are all in essence egocentric and the best way to deal with 3 Evidence Mounts that gut bacteria can influence mood, prevent depres- clients is to do a lot of listening. Give them the professional advice they sion/Science/AAAS seek without being argumentative. Learn techniques in handling peo- www.sciencemag.org Feb 4,2019 ple. “I see where you are coming from but have you considered………….” “That’s very observant of you but there might be something else going on Books here……………….” There are lots of ways people respond to professional services. For “Authentic Happiness” Prof. Martin Seligman instance if you give your best option first and worst option last, people usually go with the first option. Give too many options and most will “Flourish” Prof. Martin Seligman struggle. Think of your car if it is in for repairs and how too many options “The Depression Cure” Prof. Stephen Ilardi can baffle you. 4 “How to Win Friends and Influence People” Dale Carnegie Protect your mentation. Exercise, connection and diet should be your mantra for good menta- tion2,3. Sleep should follow. If you feel low exercise will probably be your best option. Exercise would be the number one pill in medical practice if it could be put in a pill. Connection provides support and is a free form of counselling. Now that we know the microbiome affects our mentation we should be getting away from sugary drinks and fast food. Sleep is very important too. Caffeine is enemy number one. In some of us the half-life is prolonged. 124 WSAVA GLOBAL COMMUNITY CONGRESS

0074 0075 A NEW GRADUATE’S PERSPECTIVE AND MEDIAL SHOULDER INSTABILITY: DIAGNOSIS AND TRANSITIONING - WHAT HELPED & WHAT DIDN’T. MANAGEMENT V. Lim G. Wasiatycz1,2 Auckland/New Zealand 1Torun/Poland, 2Torun/Poland Qualifications: Qualifications: Vicki Lim Grzegorz Wasiatycz DVM, PhD BVSc Academic Teacher at the Institute of Veterinary Medicine, Nicolaus Coper- nicus University, Torun, Poland [email protected] Transitioning to practice is a stressful time for most new graduates. e-mail: [email protected] Diagnosing front leg lameness in dogs and cats can be frustrated for vet- You’ve slogged to get into vet school, you’ve slogged to get through vet erinarians more than hind leg lameness in their orthopedic practice. One school.. now what? of this problems may be Medial Shoulder Instability MSI (Medial Shoulder Syndrome MSS). This condition is a frequently underdiagnosed as causing In this presentation I will be talking about steps I found helpful for my chronic lameness in dogs. transition into practice, what helped for my mentees, and the trappings that many new vets fall into. Anatomy. Anatomically the shoulder joint is the most mobile, spheroidal joint of all main limb joints., but at the same time it is one of the least stable joints in the dog. The stability of the joint is maintained by passive and active mechanisms. Passive mechanisms create by soft structures, the most of important there are medial (MGLH), lateral glenohumeral ligaments (MGHL), the joint capsule, and the fibrocartilaginous labrum. Glenoid cavity and adhesion/cohesion of the synovial fluid between articu- lar surfaces help stabilizing the joint as well. The second group of soft tissue active stabilizing the shoulder joint there are muscles: supraspinatus, infraspinatus, teres minor, subscapularis and biceps brachia) The primary motion of the shoulder joint while moving in walk, trot and gallop is flexion and extension. For the joint evaluation the goniometry may be helpful for assessment ROM: flexion/extension 47- 57°/159-167°, abduction ~30°. Patophysiology. The cause of the MSI usually is acute trauma or chronic repetitive microtraumas. The result of it can be damage lMGHL, subscapu- laris tendon, labral or capsular tearing. Based on damage one or more of these structures and resulting from this different joint shoulder abduction angle, shoulder medial instability can be defined in varying degrees: 1° mild m. instability (abduction angle 30-39°) 2° moderate m. instability (abduction angle 40-55°) 3° severe m. instability (abduction angle > 55°) 4° complete m. displacement of the humeral head (abduction angle not applicable) History. The anamnesis and medical history may be helpful for focus on the shoulder. Intensive play with other dogs on slippery surface, agility ect. should direct our attention for traumatic overload of the shoulder joint. Intermittent lameness, not improvement after NSAIDs treatment may be useful for our next consider- ations. Diagnosis. Clinical signs there are mainly intermittent front limb lameness in walk and trot with head bob on the affected leg. After intense excercises or heavy activity, the lameness is more no- ticeable. If the activity is restricted, walking on the leash ect., the gait improvement may be observed. If the lameness is not clear visible, the ground reaction force (GRF) may be helpful for exactly, objective gait evaluation. 125

13–15 NOVEMBER, 2021 Orthopedic examination. When examining the shoulder joint, the exten- capsule by thermal „collagen shrinkage” of the capsule. sion, rotation, flexion, ”draw” test, abduction and abduction should be as- sessment with goniometry. The shoulder abduction test is best performed Following RF treatment the healing process of soft tissue continues with after sedation and positioned the dog in lateral recumbency to reduce inflammation and remodeling. Inflammation is the crucial step for healing defensive muscle strain. The score should be measure to contralateral so anti-inflammatory drugs, laser therapy ect. should be not be used shoulder abduction for comparison. The abduction of the shoulder above until 6 weeks. Immediately post surgery, the Vulpeau sling or shoulder 30 degrees may suggest a subluxation (medial instability) of the shoulder. support system/hobbles should be worn (use?) for the dog to strengthen But excessive abduction angle of the shoulder can be find as well in dog weaker and extended soft tissues then before RF treatment. Phisiotherapy with muscle atrophic with other chronic conditions like elbow dysplasia, includes exercises like PROM, gradual weight-bearing exercises ect. every carpal OA, tumors and others. week should be conducted. If conservative or arthroscopic treatment of MSI fails, after 3 months the surgery treatment may be recommended. The abduction test for the first is recommended for the healthy shoulder then for affected limb. Following there are two most popular techniques for MSI surgical repairs, which can be used by veterinary orthopedists: Radiographs. The next step in diagnostic procedure there are radiographs of the shoulder, elbow and carpus. Results of radiographs for MSI are • Imbrication of the subscapularis muscle tendon of insertion (SSTOI) limited but these are recommended to rule out other causes of forelimb lameness like DJD and tendinopathy of the biceps or supraspinatus The approach to the shoulder is craniomedial. For better subscapularis tendon. muscle visualization the tendon should be identificated and dissected from the joint capsule. Then a few horizontal mattress sutures are placed Sometimes stress view radiograph may be useful for confirmation the from proximal to distal extremities of the tendon of insertion of the larger abduction angle measured by goniometry. subscapularis muscle. After sutures tensing the imbrication of the tendon is achieved, it should be check by abducting the arm for measurement the Arthroscopy. This procedure is the most informative method for shoulder abduction angle. Four to six weeks post op the Velpeau sling should be joint assessment. It allows to identify intraarticular structures, helps used for healing damaged soft structures of the shoulder. dynamic evaluation of soft tissue pathologies while moving the arm (esp. adduction/abduction). It is very useful in assesing MGHL, LGHM, joint 2. Extrascapular stabilization with a prosthetic ligament using bone capsule, subscapularis tendom, tearing of labrum, stage of synovitis, tunels: CanineTightrope Shoulder Stabilization. This method is designed inflammation and tearing of the biceps tendon, the surface of the glenoid for more experienced veterinary orthopedists. The procedure can be used and the head of the humerus. In practice, definitive diagnosis of SMI is for shoulder joint stabilization in case damage/tearing subscapularis based on orthopedic examination and exploratory arthroscopy. tendon, medial glenohumeral ligament (MGL) or both. In this procedure can be helpful arthroscopy and fluoroscopy. MRI helps to assess the tendon of the biceps brachii, subscapularis, supraspinatus, infraspinatus, teres minor and muscles. It is possible to Following any type of surgical repair of MSI, the joint shoulder should be identify and evaluate medial and lateral glenohumeral ligaments as well. protected by spica sling or hobbles immediately after surgery. It should MRI has the potential to be a useful tool in the diagnosis of canine soft be maintained four-six weeks together with activity restriction. After tissue shoulder injuries including MSI. removing shoulder support, short walks on leash, restricted activity and the program of physiotherapy should be introduced. Differential diagnosis. Differential diagnoses include trauma, osteochon- drosis, panosteitis, osteoarthritis, infraspinatus contracture, biceps brachii Taking care at home is very important for future results efficiency affected tenosynovitis, calcification of the supraspinatus, neoplasia, cervical inter- shoulder joint. vertebral disk disease, and brachial plexus injuries or neoplasia. Surgical and and medical treatment of medial shoulder instability can be Treatment. Medial shoulder joint instability can be conservative or surgi- successful, with no strong evidence to support one surgical treatment cally treated. over another. The choice of the treatment is depend on the severity of soft tissue 1. Bardet J. Diagnosis of shoulder instability in dogs and cats: a retro- injured, degree of MSI, surgeon preference, the age of the patient, the spective study. Journal of the American Animal Hospital Association. expections of the owners. 1998;34(1). Conservative management is possible for mild pathology (1° of joint insta- 2. Beale BS. Donald Hulse Kurt Schulz Wayne Whitney, Hulse DA, Schulż bility) with hobbles for periodic immobilization and the shoulder abduction KS., Whitney W. Small Animal Arthroscopy. Vol 1. (Saunders, ed.).; 2003. prevention. The hobbles are recommended for 4-6 weeks. 3. Cook JL, Tomlinson JL, Fox DB, Kenter K, Cook CR. Treatment of Dogs Pharmacological treatment - NSAID-s administration (?), chondroprotec- Diagnosed with Medial Shoulder Instability Using Radiofrequency-Induced tors. Every year in veterinary medicine is more popular regenerative medi- Thermal Capsulorrhaphy. Veterinary Surgery. 2005;34(5). cine therapy including PRP (Platelet Reach Plasma) and stem cell therapy (SCT) for healing inducing and for regeneration of the joint structures. 4. Frostick SP, Sinopidis C, al Maskari S, Gibson J, Kemp GJ, Richmond JC. Arthroscopic capsular shrinkage of the shoulder for the treatment Physiotherapy plays an important role in management of the MSI for of patients with multidirectional instability: Minimum 2-year follow-up. conservative, arthroscopic or surgically treatment. Different modalities Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2003;19(3). help with healing of the ligaments, tendons and muscles stabilizing the shoulder joint: manual therapies, laser therapy, extracorporeal shockwave 5. Kieves NR, Jones S. There is no superior treatment method for medial therapy, ultrasound, pulsed electromagnetic field, hydrotherapy, manual shoulder instability in dogs. Veterinary Evidence. 2020;5(1). therapies ect. For each patient should be recommend individual rehabilita- tion program. 6. Levy O, Wilson M, Williams H, et al. Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study. The Journal of Arthroscopic treatment. After debridement and joint is possible to use Bone and Joint Surgery. 2001;83(5). radiofrequency induced thermal capsulorrhaphy (RITC) with monopoly generator for MSI treatment. The idea is based on tightening the joint 7. Pettitt RA, Clements DN, Guilliard MJ. Stabilisation of medial shoulder instability by imbrication of the subscapularis muscle tendon of insertion. 126 WSAVA GLOBAL COMMUNITY CONGRESS

Journal of Small Animal Practice. 2007;48(11). 0076 FRACTURE ASSESSMENT AND DECISION MAKING C. Tan Sydney/Australia Qualifications: Christopher John Tan BVSc BSc (vet) PhD FANZCVS Diplomate ECVS (small animal surgery) [email protected] When presented with a patient with a fracture, the clinician has an almost inexhaustible number of options to which to treat the fracture. It is impera- tive, that it is recognised that there are no such things as good techniques or bad techniques, but rather good case selection and inappropriate case selection. Fracture description The first step towards selecting the most appropriate treatment option is to accurately assess the fracture. This starts with a simple description of the fracture. Although there are alpha-numeric grading systems that have been devised for both human and animal patients, a simpler approach is to use standard descriptive terms based upon the following: The bone involved The location of the fracture within the bone (articular, metaphyseal, physe- al, diaphyseal etc) The configuration of the fracture (incomplete, transverse, oblique, commi- nuted, spiral) The displacement (using three planes in the description ie proximal or distal, medial or lateral, cranial or caudal) Open or closed Fracture assessment Based on the above fracture description, history, signalment and physical examination, the fracture can be assessed using three broad categories. Mechanical factors include: if any load sharing between the implant and the bone can be achieved with repair (this is only possible with 2 or 3 piece fractures, otherwise it is considered non-reconstructable) the size of the patient if the injury involves a single limb or multiple limbs. These factors will influence the surgeon’s decision on the stiffness and strength of the construct. Biological factors include the age and overall health of the patient the amount and condition of the soft tissue envelope the type of bone involved (cortical vs cancellous) the effect of the surgical approach on the soft tissue coverage. These factors will have influence over the time it takes for the fracture to heal and hence determines how long the construct must maintain rigidity. 127

13–15 NOVEMBER, 2021 Client/patient factors include: The configuration of the fixation owner compliance and the demeanour of the animal, which may preclude As seen above, the ideal form of fixation does not exist and modifications certain forms of fixation which require a higher level of care and monitor- of the above forms of internal fixation are designed to overcome their ing. weaknesses. For example, to overcome weak bending in bone plates, a second orthogonal plate can be added. Additionally, the excellent Although these factors can all be assigned a numerical grade (eg 1-10), resistance to bending of an IM pin can be combined with the ability of a an alternative or simpler approach may be to classify mechanical and bone plate to neutralise compressive and torsional loads in a plate-rod biological factors as either good, moderate or poor. Fractures which have construct. Being modular, external skeletal fixation shows great versatility a poor mechanical classification will require a very rigid construct that can and can be configured in an almost limitless number of ways to produce sustain the entire weight bearing load, whilst those with good mechanical the desired mechanical stiffness within anatomical limitations classifications will require a less rigid construct to achieve healing. Simi- larly, poor biology indicates prolonged healing and require a construct that The method of application maintains stability for prolonged periods, which most commonly involve threaded implants, such as bone screws. Fractures with good biology will Although bone plates require some damage to soft tissues to properly ap- heal quickly and therefore may utilise fixation that requires friction alone, ply, this impact can be offset by utilising less invasive approaches. When such as smooth pins. applied in bridging fashion, all bone plates are applied using an open but do not touch approach to minimise soft tissue damage. More recently Non-surgical management of fractures minimally invasive plate osteosynthesis (MIPO) has gained popularity and allows plate application through 2 separate incisions away from the frac- After describing and assessing the fracture, the surgeon must then select ture itself. Interlocking nails can be applied in a similar minimally invasive an appropriate form of fixation. Non-surgical treatment options (splints, fashion. External skeletal fixation is generally applied in closed fashion, casts and bandages) should be considered before recommending a sparing soft tissues from further damage. surgical approach, however, it is essential to recognise the limitations of external coaptation. External coaptation helps preserve the soft tissue envelope but has limit- ed ability to re-align the fracture and maintain stability (particularly in axial compression). Bandages will also loosen readily, further reducing stabili- ty, whilst casting is commonly associated with pressure sores. Therefore, the ideal fractures for external coaptation are those which are: minimally displaced (with a minimum of 50% overlap) have an inherent resistance to axial compression (such as a paired bone with intact pair) will heal rapidly (as seen in juvenile patients) compliant owner and manageable animal In other circumstances, it is likely that a surgical option will produce a better clinical result. Surgical management of fractures When compared to closed reduction and external coaptation, surgical sta- bilisation of fractures will produce improved longevity and rigidity between fragments, however, will have a more detrimental impact on biology. Stability and biological effect will vary based upon: The form of fixation selected. Bone plates will resist all forces experienced by long bones (compression and tension, bending and torsion). They are most vulnerable to bending towards their shortest dimension when used as bridging fixation. They generally require a more extensive approach for application and therefore have a more detrimental effect on biology. Intramedullary pins will resist bending but will not neutralise torsional or compressive loads and so are never used alone as a form of long bone fixation. The interlocking nail was developed to overcome these limita- tions and comprises an intramedullary pin with holes at either ends which receive either screws or bolts, which prevent torsion or compression between the bone segments External skeletal fixation utilises three basic components. Pins, clamps and connecting bars. The pins engage the bone segments and are attached to and external frame (linear or circular) with clamps of various designs. They effectively neutralise compression, bending and torsion. 128 WSAVA GLOBAL COMMUNITY CONGRESS

0077 tion, secondary pyoderma and Malassezia infection. FOOD ALLERGY IN DOGS AND CATS 360°: THE In cats miliary dermatitis, eosinophilic granuloma, eosinophilic plaque and BEST WAY TO DIAGNOSE self induced alopecia have also been associated with food allergy. C. Noli Diagnosis CN/Italy The main differential diagnoses of food allergy in the dog are atopic dermatitis, drug reaction, flea bite hypersensitivity, scabies, Malassezia Qualifications: infection and bacterial folliculitis. Chiara Noli In the cat differential diagnoses are atopic dermatitis, flea bite hypersensi- tivity, psychogenic alopecia, dermatophytosis, otodectic mange, Cheyle- DVM, Dip ECVD tiella infestation and notoedric mange. [email protected] In order to diagnose food allergy an elimination diet must be fed for at least 8 weeks. A shorter diet is often insufficient and a longer one would Introduction not improve the diagnostic power. The major clinical sign being evaluated during the elimination diet is pruritus, which should ideally completely Dogs and cats can have adverse reactions to dietary ingredients for a disappear if the animal is food allergic. If only partial improvement is seen number of reasons: these reactions can be immunologic (food allergy) or (at least 40%) dietary contents should be reevaluated or other concurrent non immunologic (food intolerance). hypersensitivities considered. On a clinical basis it is often impossible to distinguish between a food A homemade pet food is best as an elimination diet, because some pets allergy and food intolerance (particularly idiosyncrasy). Dietary elimination with food hypersensitivity will still react to commercial diets. It is possible and challenge testing may incriminate a certain food, but cannot define that some processing procedures which are used for commercial pet the mechanism. Therefore the terms “hypersensitivity” and “allergy” are foods increase the antigenicity of certain dietary components. This could still accepted in most cases to define both food allergy and intolerance. explain why some allergic pets tolerate homemade diets but develop an allergic response to commercial diets that contain the same ingredients. Everything which is ingested, with the exception of drugs, may be consid- The main characteristics of a good homecooked elimination diet are one ered as “food”. The food components responsible for allergic reactions new source of protein and one new source of carbohydrate with a well are usually only one (40% of the cases), or two (40% of the cases). Rarely balanced ration and no additives, added oil, butter or margarine, added multiple allergens are responsible (three in 10% of the cases, five in 10% vitamins, minerals etc. As an alternative to a homecooked diet, hydrolysed of the cases. Beef and dairy products are responsible for 40-80% or more protein-based hypoallergenic diets with starch as a source of carbohy- of the cases in dogs, while fish is an important ingredient in cats. This re- drates probably are the bset choice. Many limited antigen diets have been flects the ingredients most frequently used to feed pets Other ingredients found to be contaminated with undevlared protein sources and several include cereals, grains, pork, chicken, soja, eggs. In some food groups, cross-reaction between proteins within the same protein group (eg. poul- especially legumes and seafood, allergy to one member of the group may try) and between groups (e.g. between chicken and fish), make it fìdifficult result in an allergy to another member because of antigen cross-reactivity. to chose a reliable protein source that the animal will not react to. Clinical history The owners must understand that even minimal amounts of the original pet food, all treats, bones, bread, the owners’ food leftovers and chewable Food allergy is believed to represent 1-5% of all feline and canine dermato- medications must not be given during a diet trial. Cats must be kept inside ses, 10-15% of all allergic skin diseases excluding flea bite hypersensitivi- during the elimination diet period, because they usually find other sources ty and 23-62% of all nonseasonal allergic dermatoses. of food outside.If there are several animals in the same household they should be either fed separately or all given the same elimination diet, in There is no sex and breed predisposition, age of onset is less than one order to avoid the allergic animal to eat the food of another animal. year of age in 19-52% of the animals, and a food allergy must be strongly suspected in pruritic puppies younger than 6 months of age with no para- The diagnosis of food allergy must be confirmed by challenging the ani- sitic disease. In the cats the average age of developing a food allergy is 4 mal with the old food: pruritus should be observed again after 4 hours to years, but even very young or very old animals may develop one. 7 days in dogs and 14 in cats. If the owner is willing to find the offending food, one food component (e.g. beef, egg, bread) from the old diet can be Clinical disease introduced every week until a reaction is obtained. If pruritus recurs, the animal must be fed the original elimination diet until pruritus disappears The integumentary, gastrointestinal, respiratory, neurologic and urinary again, before trying another food component. Pruritus in this case takes systems may be involved in food hypersensitivity. Of the animals with skin only a few days to disappear. disease 10-15% may also have gastrointestinal symptoms. If the allergic animal has a secondary pyoderma, ideally the bacterial The most frequent dermatological sign is pruritus, which is present in the folliculitis should be resolved before the diet trial begins. If the trial diet vast majority of the cases. Pruritus in the dog is observed more frequently and secondary treatments are performed concurrently, the diet should on the feet, armpits, groin , and periorbital areas. In the cat pruritus is be continued for a minimum of 2 weeks beyond the discontinuation of often localized on the head, neck and ears. therapy for the secondary dermatitis. The same should happen if the dog is administered short acting glucocorticoids. These should be avoided if Otitis externa is frequently seen in food allergic dogs: it is observed as possible, and should only be given if there is a very severe pruritus and the the only sign in 24% of the cases, and in 80% of food allergic dogs it is owner is worried about it. In every case of concurrent drug administration associated with pruritus in other body regions. during the first part of the trial, it is important to confirm the diagnosis by challenging the animal with the previous food. In dogs the primary lesions of a food allergy are papules, which are seen in 40% of the cases. Secondary changes include scratching, self trauma, Other diagnostic tools such as serology (ELISA and RAST), skin testing chronic inflammation, crusting, seborrhea, hyperpigmentation, lichenifica- 129

13–15 NOVEMBER, 2021 with food allergens, saliva and hair test and skin biopsy are not reliable 0078 for the diagnosis of food allergy, not for the identification of responsi- bile allergens or of ingredients that can be safely fed without eliciting a QUALITY OF LIFE IN DERMATOLOGY AND ALLERGIC reaction. DERMATITIS C. Noli CN/Italy Qualifications: Chiara Noli DVM, Dip. ECVD [email protected] INTRODUCTION The expression ‘quality of life’ (QoL) is used to assess general well-be- ing, and is defined as ‘the degree to which an individual enjoys his or her life’. In healthcare, QoL is often evaluated in terms of how it is negatively affected by disease. In spite of the obvious fact that itch and pain due to dermatological con- ditions can have an impact on QoL of affected animals, until 2010 there have only been two studies evaluating QoL in dogs with skin disease. Since then, two research groups have developed and validated question- naires for quality of life assessment in dogs with dermatological condi- tions, the first being limited to canine atopic dermatitis, and the second one applicable to all skin conditions.1-4 Very recently another research group has been working on developing and validating a new questionnaire on QoL and treatment success (TS) in dogs with atopic dermatitis, using methodology informed by the FDA questionnaire development guidance.5 Besides taking TS into account, this questionnaire differs by the previous ones in that in two studies it was completed by owners at home by means of an app on a smartphone (PicorCan, ItchTracker).6 THE IMPACT OF CAD ON QUALITY OF LIFE In validation process of the above mentioned questionnaires, these were administered to owners of atopic dogs, in which lesional CADESI-03 and VAS pruritus scores were also measured. In the study by Noli et al. correlation between QoL and pruritus scores was good and significant, indicating that pruritus has an important impact on QoL of dogs and their owners.3 On the other hand correlation was not as good between QoL and CADESI-03, confirming that the sole evaluation of lesional improvement in trials is not sufficient, and that the success of a therapeutical interven- tion, as experienced by owners and pets, is determined by other factors besides clinical improvement. It is clear that clinical scores alone do not reflect the disease experienced by the patient as they do not take into account any impairment of QoL. To a similar conclusion came Favrot et al., who reported correlations between “overall assessment questions” and CADESI-03, but “never close to full concordance unity, emphasizing that the different parameters measure different facets of the same phe- nomenon and are consequently all useful to evaluate the severity of the disease.” 1 In the study by Linek and Favrot, 73% of the owners considered that atopic dermatitis had an impact on the QoL of their animals, and the higher the CADESI and the pruritus, the higher was the impact on QoL.2 The areas of the dogs’ lives that were most impaired by atopic dermatitis in the questionnaire by Noli et al. were behavioural or mood changes, playing/ working activities and the burden of administering treatment.3 In contrast, Linek and Favrot judged sleep disturbance to be an important factor, while playing was not strongly affected. These differences could be determined 130 WSAVA GLOBAL COMMUNITY CONGRESS

by the different questionnaire structure or wording, as well as by different disease and of their owners - Part 2: administration of a questionnaire in life styles in the two study populations, which came from Italy and Germa- various skin diseases and correlation to efficacy of therapy. Vet Dermatol ny/Austria, respectively. In both studies, meals were not greatly affected. 2011; 22: 344-351. In the study by Linek and Favrot, 48% of the owners considered that atopic 5. Wright A, Tatlock S, Wells J et al. Development of the canine dermatitis dermatitis had an impact on their own QoL, and the higher the CADESI quality of life and treatment satisfaction questionnaire: a tool for clinical and the closer the relationship to the animals, the higher was the impact practice. Proceedings NAVDF (abstract), Vet Dermatol 2017; 28: 453. on QoL.2 The areas of the owners’ life which were most impaired in both studies were increased expenditure, time loss, and emotional and physical 6. Wright A, Alaman C, Holland R. Preliminary results from a mobile app distress, while family activities and intra-family relationships were less monitoring canine pruritus and quality of life in dogs prescribed oclaci- involved. tinib (abstract). Vet Dermatol 2018; 29: 270-271. THE USE OF QoL QUESTIONNAIRES IN CLINICAL STUDIES 7. Noli C, Della Valle MF, Miolo A, et al. Effect of dietary supplementation with ultramicronized palmitoylethanolamide in maintaining remission in In studies using the questionnaire developed by Noli et al., improvement cats with nonflea hypersensitivity dermatitis: a double-blind, multicentre, after treatment of QoL of dogs (QoL1) and that of owners (QoL2) were randomized, placebo-controlled study. Vet Dermatol. 2019; 30:387-e117. assessed separately. Most studies report a higher mean improvement for QoL1 compared to QoL2, and analysis of the single questions clearly 8. Noli C, Borio S, Varina A, et al. Development and validation of a ques- highligh that the therapeutical interventions necessary to keep the pet’s tionnaire to evaluate the Quality of Life of cats with skin disease and their dermatological conditions under control did impact negatively on the owners, and its use in 185 cats with skin disease. Vet Dermatol 2016; owner’s and the dog’s QoL. 27:247-e58. However, it is worth noting that this is particularly true for studies that included interventions which are expensive (e.g. ciclosporin) or labour intensive (e.g. shampoo). In one study however, dogs received just one or two daily palatable ultramicronized palmythoiletanolamide capsules, which were free of cost for the owner.7 Interestingly in this study the two QoL subclusters improved to a similar extent in response to treatment, maybe confirming that an inexpensive and not labour intensive treatment for CAD will improve owner’s QoL too. QUALITY OF LIFE ASSESSMENT IN FELINE DERMATOLOGY There are only a few studies proposing quality of life assessments in cats, and none of them deals with skin disease. Our group has developed and validated a questionnaire for the assess- ment of QoL in cats with skin disease, with a similar format to that developed for dogs, e.g. with one subset for animals and one for their owners.8 It became evident that items such as stress due to administra- tion of therapies and to visits to the veterinarian were more important for cats and their owners than for dogs and their owners, highlighting the fact that treating cats is certainly more difficult and a bigger source of psycho- logical stress than treating dogs. In its validating procedure this questionnaire was used in a clinical study assessing the efficacy of liquid ciclosporin in cats with allergic derma- titis. Lesional (SCORFAD) improvement was good/excellent in 91.6% of cases, pruritus in 81,5%, albeit quality of life only in 56,25%. Improvement of SCORFAD and pruritus were statistically significant, but not quality of life. A detailed analysis of the two subsets QoL1 and QoL2 confirmed that quality of life of cats and onwers is greatly influenced by treatment administration. REFERENCES 1. Favrot C, Linek M, Mueller R et al. Development of a questionnaire to assess the impact of atopic dermatitis on health-related quality of life of affected dogs and their owners. Vet Dermatol 2010; 21: 64-70. 2. Linek M, Favrot C. Impact of canine atopic dermatitis on the health-re- lated quality of life of affected dogs and quality of life of their owners. Vet Dermatol 2010; 21: 456-462. 3. Noli C, Minafò G, Galzerano M. Quality of life of dogs with skin disease and their owners - Part 1: development and validation of a questionnaire. Vet Dermatol 2011; 22: 335-343. 4. Noli C, Colombo S, Cornegliani L, et al. Quality of life of dogs with skin 131

13–15 NOVEMBER, 2021 0079 Important medical history MANAGING RESPIRATORY DISTRESS IN THE While it is important to obtain a complete medical history for your patient, EMERGENCY PATIENT with those in respiratory distress only limited questions are needed early M. Hickey on. Beyond inquiring if there is a known history of medical problems which could lead to breathing difficulties, identifying any recent trauma, recent Camperdown/Australia coughing, reports of cats trying to vomit up a hairball (often owners con- fuse coughing in cats with this), or recent true vomiting or regurgitation can help with pattern recognition. Qualifications: Pattern recognition Mara Hickey Generalizations based on species, breed, body size and age can help identify most likely causes of respiratory distress. Knowing regional DVM DACVECC prevalences for infectious diseases and toxicities can also help guide the veterinarian to a likely diagnosis. [email protected] Patients presenting with respiratory distress is a relatively common occur- Adult to geriatric small breed dogs are more likely to have congestive rence in small animal emergency medicine. Using physical examination, heart failure secondary to valvular disease or tracheal collapse as the identifying respiratory patterns, and considering the patient’s signalment causes of their respiratory distress. Brachycephalic dogs of any age are can help clinicians determine the most likely causes of respiratory dis- more likely to present for BOAS or aspiration pneumonia/pneumonitis. tress and identify which emergency therapies would be most beneficial. Medium to large breed geriatric dogs are more likely to have laryngeal paralysis. Initial evaluation of a respiratory patient often involves making decisions based on limited information as these patients are very fragile which can Juvenile cats and dogs are more likely to have noncardiogenic pulmonary prevent performing a full examination safely as well as restrict the number oedema (from choaking, strangulation or electrocution) with puppies also and type of diagnostics early on. Therefore, assessment, diagnostics and having infectious bronchopneumonia (associated with kennel cough). treatment are performed in short bursts and the veterinarian often has to use pattern recognition at first to help direct patient stabilization. FIP, upper respiratory tract infections and nasopharyngeal polyps are more common in young cats. Middle-aged to geriatric cats are more likely to Initial handling/treatment have “asthma” or congestive heart failure. Respiratory patients need limited handling at first. Giving supplemental Overall, patient with respiratory distress secondary to cardiac disease oxygen and administering a sedative/anxiolytic are often best to do prior are more likely to be hypothermic. Those presenting with upper airway to performing a physical exam. Butorphanol IM is the sedative of choice. disease/obstruction or infectious diseases are more likely to be hyperther- If a TPR can be obtained at the time of presentation, this will help with mic or pyrexic/febrile. pattern recognition and help guide treatment and diagnostics. Immediate stabilization Oxygen should be administered in the manner which causes the least struggle for the patient – flow-by or mark oxygen may be simplest, but If the patient is showing signs of impending respiratory arrest, intubate some patients won’t tolerate this. In the short term, use of an oxygen cage the patient and be prepared to manually or mechanically ventilate them. or an oxygen hood (plastic wrap covering 60-70% of the opening of a hard This gives the veterinarian control over the airway and breathing, prevents e-collar with an oxygen line) can be effective. patient suffering, and allows a more organized investigation without panic interfering. Assessing respiratory character If you suspect the patient has upper airway obstruction, give adequate There are several parts to assessing a patient’s respiratory character, sedation and begin active cooling if needed. It is much safer to intubate most of which can be evaluated in a hands-off manner. these patients pre-emptively than to wait until they go into respiratory arrest. Depending on the cause of the upper airway obstruction, you may First, measure the patient’s respiratory rate. The majority of patients with need to use a smaller than expected endotracheal tube. Be prepared to respiratory distress will be tachypneic – those with bradypnea are about need to perform a tracheostomy if the patient cannot be intubated. to go into respiratory arrest. If you suspect the patient has pleural space disease, perform a thora- Respiratory effort is potentially the most important factor to evaluate. cocentesis. Thoracocentesis is both a therapeutic and a diagnostic pro- Patients can exhibit a general hyperpnea or may have increased effort cedure, so do not wait to perform this until imaging is completed if your with inspiration or expiration. Severe respiratory effort may include an suspicion is high. While continuing oxygen supplementation is helpful, expiratory grunt or push, or a paradoxical abdominal component where the removing the fluid or air from the pleural space will go much farther for abdomen distends with inspiration rather than with expiration. stabilizing the patient’s breathing. An orthopneic posture, rapid changes in body position, open mouth If you suspect congestive heart failure is present and the patient has not breathing, limited movement of the chest wall and the previously men- received diuretics before, start with 2 mg/kg of furosemide IM or IV. If tioned signs of severe respiratory effort indicate that the patient is at high the patient is a known heart patient already on diuretics, give double their risk of respiratory arrest. daily dose as a single injection IM or IV. Beyond identifying the patient’s respiratory character, auscultation of the Initial investigations thorax is a very important part of the physical examination which should be performed early on as part of the major body systems assessment. Often, diagnostics are performed after stabilization is initiated. Abnormal lung sounds, muffled lung sounds and the regional location for decreased lung sounds can help identify the most likely differential For diagnostic imaging, one idea to keep in mind at all times is that diagnosis for a patient. “nothing should die in radiology.” Therefore, limited imaging is usually 132 WSAVA GLOBAL COMMUNITY CONGRESS

performed early, and may include point of care ultrasound to evaluate for Pneumothorax – trauma, sponta- the presence of absence of pleural space disease or to get a quick look at the left atrial size. While three views are the standard for radiographs, with neous, iatrogenic Tachypnoea, short and shallow respiratory patients a single radiographic view (lateral or dorsoventral) may be enough to allow the veterinarian to identify the problem. Complet- Pleural space Pleural effusion – CHF, neopla- breathing, paradoxical breathing, ing the radiographic study is indicated once the patient is more stable. sia, FIP, coagulopathy, trauma, muffled lung sounds +/- heart Laboratory tests that should be considered early on include venous or arterial blood gas as well as PCV/TP. Additional tests which may be infection, lymph/chyle sounds, +/-orthopneic stance indicated based on pattern recognition include electrolytes, glucose and coagulation testing. Once stabilized you may include full haematology and Diaphragmatic hernia serum biochemistry. Extra-pleural Chest wall injuries Weak ventilatory effort, limited or Sedated airway exam should be performed if the patient requires emer- structures increased chest wall movement, gency intubation. Otherwise, further diagnostics such as airway exam, en- Phrenic nerve transection open mouth breathing dotracheal or transtracheal wash, rhinoscopy, bronchoscopy with alveolar lavage, or computed tomography should be performed on stable patients Abdominal distension – fluid, when there are sufficient staff available. organomegaly, mass effect Causes of respiratory distress Non-respiratory lookalikes Dividing the respiratory system into zones is the simplest way to ensure Non-respiratory causes of tachypnea and hyperpnea should be considered you investigate all possible causes of respiratory distress. The following for all patients. The following chart lists the causes of respiratory looka- table provides information on the zones, common conditions for each likes as well as any important changes which may be found on physical zone and important physical exam findings. exam. Causes Important PE changes Respiratory Common Conditions Important PE changes Buffering metabolic acidosis Prolonged inspiratory phase, increased Zones respiratory rate, normal respiratory effort Dogs: Severe anaemia or haemoglobin dys- Upper airway function Prolonged inspiratory phase, increased Nasopharyngeal: Brachycephalic Pain, Stress, Anxiety respiratory rate, normal to increased Obstructive Airway Syndrome, Fever/Pyrexia, Opioid administration respiratory effort, tachycardia neoplasia, polyps Electrolyte or glucose abnormalities Tachypnoea, panting Laryngeal: idiopathic paralysis, “honking” cough, stertor vs Neurologic disease foreign body stridor, dysphonia, panting, hy- Tachypnoea, normal respiratory effort perthermia, increased inspiratory Tracheal: collapse effort Tachypnoea, normal respiratory effort Cats: For the CNS can have varying changes in respiratory pattern. Nasopharyngeal: stenosis, polyps Neuromuscular junctionopathies tend to lead to shallow breaths, limited chest Laryngeal: neoplasia, idiopathic excursion, abdominal effort paralysis Lower airway Feline lower airway disease Expiratory “push”, cough, wheez- References: (asthma) es or crackles Lee JA. Nonrespiratory Look-Alikes. In: Silverstein DC, Hopper K, editors. Canine chronic bronchitis Small Animal Critical Care Medicine, 2nd Ed. St Louis: Elsevier Saunders; 2015. p. 157-160. Oedema – cardiogenic, non-car- diogenic Rozanski E. Respiratory Distress. In: Drobatz KJ, Hopper K, Rozanski E, Silverstein DC, editors. Textbook of Small Animal Emergency Medicine, Pneumonia/pneumonitis – aspi- Short and shallow breaths, I&II. Wiley; 2018. p. 18-21. ration, infectious tachypnoea, crackles or harsh Sumner C, Rozanski E. Management of Respiratory Emergencies in Small Haemorrhage – coagulopathy, lung sounds, increased effort Animals. Vet Clin Small Anim 2013; 43:799-815. Alveoli/Vascular trauma (both inspiratory and expiratory). May have paradoxical abdom- Neoplasia inal movement with severe Interstitial fibrosis hypoxaemia. +/- Heart murmur or arrhythmia. Vascular – pulmonary hyper- tension, pulmonary thromboem- bolism 133

13–15 NOVEMBER, 2021 0080 tion. An initial assessment should be performed by assessing the ABCs (airway, breathing circulation), identifying signs of possible hemorrhage, THE INITIAL APPROACH FOR COLLAPSED PATIENTS and determine if severe neurologic abnormalities are present. Evaluating perfusion parameters, measuring the patient’s blood pressure, and calcu- M. Hickey lating a shock index can also be rapidly performed. Immediate diagnos- tics to perform would include point-of care ultrasound (POCUS) to look Camperdown/Australia for glaring abnormalities within the thoracic and peritoneal cavities, as well as a venous blood gas, electrolyte levels, blood glucose, lactate, and Qualifications: packed cell volume with total protein via refractometer (PCV/TP). Mara C Hickey ECG is indicated if any arrhythmias are ausculted or if pulse deficits are identified. You may want to perform pulse oximetry as well, but this may DVM, DACVECC be less helpful due to environmental and patient factors potentially not allowing accurate readings. Following your initial assessment and any [email protected] appropriate stabilization, a complete medical history should be obtained and a full physical exam including neurologic and orthopedic evaluation THE INITIAL APPROACH FOR COLLAPSED PATIENTS should be performed. There are 3 main mechanisms which lead to patients presenting physically Any immediate threats to life (shock, respiratory difficulties, severe hem- collapsed. These include cardiovascular collapse, neurologic or neuro- orrhage) should be addressed immediately. Most collapsed patients are muscular collapse, and musculoskeletal/metabolic collapse. appropriate to immediately treat with flow-by oxygen supplementation and to have an IV catheter placed. However, caution is indicated if IV fluids Cardiovascular collapse in essence is due to a failure for oxygen to be are started without evidence of shock as this can be detrimental for some delivered to the tissues (DO2). Oxygen delivery is a product of cardiac causes of collapse such as cardiac disease and uncontrolled hemorrhage output (CO) and the arterial oxygen content (CaO2). Anything decreasing and may not be helpful for other problems such as orthopedic injuries or either variable will lead to cardiovascular collapse. some respiratory diseases. Cardiac output is dependent on both heart rate and stroke volume, with References: stroke volume being affected by preload, afterload, and mycocyte con- tractility. Preload, often thought of as ventricular filling, can be decreased Aldrich J. Global Assessment of the Emergency Patient. Vet Clin Small by a low venous blood pressure, impaired atrial contraction, tachycardia, Anim 2005; 35:281-305. decreased ventricular compliance (such as with hypertrophic cardiomy- opathy), and valvular inflow stenosis. Afterload, the load or “pressure” the Brignole M, Benditt DG. Syncope: An Evidence-Based Approach. London: ventricles are pumping against, can decrease CO when elevated. Causes Springer; 2011. of elevated afterload may include increased systemic vascular resistance (SVR), increased aortic pressure, or outflow valvular stenosis. Cardiac Clark D. Triage and Initial Stabilization of the Emergency Small Animal contractility is decreased by acidosis, hypothermia, hypocalcemia, Dilated Surgical Patient. In: Aronson LR, editor. Small Animal Surgical Emergen- Cardiomyopathy, increased parasympathetic stimulation, hypercapnia, or cies. Ames: Wiley Blackwell; 2016. p.1-14. cardiac infarction. Fletcher DJ. Neurologic Disorders. In: Drobatz KJ, Hopper K, Rozanski E, The two factors contributing to CaO2 include hemoglobin (Hb) concentra- Silverstein DC, editors. Textbook of Small Animal Emergency Medicine, tion and the partial pressure of arterial oxygen (PaO2). Beyond anemia as I&II. Wiley; 2018. p. 13-17. a cause of low hemoglobin, diseases affecting Hb such as methemoglo- binemia and carboxyhemoglobinemia lead to a functional decrease in Hb Gelzer AR, Kraus MS. The Collapsed Patient. In: Drobatz KJ, Hopper K, within the bloodstream. PaO2 is decreased by low fractions of inspired Rozanski E, Silverstein DC, editors. Textbook of Small Animal Emergency oxygen (FiO2), hypoventilation, impaired alveolar diffusion, ventilation-per- Medicine, I&II. Wiley; 2018. p. 31-38. fusion (VQ) mismatch, and pulmonary shunting. While low FiO2 is not common in patients when first presenting, numerous respiratory, thoracic Reineke EL. Evaluation and Triage of the Critically Ill Patient. In: Silverstein and cardiovascular diseases may lead to low PaO2 in emergency patients. DC, Hopper K, editors. Small Animal Critical Care Medicine, 2nd Ed. St Louis: Elsevier Saunders; 2015. p. 1-5. Neurologic & neuromotor diseases or injuries lead to either a central or peripheral dysfunction, which appears as varying forms of collapse. Cen- tral dysfunction may include any cerebral, cerebellar, brain stem or spinal cord diseases, such as trauma, neoplasia, infection, inflammatory disease or toxins. More peripheral dysfunction most commonly is associated with lower motor neuron diseases or junctionopathies such as tick paralysis, snake envenomation, immune-mediated disease, polyrediculoneuritis or intoxication. Patients with musculoskeletal or metabolic causes of collapse are collapsed as the physical structures contributing to standing and walking have been affected. Orthopedic injuries including multiple fractures or luxations and bilateral cruciate ligament ruptures should be considered. Muscle function requires access to certain nutrients and electrolyte, with hypokalemia, hypo- and hypercalcemia and hypoglycemia leading to acute dysfunction. Understanding these underlying causes of collapse, the approach to determing the cause is not too different from any emergency examina- 134 WSAVA GLOBAL COMMUNITY CONGRESS

0081 straight into ‘handling’ the feline patient may not be the most cat friendly approach. So the second big tip of ‘Cat Friendly Handling’ is keep your CAT FRIENDLY HANDLING TIPS AND TRICKS hands off! Place the cat carrier on the floor, open the door and allow the cat to come out on their own accord. Then ignore the cat, talk to the N. Dowgray owner, gather the history and while you are doing that watch the cat out of the corner of you eye, assess their body language, are they fearful or Tisbury/United Kingdom confident? Listen to any noises they make – growling, chatting or purring? And watch them move, a visual distance exam make give you a feel for if Qualifications: there is anything painful going on and may direct the order of your clinical examination. This period of assessment should help you determine what Nathalie Dowgray approach you may then need to take with the next step in your consulta- tion. BVSc, MRCVS, PGDip, PhD What do you do if the cat chooses not to come out of the carrier? Tip [email protected] number three is work with your owner to ensure they understand what to look for in a good cat carrier. If you have a shy cat and they are in an It’s all about you appropriate carrier you can remove the top half for the carrier and cover them with a towel, allowing them to still feel safe and secure and you to The first tip in cat friendly handling is to look at yourself and how you proceed with aspects of the examination. interact with cats. Modifying you own behaviour is the first step to im- proving the cats experience in the clinic; Move slowly, cats are sensitive Top tip number four is to reiterate when you do start to physically interact to sudden movement, be calm, quiet and predicable. The cat is in a novel or handle the cat be gentle, any forceful handling such as scruffing the cat unfamiliar environment and the more settled you are with your behaviour should never occur. It may achieve in the short term the desired effect but the more settled they will become. Always be gentle with the cats, any causes a negative emotional state in the cat, can cause injury to the soft forceful handling will put the cat in a negative emotional state making tissues of the back of the neck and is likely to lead to fearful and aggres- what the rest of the appointment more difficult and also negatively im- sive behaviour in that and future visits. pacting future appointments. Tip number five is work with the cat, perform examinations in a way and Respect the paw pace they feel comfortable. Sitting in the bottom of the cat carrier, under a towel, on their owners knee or on the clinic chair, learn to adapt how you International Cat Care’s first Cat Friendly Principle is Respect Cats; work to suit your patient. Respect the diversity of the species and understand the individual. As a species cats have some very specific behavioural biology, whilst they are Tip number six is not be stuck in the pattern of performing a head to tail social diverse as a species as individuals their sociability is fixed. In terms examination, following on from your discussion and history taking you will of survival they are a solitary animal and can live independently, they are likely have a mental list of what clinical examinations are required. Try and an obligate carnivore and will defend a core territory whilst maintaining do the most important aspects first but make sure you perform anything a wide range. Cats are highly sensorial and particularly sensitive to that might be potentially painful last. Always ask yourself if you need to chemical communication. Like people they are cognitive and emotionally perform an aspect of an examination on that patient, for some appoint- complex animals. ments knowing a cats temperature is essential but for others it may be an aspect of your examination that can be left. The individual cat may sit anywhere along the social spectrum, in the clin- ic we may interact with feral or street cats who have low sociability to peo- Tip number seven, many cats like a treat! The use of food distraction can ple but more commonly we will interact with pet cats how have a stronger be really useful in cats and help move them into a positive emotional desire to be with people. This individualism comes from a combination state. On occasion they can also be a way for procedures being performed of genetics factors, from the parents and breed, the environment effects without any form of handling or restraint. Liquid food treats especially are of early socialisation and life experiences (including previous veterinary highly palatable. visits) in addition to epigenetics effects, for example prenatal stress. Tip number eight, be prepared. Have all the equipment you are likely As well as respecting the species specific biology of you feline patients to need on hand in your consult room or the examination area you are and recognising your approach and handling will need to vary based on working in. For example quiet clippers, EMLA cream, blood pressure their sociability, you also need to be able to recognise the cats current monitor, blood sampling equipment, towels or blankets. Plan ahead, if you emotional state. With cats in a negative emotional state e.g. fear, pain, are need to take a blood sample clip the fur and apply some EMLA cream, frustration, panic or anxiety, every effort should be made to bring them the longer you wait the more effective it will be but even 10-15min before back to a neutral emotional state or if possible, a positive emotional state! sampling has a beneficial effect. Remember how sensitive cats are to It is important to recognise that sometimes this is not possible and either smell, avoid the sue of products like surgical sprit in your procedures. rescheduling the appointment or chemical restraint should be considered. Persisting may lead to an aggressive response preventing any further Tip number nine, any restraint should be minimal and gentle. Don’t hyper- examination or investigations and making future visits less likely to be extend joints, lift the neck for a jugular blood sample with 1-2 fingers and successful. don’t trap the whiskers. If you need to use a towel wrap make it loose and drapey, avoid a tight wrap which may cause the cat to struggle. Cat Friendly Handling? Tip number ten, drugs are your friend. Don’t be afraid of to send the cats Handling is defined as to feel or manipulate sometime with your hands home to return another day with some pre-appointment gabapentin or if and that most certainly is required for aspects of our clinical examination further clinical investigations are required sooner than admit the cat for of cats. However handing can also be defined as to manage a situation sedation. or a problem and our goal with all cat consultations should be to manage the situation so it does not become a problem! Cat Friendly interactions may be more appropriate term for what we are aiming to achieve, going 135

13–15 NOVEMBER, 2021 0082 Source of blood LIQUID GOLD: TRANSFUSION OF BLOOD AND Blood and blood products may, in some countries, be available from a BLOOD PRODUCTS IN CATS blood bank, and for others will be from a list of potential donors, or often S. Taylor staff pets or the anaemic cat owner’s other cats. Donors need adequate assessment to ensure their welfare (which includes mental wellbeing and Tisbury/United Kingdom physical health) as well as suitability for donation (eg infectious disease status). Ideal donor characteristics will be discussed in the talk along Qualifications: with risks to the donor cat. Owner’s of donor cats must provide informed Samantha Taylor consent. If buying from a blood bank be sure to understand that blood bank’s ethics and cat handling. If handling donors in your clinic ensure Cat Friendly Clinic handling and care (see www.catfriendlyclinic.org). BVetMed(Hons) CertSAM DipECVIM-CA MANZCVS FRCVS Sedation for donors [email protected] Most cats are sedated for blood donation unless habituated to the tech- nique. Unsedated donations risk damage to the jugular vein. There are a Introduction variety of possible sedative combinations such as butorphanol/alfaxalone, ketamine/midazolam, monitoring of the donor is vital. Fluid therapy is not Blood and blood product transfusion in cats is increasingly performed in always provided and will be discussed in the talk. small animal practice, and with the growth of the procedure, questions are asked about the source of the blood, risks of the procedure for both donor Blood collection and recipient, and how best to optimise the outcomes for cats. In this talk we briefly cover blood types, blood collection and administration and Blood can be collected using an open or closed technique. Using a open types of blood products and when to give them. For more details please technique is more common and does not require a special kit. Sterile see the 2021 ISFM Consensus Guidelines on the collection and adminis- preparation of the jugular is important to limit contamination of the blood. tration of blood and blood products in cats (open access). Usually 10ml/kg (lean body weight) is removed from the donor which is in lateral or dorsal recumbancy, or sternal if conscious. For open techniques Blood types usually 5 syringes with anti-coagulant are prepared (1ml ACD-A, CPD, CPDA-1 per 7ml blood or sodium citrate alone, 1ml for 9ml blood). Blood Cats have genetically determined antigenic markers on their red cells de- should be given within 4 hours or within 24 hours if refrigerated (from termining their blood type. These antigens induce an immune response in open collection). Closed collection means storage can be longer. a cat receiving a transfusion of blood of a different type. Cats may be type A, B or AB with A the most common, and B found in certain breeds such Blood administration as British Shorthairs, as well as in domestic short and longhaired cats in variable prevalence around the world. Cats possess naturally occuring Blood should be given with close monitoring starting at 0.5ml/kg/hr for alloantibodies, type A cats have low numbers of anti-B antibodies but type 15 minutes, monitoring TPR (after recording baseline parameters) every B cats have high numbers of anti-A antibodies. Non-matched transfusions 5 minutes and demeanour constantly. Then increase to 1ml/kg/hr for can result in serious, even fatal transfusion reactions. Type AB cats never a further 15 minutes before then adjusting rate to administer within an have alloantibodies to type A or B. appropriate time frame for the case and considering 4 hour limit when not refridgerated. Type A cats should receive type A blood Monitoring and transfusion reactions Type B cats should receive type B blood Type AB cats should receive type AB blood, or in not available then type A A monitoring sheet should be used at all times and changes/trends in blood - ideally just red cells following sepearation. parameters noted. TPR, demeanour, blood pressure, mentation etc and looking for signs of reaction including febrile non-haemolytic, allergic, vol- Cross-matching ume overload and haemolytic reactions. Vomiting/diarrhoea, hypotension, fever, tachycardia for example should raise concern. In some cases of This can be performed in clinic or in a laboratory. In an emergency mild reaction eg fever, the rate can be slowed and the patient monitored, cross-matching may not be possible but ideally is performed for every in more severe cases the transfusion must be stopped and adrenaline and transfusion as transfusion-naive cats can have reactions to type matched anti-histamines may be needed. Corticosteroids are generally no longer blood. Minor and major cross-matches can be done and certainly recom- recommended - fluid therapy as a bolus is important (10ml/kg) for transfu- mended for cats which have had a transfusion more than 2 days before, sion reactions (unless volume overload). More information is available in has an unknown history or a previous reaction to a transfusion. the guidelines. When to give a transfusion Ethics There is not a specific transfusion trigger. Cats should be assessed The ethics of blood ‘donation’ are discussed as cats cannot consent to the individually as cats with more chronic anaemia (often non-regenerative) procedure and healthy cats are put at risk to help other cats. Their welfare tolerate a lower PCV than cats with acute blood loss for example. So is paramount and alternatives to blood should be considered. assess for signs of decompensation such as tachypnoea/panting, weak- ness/collapse, tachycardia, bounding pulses and intolerance of handling. Refererences: Transfusion may be given during surgery if haemorrhage occurs. However, a transfusion may not be appropriate if a cat has a poor prognosis, is Taylor S et al. (2021) 2021 ISFM Consensus Guidelines on the collection tolerating anaemia and the anaemia is being treated, or there are financial and administration of blood and blood products in cats. Journal of Feline limitations. Medicine and Surgery 23, 410-432 136 WSAVA GLOBAL COMMUNITY CONGRESS

0083 CDH2 was not associated with human OCD9. DIAGNOSIS AND MANAGEMENT OF COMPULSIVE Brain-derived neurotrophic factor (BDNF) plays an important role in neural DISORDERS IN DOGS development. Studies showed that BDNF plasma levels are lower in OCD patients compared to healthy controls regardless of treatment status10. M. Irimajiri Human OCD studies and some reports from canine compulsive disorder studies suggest that different phenotypes of compulsive disorders might Tokyo/Japan have different pathophysiology and causes. The etiology and pathophys- iology behind OCD and canine compulsive disorder are still “ongoing” Qualifications: search. Still many studies need to be conducted to fully understand the disease. Mami Irimajiri Diagnosis BVSc, PhD, Dipl. ACVB Rule out medical conditions. Differential diagnosis includes neurological [email protected] disorders (central and peripheral), dermatological problems, endocrinolog- ical diseases. What is Compulsive Disorder? Rule out behavioral problems such as attention-seeking behavior, conflict Compulsive disorder is a condition in which an animal displays repetitive, behaviors (e.g. behaviors to release frustrations), stress from other anxi- exaggerated, or sustained behavior out of original context. It is believed to ety disorders, cognitive dysfunction. occur in animals subjected to stressful situations resulting in conflict or frustration1. Compulsive disorder can develop in many species, including Observe the behavior itself. Video images of behaviors that animals dogs, cats, birds, horses, rabbits, and rats. Typical clinical signs for dogs presenting at home are helpful. are excessive licking and chewing possibly develop into acral lick dermati- tis, tail chasing, spinning, circling, licking air or objects chasing imaginary Getting thorough history by using open-ended questions and getting the flies, fixating on certain objects, shadow or light chasing. whole story about several incidents including the response (or reaction) to the behavior of animals. Compulsive disorder in dogs appears similar to human obsessive-com- pulsive disorder in its behavioral presentation, medication response, and Treatment genetic predisposition2. A recent imaging study with MRI revealed that there is a parallel between canine compulsive disorder and human obses- If identified early, cases of compulsive disorders may be treatable without sive-compulsive disorder (OCD). Compulsive disorder dogs exhibited brain medication, but most cases require psychotropic medication and behavior abnormality in MRI images similar to those of human OCD. Compulsive modification on top of environmental modification. disorder dogs3. Medication Human OCD was classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV). In DSM Anti-depressants: 5th edition, OCD is taken out from the anxiety disorder group and became independent. We also should reconsider that this disease in animals is Fluoxetine (Reconcile) 1.0-2.0 mg/kg Q24H also independent of anxiety disorder. Clomipramine (Clomicalm, Anafranil) 1.0-3.0mg/kg Q12H Science Behind OCD Fluvoxamine 1-2mg/kg Q24h Studies looking at the effect of serotonergic agents such as serotonin reuptake inhibitors (eg. clomipramine, fluoxetine, fluvoxamine, sertraline, Sertraline 0.5‐4mg/kg　Q24h and paroxetine) have provided mainstream OCD treatment. The success of pharmacological treatment with serotonin reuptake inhibitors and Paroxetine 1-1.5mg/kg Q 24h atypical antipsychotic drugs suggests that both the central serotonergic and dopaminergic systems are involved in the pathophysiology of the Do not give anti-depressant(SRIs) with MAOIs (Selegiline). disorder4. Anxiolytics (SSRIs will not show effect for the first 1-2month, thus if, in Neuroimaging studies utilizing fMRI, PET, SPECT are still ongoing. need of quick relief of animal’s fear and stress, benzodiazepines or gab- Increase activities in the orbitofrontal cortex are repeatedly reported in apentin may be helpful. many neuroimaging studies. Striatum, anterior cingulate cortex, thala- mus, parietal cortex are also reported to affect OCD patients. One of the Supplements and synthetic pheromones can be used to support treat- neurobiological models from imaging data widely accepted had been ment. the OCD-loop hypothesis5. OCD multi-dimensional model was developed by Matrix-Cols et. al. with the conclusion that the unitary disorder view Alpha-S1-tryptic casein (Zylkene): works on GABA-A receptor to reduce of OCD is flawed. The group summarized that research should focus on anxiety common and distinct etiological mechanisms but need to develop specific interventions for specific problems6. Dog Appeasing Pheromone (DAP) Search for candidate genes associated with OCD has been the topic in Environmental modification many studies. Some studies hypothesized that serotonin transporter poly- morphism has been associated with OCD but still not clear and results are Keep the environment safe for the animals as well as the family members. inconsistent7. The neuronal cadherin gene (CDH2) region on chromosome If aggression is involved, do not let the owner touch the dog to stop the 7 was highly associated with canine compulsive disorder8. However, behavior. No punishment for the behavior. This is behavior from stress and frustra- tion. Punishment will just increase stress and it will not help. Recognize and address stress and remove it if it is possible. 137

13–15 NOVEMBER, 2021 If the animal is self-mutilating, introducing a basket muzzle may help. 0084 Behavior modification DIAGNOSIS AND MANAGEMENT OF COMPULSIVE DISORDERS IN CATS When the animal is showing the behavior or almost showing the behavior, distract the behavior, give other behavior that is incompatible, if animal M. Irimajiri gives its response, reward it for the other incompatible behavior (response substitution). Tokyo/Japan Be consistent especially interaction between the family and the animal Qualifications: should be consistent and predictable. Mami Irimajiri Give proper stimulus to the animals. If needed, take some time to take dogs out for a walk or get time to play with them. Providing puzzle feeders BVSc, PhD, Dipl.ACVB is easy to try. [email protected] In order to conduct response substitution for treatment, basic obedience training and some trick teaching with positive reinforcement are recom- What is Compulsive Disorder? mended. Compulsive disorder is a condition in which an animal displays repetitive, References exaggerated, or sustained behavior out of original context. It is believed to occur in animals subjected to stressful situations resulting in conflict or 1. Hewson CJ, Luescher UA. (1996) Compulsive Disorder in Dogs. In Voith frustration1. Compulsive disorder can develop in many species, including VL et al ed. Readings in Companion Animal Behavior. pp. 153-58 dogs, cats, birds, horses, rabbits, and rats. Typical clinical signs for cats are often presented for wool sucking, nibbling and eating cloths, tail chas- 2. Rapoport JL, Ryland DH et. al. (1992) Drug treatment of canine acral ing, excessive self-grooming. lick- An animal model of obsessive-compulsive disorder. Arch Gen Psychi- atry 49. 517-521 Compulsive disorder in animals appears similar to human obsessive-com- pulsive disorder in its behavioral presentation, medication response, and 3. Ogata N, Gillis TE, Liu X et al. (2013) Brain Structural abnormalities in genetic predisposition2. A recent imaging study with MRI revealed that Doberman pinschers with canine compulsive disorder. Prog. Neuro-Phy- there is a parallel between canine compulsive disorder and human obses- chopharmacology and Biol. Psychi 45. 1-6 sive-compulsive disorder (OCD). 4. Heese S, Muller U, Lincke T et.al. (2005) Serotonin and dopamine Human OCD was classified as an anxiety disorder in the Diagnostic and transporter imaging in patients with obsessive–compulsive disorder. Statistical Manual of Mental Disorders 4th edition (DSM-IV). In DSM Neuroimaging 140. 63-72 5th edition, OCD is taken out from the anxiety disorder group and became independent. We had hypothesized that compulsive disorders in animals 5. Sexana S, Brody AL, Schwartz JM et al. (1998) Neuroimaging and fron- were also suffering from one of anxiety disorder as in human OCD, howev- tal circuitry in obsessive compulsive disorder. Br. J Psychiatry 173. 26-37 er, we might reconsider that this disease in animals is also independent of anxiety disorder. 6. Matrix-Cols D, Wooderson S, Lawrence N, et.al. (2004) Distinct neural correlates of washing, checking and hoarding symptom dimensions in Science Behind OCD obsessive-compulsive disorder. Arch Gen Psychiatry 61. 564-576 Studies looking at the effect of serotonergic agents such as serotonin 7. Mak L, Streiner DL, Steiner M (2015) Is serotonin transporter polymor- reuptake inhibitors (eg. clomipramine, fluoxetine, fluvoxamine, sertraline, phism (5-HTTLPR) allele status a predictor for obsessive-compulsive and paroxetine) have provided mainstream OCD treatment. The success disorder? A meta-analysis. Arch Women’s Mental Health DOI 10.1007/ of pharmacological treatment with serotonin reuptake inhibitors and s00737-015-0526-z atypical antipsychotic drugs suggests that both the central serotonergic and dopaminergic systems are involved in the pathophysiology of the dis- 8. Dodman NH, Karlsson EK, Moon-Fanelli et al. (2010) A canine chro- order3. Glutamatergic augmenting agent (memantine) provided supportive mosome 7 locus confers compulsive disorder susceptibility. Molecular evidence for effectiveness in treating severe OCD4. Psychiatry 15. 8-10 Neuroimaging studies utilizing fMRI, PET, SPECT are still ongoing. 9. Moya PR, Dodman NH, Timpano KR et al. (2013) Rare missense Increase activities in orbitofrontal cortex are repeatedly reported in many neuronal cadherin gene (CDH2) variants in specific obsessive-compulsive neuroimaging studies. Striatum, anterior cingulate cortex, thalamus, pari- disorder and Tourette disorder phenotypes. etal cortex are also reported to affect OCD patients. One of the neurobio- logical models from imaging data widely accepted had been the OCD-loop 10. Wang Y, Mathews CA, Li Y, et al. (2011) Brain-derived neurotrophic hypothesis5. OCD multi-dimensional model was developed by Matrix-Cols factor (BDNF) plasma levels in drug-naïve OCD patients are lower than et. al. with the conclusion that the unitary disorder view of OCD is flawed. those in healthy people, but are not lower than those in drug treated OCD The group summarized that research should focus on common and dis- patients. Journal of Affected Disorders 133. 305-310 tinct etiological mechanisms but need to develop a specific interventions for specific problems6. Search for candidate genes associated with OCD have been the topic in many studies. Some studies hypothesized that serotonin transporter poly- morphism has been associated with OCD but still not clear and results are inconsistent7. The neuronal cadherin gene (CDH2) region on chromosome 7 was highly associated with canine compulsive disorder8. However, 138 WSAVA GLOBAL COMMUNITY CONGRESS

CDH2 was not associated with human OCD9. No punishment for the behavior. This is behavior from stress and frustra- tion. Punishment will just increase stress and it will not help. Brain-derived neurotrophic factor (BDNF) plays an important role in neural development. Studies showed that BDNF plasma levels are lower in OCD Recognize and address stress and remove it if it is possible. patients compared to healthy controls regardless of treatment status10. BDFN seems to be an interesting candidate for molecular analysis in If the cat is self-mutilating, introducing shirts or e-color to protect from OCD-reported interaction between this gene and neurotransmitters associ- mutilating itself may help vicious cycle of lick-sore-lick-more sore cycle ated with this disease. Behavior modification Human OCD studies and some reports from canine compulsive disorder studies suggest that different phenotypes of compulsive disorders might When the animal is showing the behavior or almost showing the behavior, have different pathophysiology and causes. The etiology and pathophys- distract the behavior, give other behavior that is incompatible, If the an- iology behind OCD and canine compulsive disorder are still “ongoing” imal gives its response, reward it for other behavior (response substitu- search. Still many studies need to be conducted to fully understand the tion). disease. Be consistent and predictable. Diagnosis Give proper stimulus to the animals. If needed, take some time to play Rule out medical conditions. Differential diagnosis includes neurological with cats are important. Provide interactive toys. disorders (central and peripheral), dermatological problems, endocrinolog- ical diseases. In order to conduct response substitution for treatment, some trick teach- ing with positive reinforcement is recommended. Rule out behavioral problems such as attention-seeking behavior, conflict behaviors (e.g. behaviors to release frustrations), stress from other anxi- References ety disorders, cognitive dysfunction. Hewson CJ, Luescher UA. (1996) Compulsive Disorder in Dogs. In Voith Observe the behavior itself. Video images of behaviors that animals VL et al ed. Readings in Companion Animal Behavior. pp. 153-58 presenting at home are helpful. Rapoport JL, Ryland DH et. al. (1992) Drug treatment of canine acral lick- Getting thorough history by using open-ended questions and getting the An animal model of obsessive-compulsive disorder. Arch Gen Psychiatry whole story about several incidents including the response (or reaction) to 49. 517-521 the behavior of animals. Heese S, Muller U, Lincke T et.al. (2005) Serotonin and dopamine trans- Treatment porter imaging in patients with obsessive-compulsive disorder. Neuroim- aging 140. 63-72 If identified early, cases of compulsive disorders may be treatable without medication, but most cases require psychotropic medication and behavior Stewart SE, Jenike EA Hezel DM et.al. (2010) A single-blinded case-con- modification on top of environmental modification. trol study of memantine in severe obsessive-compulsive disorder. J Clini Psychopharmacol. 30. 34-39 Medication Sexana S, Brody AL, Schwartz JM et al. (1998) Neuroimaging and frontal Anti-depressants: circuitry in obsessive-compulsive disorder. Br. J Psychiatry 173. 26-37 Fluoxetine (Reconcil) 0.5-1.0 mg/kg Q24H Matrix-Cols D, Wooderson S, Lawrence N, et.al. (2004) Distinct neural correlates of washing, checking and hoarding symptom dimensions in Clomipramine (Clomicalm, Anafranil) 0.5-1.0mg/kg Q24H obsessive-compulsive disorder. Arch Gen Psychiatry 61. 564-576 Paroxetine (Paxil) 0.5-1.5mg/kg Q24H Mak L, Streiner DL, Steiner M (2015) Is serotonin transporter polymor- phism (5-HTTLPR) allele status a predictor for obsessive-compulsive Fluvoxamine 0.25-0.5mg/kg Q24H disorder? A meta-analysis. Arch Womens Mental Health DOI 10.1007/ s00737-015-0526-z Sertraline 0.5-1.5mg/kg Q24H Dodman NH, Karlsson EK, Moon-Fanelli et al. (2010) A canine chromo- Do not give anti-depressant (SRIs) with MAOIs (Selegiline). some 7 locus confers compulsive disorder susceptibility. Molecular Psychiatry 15. 8-10 Anxiolytics (SSRIs will not show effect for the first 1-2month, thus if in need for quick relief of animal’s fear and stress, benzodiazepines may be Moya PR, Dodman NH, Timpano KR et al. (2013) Rare missense neuronal helpful. cadherin gene (CDH2) variants in specific obsessive-compulsive disorder and Tourette disorder phenotypes. Supplements and synthetic pheromones can be used Wang Y, Mathews CA, Li Y, et al. (2011) Brain-derived neurotrophic factor Alpha-S1-tryptic casein (Zylkene): works on GABA-A receptor to reduce (BDNF) plasma levels in drug-naïve OCD patients are lower than those in anxiety healthy people but are not lower than those in drug treated OCD patients. Journal of Affected Disorders 133. 305-310 Feline F3 facial pheromone (Feliway) Crowell-Davis SL, Murray T (2006) Veterinary Psychopharmacology. Feline F4 appeasing pheromone (Felifriend) Blackwell Publishing Environmental modification Keep the environment safe and enriched for cats. Cat trees, easy access to water and food, soft beds, places to hide, toys to play. 139

13–15 NOVEMBER, 2021 0085 The owners should be taught to use positive reinforcement for acceptable behaviours, to spend enough time with the parrot to fulfil its social needs COMMON BEHAVIOURAL CONDITIONS IN PARROTS and to react by moving away when the parrot screams excessively. Short (5min) periods of covering the cage with a blanket may be used to stop D. Elliott the screaming but the blanket should be removed or lifted immediately the bird stops screaming. Placing a blanket over the cage for hours at a time Pretoria/South Africa may stop the screaming in the short term but will play no role in teaching the parrot not to scream. Qualifications: Owners should also develop a communication call that the parrot can Dr Dorianne Elliott use when it needs interaction. Responding to a quiet call by approaching the cage (or even by answering the bird “I’m here” or “Hi bird” etc when Dip Vet Nur BVSc in another part of the house) will teach the bird that interaction can be achieved without loud vocalisations. [email protected] Selected behavioural disorders in parrots Biting: Biting may occur for many different reasons: territorial aggression around the bird’s cage or mate, learned fear of the owner or the owner’s Elliott DL. Dip Vet Nur BVSc. Bird and Exotic Animal Hospital, Onderste- hands, hormonal aggression, a learned response to prevent being moved poort Pretoria. Extraordinary Lecturer, Dept of Companion Animal Clinical or re-introduced to the cage and defensive aggression of a favoured studies, University of Pretoria. [email protected] owner or toy. ABSTRACT: Parrots are extremely intelligent, social animals and captive Biting is much easier to prevent than correct and all inexperienced parrot parrots are particularly prone to developing behavioural disorders if their owners should be helped to teach their bird the basics of polite behaviour. psychological needs are not met. Excessive screaming, aggression, A bird should never be placed into a situation where it can learn to bite feather destructive behaviour, self-mutilation, masturbation, obsessive and any early biting behaviours should be corrected by a gentle negative compulsive behaviours and the development of phobias are commonly reinforcer such as wobbling the hand on which the bird is sitting to make seen. The management of these disorders can be challenging and a ho- the bird lose balance, or gently pushing the gripped finger into the bird’s listic approach to the problem, including thorough evaluation of the home mouth instead of pulling away, to make the bird open its mouth. Flicking environment, observation of the owner’s interaction with the bird, diet the beak, shouting etc is counter-productive. A release command such as modification, treatment of any underlying medical conditions, behavioural “gently” or “ouch” should also be used. modification training of both bird and owner and occasionally the use of psychotropic medication must be considered. Hormonally driven biting may be reduced by using an implant such as Suprelorin (gonadotropin releasing hormone agonist) to decrease the INTRODUCTION: In their natural environment parrots are very rarely seen hormone levels. alone. Bonded breeding pairs spend all their time within a short distance of one other and large groups, up to hundreds of birds will collect at Feather Destructive Behaviour (FDB): With over 50 recognised causes, a favoured feeding spots. Psittacines have complex social behaviours and plucker should have a full medical workup with bloods and a radiograph are constantly interacting with each other. Feeding on fruit, seeds, flowers, to rule out underlying disease. Most pluckers will have nutritional defi- nuts and bark, parrots spend up to 70% of their waking hours foraging. ciencies and supplementation with Vitamin A, B vitamins, Vitamin E and Selenium are recommended. Conversion to a balanced diet is imperative. For this reason, captive parrots need extensive environmental and social enrichment as a substitute for their active lives in the wild. Very few cap- Sources of airborne irritants such as people smoking near the bird, paint tive parrots are suitably enriched, and bored frustrated birds can develop and air fresheners must be removed. Owners should wash their hands a range of behavioural disorders. Parrots can also develop behavioural before handling their pet. problems due to underlying chronic disease, nutritional deficiencies and stressful or inappropriate environments. Bathing is very healthy for the bird. It is excellent exercise and stimulation and washes allergens from the feathers. The veterinarian presented with a behavioural case has extensive work ahead of him to evaluate, diagnose and effectively treat the patient. The use of Elizabethan collars should be avoided unless necessary to pre- vent self-injury. A collar prevents FDB but does not correct the underlying SPECIFIC BEHAVIOURAL DISORDERS: problem. Excessive Screaming: One of the most common presenting complaints. Self-mutilation: Can be caused by pain or discomfort in a specific region. Parrots can vocalise very loudly and will do so when they need or desire Collars and bandages as well as analgesia and a workup to establish the cause of the discomfort are recommended. social interaction. When kept alone parrots will often accept human members of the household as surrogate flock members and will attempt Psychological self-mutilation can be a progression from FDB. Cockatoos, to interact with them in the same way that they would interact with con- quaker parrots and lovebirds are over-represented. Probably the most diffi- specifics. cult and unrewarding of behavioural problems to control, early intervention is critical. Haloperidol may be useful in rare cases as can gabapentin and Parrots will typically vocalise loudly for 10-30 minutes at dawn and dusk, NSAIDs in cases where neuralgia is suspected. when the flock would be gathering to forage or to roost. This is a normal and healthy behaviour and should not be mistaken for excessive scream- Special jackets are available that are permanently worn. These jackets ing. Owners should be educated to accept this vocalisation and not to have reinforced chests to prevent self-mutilation of the sternal area, the react or attempt to correct it. most common site for chronic behavioural self-mutilation. Excessive screaming develops when the owners react by approaching the Some birds, especially chronic self-mutilators may improve for short peri- cage and interacting with the parrot while it is calling. Even an attempt by ods and relapse when stressed or may need permanent collars or jackets. the owner to correct or punish the behaviour may be a positive reinforce- ment for the parrot. The parrot, thus enforced, will repeat the behaviour to Masturbation: Birds may begin to stimulate themselves on perches or communicate with its surrogate flock members. toys. This behaviour is often reported by the owner as the bird having an 140 WSAVA GLOBAL COMMUNITY CONGRESS

“itchy bum” as they will hunch over and repeatedly rub the cloacal area 0086 on the chosen object. The self-stimulation is often preceded by the bird regurgitating food and smearing it onto the object. The favoured toy may ANAESTHESIA IN BIRDS be coated with layers of regurgitated food. Birds will also occasionally masturbate on a person’s hand, foot or shoulder. Occasionally birds will D. Elliott masturbate excessively and traumatise the cloaca. Depending on the situation, using foraging toys to keep the bird busy, giving the bird a mate Pretoria/South Africa and teaching the owner not to inadvertently stimulate the bird by cuddling for long periods (especially stroking the bird over the body or under the Qualifications: wings) may be useful. Dr Dorianne Elliott Obsessive Compulsive Disorders: most often the result of inadequate stimulation, small cages and chronic stress. Each case should be evalu- Dip Vet Nur, BVSc (Pret) ated individually. Enrichment is important but often these birds must be introduced to new experiences very slowly as they may show exaggerated [email protected] fear responses to any changes in the environment. AVIAN ANAESTHESIA Phobias: More commonly seen in certain species (Galah cockatoo, African Elliott DL. Dip Vet Nur BVSc. Bird and Exotic Animal Hospital, Onderste- Grey), phobic behaviours to previously innocuous stimuli can develop for poort. [email protected] what, to outside observers can be very insignificant reasons. Naturally a traumatic experience in the bird’s life may be the trigger, but what the bird ABSTRACT: Avian anaesthesia may seem daunting to some general perceives as stressful may not be obvious at first glance. practitioners but can be invaluable to minimise handling and restraint associated stress in most birds. Avian patients are regularly sedated or Providing a sheltered environment (covering back and sides of the cage), anaesthetised for radiography, intravenous fluid administration, microchip ensuring that the cage is in a position where the bird can see people ap- implantation and other painful or invasive procedures. Fractious patients proaching from a distance and slow re-training with positive reinforcement may benefit from sedation even for simple procedures such as blood can improve the condition. CAPTIVE FORAGING: A technique whereby the collection. Performed properly, the risk of complications from a short bird is allowed to spend time working at foraging.1 anaesthetic can be less than the risks of feather damage, injury to staff, damage to the human-animal bond and even death from stress caused by CONCLUSION: Behavioural problems are frequent presenting complaints manual restraint. Avian anatomy and physiology are unique and a proper with avian patients. Due to their intelligent and sensitive nature many understanding of the avian cardiopulmonary system is necessary to pro- causes for aberrant behaviours have been identified. It is imperative for vide patients with an appropriate and low risk anaesthetic. the clinician to use their diagnostic skills and to gain a full history along with the clinical examination and observations. A general medical workup RELEVANT ANATOMY AND PHYSIOLOGY: Typical birds are highly adapted is recommended to exclude physical causes of the behaviour before con- for the rigors of flight, during which the metabolic rate increases enor- sidering intervention with psychotropic drugs. Although over 50% of feath- mously. One could describe them as having a “high performance” cardio- er pluckers, in our experience, have a medical cause for the behaviour vascular system. some birds may strongly benefit from anxiolytics and anti-depressants. Any psychotrophic drugs should be used for the shortest time possible Birds have extremely light skeletons and a number of avascular airsacs while the environmental and husbandry changes take effect. The owner throughout the body. Many species have diverticulae of these airsacs must be fully informed as to the amount of compliance and dedication into the medullary cavities of certain bones. The femurs, humeri, sternum needed to effectively treat most behavioural complaints. and vertebrae may all be pneumatised. The airsacs do not contribute to gaseous exchange but do play a vital role in the respiratory cycle1. With dedication from the vet and compliance from the owner, many behavioural problems can be solved or markedly reduced in intensity, so Avian tracheas are longer and wider than those of mammals and also long as an individual protocol is developed for every case. have complete tracheal rings. Insufflating cuffed endotracheal tubes may lead to tracheal necrosis and cuffed tubes are not recommended for use BIBLIOGRAPHY in birds. This larger tracheal volume increases dead space but the bird compensates for this with a larger tidal volume and extremely efficient 1. Luescher U. Manual of Parrot Behaviour. Iowa: Blackwell Publishing; gaseous exchange. 1. 2006. Birds do not have a diaphragm. Ventilation is achieved by contraction of the intercostal and abdominal muscles, causing outward and downward movement of the ribs and sternum. There is no negative intra-thoracic pressure. It is important never to place pressure on the bird’s body during restraint as this may restrict chest movement and ventilation. The avian lung is non-expansile and air flow through the lung is unidirec- tional. It takes two respiratory cycles for inspired air to be moved all the way through the respiratory tract. Birds absorb O2 from fresh air on both inspiration and expiration, making their respiratory system much more effective than that of mammals1. During inspiration fresh air is moved through the lungs as well as into the caudal airsacs. The stale air in the lungs passes into the cranial airsacs. During expiration the stale air from the cranial airsacs is expired as is the stale air from the lungs. The still oxygenated air that was present in the caudal airsacs moves through the lungs, allowing for constant O2 absorption. During gaseous anaesthesia it should be remembered that a considerable volume of anaesthetic gas is stored in the airsacs and sev- 141

13–15 NOVEMBER, 2021 eral deep breaths should be administered via positive pressure ventilation Cardiac compressions may be attempted but are difficult to perform due to flush out the air sacs whenever a sudden change in anaesthetic depth to the presence of the large sternum that blocks access to the heart.2,5 is required. RECOVERY: A warm, dimly lit environment with minimal stimulation is PRE-OPERATIVE PREPARATION: Pre-anaesthetic fasting is important to required for recovery. Avian patients should be gently restrained (with minimize the risk of regurgitation as well as to decrease the size of the NO pressure over the chest as this will impede respiration) and carefully gastro-intestinal tract. A full, heavy GIT exerts pressure on the airsacs and monitored until fully conscious and able to stand, as they can easily injure will restrict ventilation. Birds have fast metabolisms and prolonged fast- themselves by flapping and struggling during the excitement phase of ing is seldom necessary. As a guideline a vulture may be fasted for one recovery. Always examine the oral cavity for secretions and immediately day, an African Grey parrot for 4hrs and a small passerine for only 20min2. turn the bird upside down to allow any fluid to drain from the mouth, away from the glottis should regurgitation occur. Cotton buds are useful for Pre-medication is seldom used as its administration would necessitate yet clearing the oral cavity2,3,5. another capture experience for the patient. Nutrition should be provided as soon as possible after recovery. Patients All equipment and drugs (including emergency drugs) should be readied unable or unwilling to eat should be crop fed (by tube or by steel gavage before the induction. Heating devices must be ready and a dim, quiet needle in hook billed species) with a suitable high energy, easily digestible environment must be available. meal.2,4. INDUCTION AND INTUBATION: 5% Isofluorane gas anaesthesia is the SUMMARY: Properly performed avian anaesthesia is relatively safe and most commonly used induction agent. A period of pre-oxygenation is ideal minimally stressful and may be used even for minor procedures in order to prior to induction. Typically birds are gassed down with an open system reduce stress on the patient. Isofluorane or sevofluorane are currently the (mask or induction chamber) and then intubated. A well-fitting mask will anaesthetic gases of choice due to their rapid onset and short duration of minimize the amount of escaping anaesthetic gas and subsequently the action. Halothane causes marked cardiopulmonary depression and cannot amount of environmental pollution. Intubation is simple due to the lack be recommended. Injectable anaesthetics have their place but have a of an epiglottis. Pressing a finger under the chin to elevate the tongue higher likelihood of side effects and complications than gas, as well as a and raise the glottis improves visualization and simplifies the intubation tendency for prolonged, rough recoveries. Birds must be comprehensive- process. Regurgitation is common and aspiration occurs easily, thus ly supported in the peri-anaesthetic period with warmth, supplemental intubation is perormed even for short procedures. The endotracheal tube oxygen, adequate nutrition, fluids and minimal stress. Intermittent positive also allows for immediate ventilation should the need arise. pressure ventilation of the intubated patient is recommended as the tidal volume of each spontaneous breath while under anaesthetic tends to be An Ayer’s T piece system with a modified open bag is used for most avian inadequate. A proper understanding of the unique structure and function patients. This allows for rapid positive pressure ventilation without the of the avian cardiopulmonary system is necessary in order to reduce risk of barotrauma from a closed pop-off valve. Larger patients (>7kg) can anaesthetic related morbidity and mortality.1,4,5 be placed on a paediatric circle circuit which will allow for lower gas flow rates and minimize heat and moisture loss.3 REFERENCES: Injectable agents can be used and there are many drug regimens available 1. Morrisey J. Avian respiratory anatomy, physiology and disease [Inter- in Exotic Animal Formularies. As they have much higher side effect and net]. [cited 2021 Sep 19]. Available from: https://lafeber.com/vet/wp-con- complication profiles and a tendency to produce prolonged and rough tent/uploads/Outline-Avian-Respiratory-Diseases-Morrisey.pdf recoveries, they are typically only used in field settings 2. Gunkel C, Lafortune M. Current techniques in avian anesthesia. Semi- MAINTENANCE AND MONITORING: It is all too easy for the surgeon to nars in Avian and Exotic Pet Medicine. 2005;14(4):263–76. inadvertently rest his hand on the bird’s chest while working, thus severely compromising its respiration, and the anaesthetist must be vigilant to 3. Crosta L. Avian Anesthesia [Internet]. [cited 2021 Sep 19]. Available ensure that this does not occur. from: https://lafeber.com/vet/wp-content/uploads/2020/01/Avian-Anes- thesia-Abstract-LV.pdf In ventral recumbency the central respiratory depression caused by the anaesthetic, an increase in dead space due to airway-apparatus and pres- 4. Raftery A. Avian anaesthesia. In Practice. 2013 May;35(5):272–8. sure on the lungs from the viscera, ventilation in the anaesthetized bird can be decreased significantly. It is thus recommended to use intermittent 5. Nevarez JG. Monitoring during avian and exotic pet anesthesia. Semi- positive pressure ventilation to ensure proper ventilation and oxygenation. nars in Avian and Exotic Pet Medicine. 2005 Oct;14(4):277–83. Birds do not display the same clear planes of anaesthesia that mammals do but there are several fairly reliable reflexes that can be monitored. A bird in a suitable plane of anaesthesia for invasive surgery will have lost the toe pinch reflex, will have slack jaw and muscle tone but will still maintain the corneal blink response (a light touch on the cornea will elicit a blink or at least a flicker of the eyelids). Loss of the corneal reflex may indicate a too deep plane of anaesthesia or other complications such as hypothermia, hypoxaemia or impending cardiac arrest5. A Doppler probe placed over the ulnar artery on the inside of the wing is useful for gauging pulse speed and strength and is also used when mea- suring blood pressure. Regardless of the level of monitoring technology used, the trained eyes and hands of the anaesthetist are by far the most valuable monitoring tool.5 Respiratory arrest is a not uncommon anaesthetic complication and is often reversible with lightening of the anaesthetic plane and positive pres- sure ventilation. The onset of cardiac arrest holds a very poor prognosis. 142 WSAVA GLOBAL COMMUNITY CONGRESS

0087 patients that present with the clinical signs of gingivitis (gingival erythema and oedema, and halitosis) should be scheduled for a professional dental THE ABC’S OF COHAT DENTISTRY cleaning. M. Burley Language & It’s Impact on the Client Perspective Brisbane/Australia When discussing dental treatment with our clients we can often fall into the trap of forgetting the client does not have our experience or knowl- Qualifications: edge. The client’s only point of reference could be their own experience with their dentist, a previous pet’s dental treatment (or lack thereof), or no Mrs Maggie Burley experience at all. Depending on the client’s perspective, the terms we use to discuss their dental treatment may have very different connotations to CVN, Dip VN (Dental), VTS (Dentistry), RVN what we expect. When we use the terms ‘a dental’, ‘scale and polish’ or ‘cleaning’, we fail to give a true representation of the procedure itself, and [email protected] the skills and knowledge of the veterinary health care team. This state- The veterinary nurse/technician (nurse) plays a vital role in the care of ment devalues the procedure and misrepresents the medical nature of the the dental patient. We are called upon to support the patient throughout procedure as a treatment of disease. When we refer to the procedure as the dental procedure, maintain and care for all dental instrumentation and a comprehensive oral health assessment, we describe the procedure as equipment, provide assistance through anticipation of our veterinarian’s diagnostic. Incorporating the word ‘treatment’ implies the medical nature needs, and educate the client on how best to provide ongoing dental of the procedure and the skills and knowledge required to perform it. homecare for the pet. In order to carry out this vital role, it is imperative to Using the acronym COHAT, reminds us to discuss dental treatments with have a thorough understanding of the disease process, its treatment and all of this in mind. A simple change in language can drastically change the management. client’s perspective of the procedure their pet is about to receive. Pathogenesis of Periodontal Disease Comprehensive Oral Health Assessment and Treatment Periodontal Disease is used to describe the early and later stages of the We can break down the COHAT, or Professional Dental Cleaning, into a se- disease process that affects the periodontium. The periodontium consists ries of steps. This ensures a systematic approach to both the assessment of the gingiva, periodontal ligament, cementum and alveolar bone which and the treatment of the patient. combined, support the teeth. Gingivitis is the earliest, reversible stage of the disease where inflammation is confined to the gingiva. It is initiated Pre-Surgical Exam & Consultation – during this step, information is by the presence of subgingival plaque and presents as erythema, oedema, gathered from the client with respect to the pet’s oral habits, including halitosis and bleeding on probing, brushing or chewing. any recent changes that may indicate signs of oral pain, current diet, any underlying health concerns and any homecare already in place. An oral Periodontitis (the loss of periodontal tissues) is the later stage of what examination on the conscious patient is carried out paying particular is defined as an inflammatory disease that results in the progressive attention to symmetry of the face, ocular or nasal discharge, swelling or destruction of the periodontal ligament, cementum and alveolar bone. wounds, pain or restriction on opening and closing the mouth, palpation of Clinically this presents as the formation of pockets and/or gingival reces- lymph nodes, bite assessment (occlusion), any abnormalities of the gingi- sion. The final stage of periodontitis is tooth loss. va and soft tissues, assessment of the crowns of the teeth, along with an assessment of any calculus attachment, gingivitis and halitosis. In prepa- Periodontal disease is initiated by plaque. Plaque is a complex coopera- ration for anaesthesia a health examination and bloodwork along with any tive community of bacteria that can resist the host defenses. Initially, sali- other diagnostic procedures are carried out to assess the patient’s risk vary glycoproteins (pellicle) form on the tooth’s surface within seconds of and an appropriate anaesthetic and analgesic plan implemented. a tooth being cleaned. Within hours, gram positive oral bacteria colonise the pellicle and the plaque biofilm is formed. Supragingival plaque will The Professional Dental Cleaning – Once the patient has reached an continue to mature to a point where anaerobic microorganisms can be appropriate anaesthetic depth and is positioned for drainage the dental supported. Periodontal disease is initiated by a change in the population cleaning can begin. of the plaque biofilm rather than an increase in its numbers. The oral cavity is rinsed with a 012% or 0.2% chlorhexidine gluconate Supragingival plaque biofilm consists of a population predominantly solution to decrease the bacterial load prior to the use of air powered aerobic bacteria. If left undisturbed, plaque will extend into the sulcus instruments. and become known as subgingival plaque. The subgingival plaque matrix is then protected by the supragingival plaque, and within an oxygen poor Supragingival calculus deposits are removed from the crowns of the teeth environment, allows the small population of gram-negative anaerobic using mechanical (ultrasonic) or hand scaling (hand scaler or curette) bacteria to proliferate. The anaerobic bacteria combined with the associ- ated release of endotoxins (and other factors) activate the host animal’s The most important step is the removal of plaque and calculus from the inflammatory response. The subsequent cytokine release and additional sulcus – known as subgingival scaling. For best results, a combination of inflammatory cells destroy the periodontal tissues while fighting the bac- hand instruments (curette) and ultrasonic scaling with the appropriate tip teria. It is for this reason that periodontal disease is instigated through the in place is needed. proliferation of subgingival plaque along with the patient’s own immune response. The progression of the disease can vary - contributing factors Once all scaling has been completed, an assessment for any residual include, but are not limited to, systemic health, effective (ineffective or plaque and calculus is carried out. Various techniques can be used – non-existent) home care, malocclusions, rotation and/or overcrowding of ‘feeling’ the teeth with an explorer for any rough surfaces, drying the teeth, professional dental cleanings, genetics and nutrition. tooth surface with air (residual calculus will appear chalky) or the use of a plaque disclosing solution. Scaling is repeated until all calculus and Mechanical removal and disruption of the plaque biofilm profession- plaque has been removed. ally and with tooth brushing is necessary in order to treat and prevent periodontal disease, respectively. (Lobprise & Dodd, 2019) Veterinary Polishing is carried out using either a commercially available polish or a slurry of flour of pumice and water in a rubber prophy cup on the 143

13–15 NOVEMBER, 2021 slow-speed handpiece. The prophy cup is filled with paste to reduce the 0088 incidence of thermal damage to the tooth. Slight pressure is applied so as to polish the subgingival areas and the crown in its entirety. HOMECARE AND GAINING CLIENT COMPLIANCE A gentle lavage of the sulcus is recommended with 0.12% chlorhexidine M. Burley solution to remove debris such as calculus and prophy paste to improve healing and patient comfort. Brisbane/Australia Periodontal Examination & Dental Charting – The entire oral cavity must Qualifications: be systematically evaluated using both visual and tactile senses. (Nie- miec, et al., 2020) The nurse can be a valuable assistant by accurately and Maggie Burley efficiently recording the clinician’s findings on the dental chart. CVN, Dip VN (Dental), VTS (Dentistry), RVN Radiographic Examination – when available, dental radiography completes the comprehensive oral examination. [email protected] Engaging, and maintaining that engagement, is one of the difficulties Treatment Planning – the veterinarian is now able to formulate a treat- faced when implementing homecare routines between our clients and ment plan using the findings from both the periodontal and radiographic their pets. It takes a motivated veterinary nurse to not only educate our examination of the patient. clients on the importance of their pet’s oral health, but also to overcome the challenges that implementing homecare routines can present. Application of Dental Sealant (optional) – the veterinarian may choose to apply a dental sealant as an ongoing barrier to help prevent attachment or Homecare Goals accumulation of plaque-forming bacteria following the procedure. The goal of homecare is simple – remove plaque. Or more specifically, Veterinary Nurse’s Role remove supragingival plaque before it extends into the sulcus becoming subgingival plaque, which then instigates the disease process that is Peri- Throughout the procedure, vigilant monitoring of the patient’s anaesthetic odontal Disease. It is through a combination of professional assessment depth, recognition of impending emergency, and ongoing assessment for and treatment along with a client-driven homecare routine that will help to pain is paramount to the successful recovery of the patient. This contin- maintain the oral health of the patient. Without homecare, the efficacy of ues into the recovery phase of anaesthesia, along with considerations for professional periodontal therapy is severely limited.(1) the patient’s comfort. Mechanical v Chemical Responsibility also lies with the nurse for the ongoing care and main- tenance of all dental instrumentation and equipment. The nurse should It is likely you have heard the terms mechanical and chemical in relation have a sound knowledge of the instruments, sharpening and sterilisation to the mode of action of homecare products. The term mechanical relates techniques and regular maintenance schedule of the dental unit. to dental care or products that physically remove plaque build-up from the tooth’s surface using abrasion. Products that have a mechanical action The well-trained and knowledgeable nurse can be a valuable asset in are toothbrushes, specifically formulated dental diets and dental chews/ providing care to the dental patient, assistant to the veterinarian and client treats. The term chemical relates to either an ingredient that will reduce educator. the bacterial load or slow the progression of plaque maturation, or its min- eralisation into calculus. Examples of these are antibacterial/antiplaque References solutions, water additives or ingredients contained in diets or chews. Both mechanical and chemical modes of action have varying degrees of Lobprise, H., & Dodd, J. (2019). Wiggs’s Veterinary Dentistry Principles effectiveness in plaque removal and work best in combination using a and Practice, 2nd Edition. Hoboken, NJ: John Wiley & Sons Inc. multi-modal approach. Niemiec, B., Gawor, J., Nemec, A., Clarke, D., McLeod, K., Tutt, C., . . . What these terms don’t do, is take into consideration the human factor. Jouppi, R. (2020). World Small Animal Veterinary Association Global Dental Guidelines. Journal Small Animal Practice, Vol 61. The Human Factor Homecare involves a certain level of participation on the part of the pet owner. We use the terms “active” and “passive” to reflect this. Active homecare relates to products and dental care that involves the active participation of the pet owner. They include daily toothbrushing, the use of antiseptic rinses (post-procedure) and the application of dental sealants. Passive homecare relies on minimal effort on the part of the pet owner, so compliance is more likely. Dental diets, chews and additives fall into this category. Their action relies on the chewing behaviours of the pet. Their effectiveness can be varied and is reliant on their design and ingredients. These products and techniques should always be used in combination with professional dental care.(1) Effective Homecare In order for homecare to be successful, it must be effective. A profession- al dental cleaning, to return the tooth to a clean surface, followed by daily home care, to remove the plaque biofilm, is the gold standard to prevent and control periodontal disease.(2) Regardless of the mode of action of 144 WSAVA GLOBAL COMMUNITY CONGRESS

the dental products and care utilised, we need to ensure the proper use, References: regime and appropriateness for the patient. Homecare is not a ‘one-size fits all’ kind of thing. Consideration needs to be given to any underlying 1. Niemiec, B., Gawor, J., Nemec, A., Clarke, D., McLeod, K., Tutt, C., . . health concerns first and the treating veterinarian will give this due consid- . Jouppi, R. (2020). World Small Animal Veterinary Association Global eration when making their homecare recommendation for the individual Dental Guidelines. Journal Small Animal Practice, Vol 61 patient. The veterinary nurses’ role then is to convey the veterinarian’s recommendation clearly and answer any concerns the client may have. 2. Lobprise, H., & Dodd, J. (2019). Wiggs’s Veterinary Dentistry Principles and Practice, 2nd Edition. Hoboken, NJ: John Wiley & Sons Inc. Client Motivation 3. Perrone, J. (2013). Small Animal Dental Procedures for Veterinary So how do we motivate clients? We educate them! The key to successful Technicians and Nurses. Ames, Iowa: John Wiley & Sons. home care is owner education. The veterinary technician (nurse) needs to help them understand the causes, effects, and means of prevention. 4. Miller, B., & Harvey, C. (1994). Compliance with oral hygiene recommen- (3) Periodontal Disease is an insidious disease that often presents dations following periodontal treatment in client-owned dogs. Journal of once well established. Given the subtlety of the signs, clients are often Veterinary Dentistry 11, 18-19. completely unaware of its presence leading to a delay in treatment being sought. Often, the discovery is an incidental finding during routine health examinations. For this reason, a comprehensive oral health assessment and the appropriate treatment (COHAT) is often recommended ahead of the implementation of any homecare routine. The discussion for the implementation of a homecare routine should commence at the discharge of the patient following their dental treat- ment. This first phase of homecare often relates directly to the short term post-operative care of the patient and any recommendations the treating veterinarian makes to allow for the successful healing of the surgical sites. These may include a change in the diet and/or cessation of existing abrasive homecare. A further recommendation should be made for the long term management and/or prevention of periodontal disease. This recommendation will include the incorporation of dental care and products meeting the patient’s needs and the participation of the client utilising both mechanical and chemical modes of action and a combina- tion of active and passive options for the client. The client’s education involves helping the client to understand their responsibility in the provision of plaque control for their pet, along with the veterinary team’s ongoing commitment to regular examinations and scheduling treatment when required. The veterinary nurse and, in fact, the entire veterinary team, should have a solid working knowledge of all the dental care products available to their client. The client requires education on the benefits of homecare – not only to their pet, but to themselves. A sound knowledge of not only the action of homecare products, but their benefits to both the pet and client are required of the veterinary nurse. The ‘benefits’ are the reasons why a client will choose to introduce and contin- ue homecare, rather than the features of the products. Clients would like to know that they will have a happier and healthier pet that is free from pain, along with knowing that homecare can be cost-effective, convenient and that they will play an active role in the long term health of their pet. Following the instigation of a homecare routine, the client will need contin- ued support to ensure its successful regular and ongoing implementation. The veterinary nurse should be committed to ongoing contact with the client as it can take weeks to months to establish an effective homecare regime. Even once established, the rate of consistent and continued com- pliance has been shown to wane as time goes on. It has been shown that the compliance rate with tooth brushing with highly motivated pet owners is only around 50% after 6 months.(4) Commencing and continuing a homecare routine for the pet owner can have various challenges. These range from misunderstanding their responsibility, the benefits to their pet or a non-compliant pet. A well- trained and confident veterinary nurse that is knowledgeable in dental care products, client communication and a passion for client education can play an active role in supporting and motivating the client to successfully implement and maintain an effective homecare regime, along with reaping the reward of knowing they have been instrumental in improving the long term health of the patient. 145

13–15 NOVEMBER, 2021 0089 lack the skill or capability to control the dog in any other ways. Similarly, acting on intentions to feed appropriately requires that the person knows HOW PSYCHOLOGY CAN IMPROVE CLIENT what and how much to feed their dog. COMMUNICATIONS 3.Opportunity T. Webb Even if people are motivated to feed appropriately and feel capable of Sheffield/United Kingdom doing so, companion animals may still become overweight because the environment is not conducive to performing the respective behaviours. Qualifications: Obvious examples include that the way the animal is integrated into the household makes it difficult to regulate its food intake – for example, a Thomas L. Webb dog might sit with the family at the dinner table or other people may give the dog treats. However, opportunity may also be about recognising good Ba, MSc, PhD opportunities to act (e.g., that owners could use a measuring scoop to keep track of how much they are feeding). [email protected] The primary purpose of a consultation between a veterinary professional Selecting behaviour change strategies and a client (or owner) is to achieve a positive outcome for the compan- ion animal – be that helping the animal to reach or maintain a healthy The behavioural diagnosis is then mapped onto potential options and body weight, or to tackle a particular health issue (e.g., dermatitis). The techniques for changing behaviour6, such as those described in tax- challenge is that many important outcomes for pets are partly determined onomies such as the BCT v1.7 For example, it is possible to identify by their owner’s behaviour which, in turn, is influenced by how those techniques that are best suited to tackling motivational challenges, such owners think and feel about the issues. Therefore, if veterinarians want to as providing information about the health consequences of obesity (BCT influence outcomes, then they must try to influence the owner’s behaviour, 5.1). Similarly, it is possible to identify techniques that might help to meaning that communication with owners is essentially a ‘behaviour address a lack of actual or perceived capability. For example, someone change intervention’. who feels unable to exercise their dog outside because of how they react to other dogs might be provided with a video illustrating ways to manage How can we understand behaviour? difficult situations (BCT 6.1). The advantage of framing the consultation in this way is that there is Delivering the intervention: The consultation a cumulative science of behaviour change1 that might be translated to inform how veterinarians communicate with owners. One such framework The final part of the puzzle is to think about delivering the intervention; is known as the ‘Behaviour Change Wheel’ (BCW2), which describes a something that may be challenging because: step-by-step method for designing behaviour change interventions. 1. Owners may be defensive and reject the message that they need to do The first step is referred to as making a ‘behavioural diagnosis’ that something about their animal’s weight, either because they don’t believe defines the problem in behavioural terms. Therefore, the problem is not that the animal is overweight or because accepting that a companion that the animal is overweight; rather, the problem is the owner’s feeding animal is overweight reflects badly on them (e.g., requires them to accept behaviour which has led that animal to become overweight. This definition that they have jeopardized the health of the animal). helps to select the behaviour that has the most significant impact on the problem. The final component of the behavioural diagnosis involves iden- 2. Owners may struggle to understand the message. Veterinarians are tifying what causes the target behaviour. The BCW uses the COM-B model, asking owners to interpret information that is not in their sphere of which suggests that behaviour is a function of motivation, capability, and experience (i.e., the information is about a dog, not a human). Evidence opportunity. When all three are aligned, then behaviour ensues; however, if suggests that people anthropomorphise their pets, so people may struggle one or more component is missing then behaviour may be difficult. with messages that challenge the idea that animals are different to people (e.g., that dogs do not need to have variety in their diet). 1.Motivation 3. Motivation wanes once owners leave consulting room. People are busy According to Protection Motivation Theory (PMT3), motivation is a func- and are often trying to do many things at once. The consequence is that tion of (i) peoples’ appraisal of the threat and (ii) their ability to cope with good intentions (e.g., to feed the dog differently) fall down the list of that threat. In turn, threat appraisal comprises people’s evaluation of (i) priorities, maybe even get forgotten. the severity of the threat, (ii) whether they (or in this case their companion animal) are vulnerable to the threat, and (iii) how much fear the threat gen- Strategies for improving communication erates. However, risk information is only motivating if people feel that they can do something to mitigate that threat.4 Therefore, PMT suggests that How can these challenges be addressed? One starting point might be to it is also important to consider peoples’ evaluation of (i) whether the ac- address the stigma around overweight and obesity, which may lead mem- tions that they take are likely to be effective (termed “response efficacy”) bers of the veterinary profession to blame, be frustrated with, and even and (ii) their ability to take the actions needed (termed “self-efficacy”). disgusted by owners of overweight dogs.8 People struggle to hide such prejudice, using stigmatizing terms to describe excess weight in dogs 2.Capability (e.g., describing them as ‘fat’).8 Therefore, owners’ defensiveness may result from cues given by the veterinary professional that if they accept People often encounter difficulties translating motivation into action, lead- the message then they join a stigmatised group. ing researchers to refer to a ‘gap’ between intentions and behaviour.5 One reason why people struggle to translate motivation into action is that they A starting point to improving communications is probably to recognise lack either capability and / or opportunity. Capability refers to the idea the potential for (implicit) bias. However, although training programmes that a certain amount of knowledge, skills, and stamina is needed to per- can help people to identify and understand the impact of implicit bias, form certain behaviours. For example, people may not feel that they have there is evidence that increasing awareness is not enough—and can even any other way to stop their dog barking than providing treats – that is, they backfire—because sending the message that bias is involuntary and wide- 146 WSAVA GLOBAL COMMUNITY CONGRESS

spread may make it seem unavoidable.16 Awareness therefore might be 0090 combined with information that challenges stereotypes that can provide the basis for respectful, patient-centred care. Indeed, understanding FEEDING RESPONSIBILITY: WHERE BEHAVIOUR the limits of motivation as discussed above might be a starting point to AND NUTRITION MERGE IN THE HUMAN ANIMAL reduce (actual or perceived) blame; shifting attention to ‘the obesogenic BOND environment’ and external challenges like limited nutritional information. S. Heath One way around the challenge that motivation can wane once owners leave the consulting room might be to help owners to make plans about Chester/United Kingdom how they will respond to particular situations.9 Forming a plan – or ‘im- plementation intention’ 10 – means that people do not need to deliberate Qualifications: about what to do ‘in the moment’ – and so rely on their motivation to steer them toward a particular course of action and has been shown to be an Dr Sarah Elizabeth Heath FRCVS effective way to help people to achieve a wide range of goals.11 We are currently exploring how the veterinary profession might be supported BVSc PgCertVE DipECAWBM(BM) CCAB FHEA FRCVS to leverage such insights to help owners to change how they think and behave with respect to their companion animals. [email protected] Feeding Responsibility: References: Where Behaviour and Nutrition Merge In The Human Animal Bond 1 Michie S, Johnston M. Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psych Rev. Sarah Heath BVSc PgCertVE DipECAWBM(BM) CCAB FHEA FRCVS 2012;6(1):1-6. Behavioural Referrals Veterinary Practice, 10 Rushton Drive Upton Chester 2 Michie S, Atkins L, West R. The Behaviour Change Wheel: A guide to CH2 1RE England designing interventions. Silverback Publishing; 2014. [email protected] 3 Rogers RW. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In Cacioppo Why is food and feeding relevant to behavioural medicine? JT, Petty RE, editors. Social Psychophysiology: A Sourcebook. London: Guilford Press; 1983. Behavioural medicine is the discipline that deals with emotional health and the link with physical disease. Emotional health is equally important 4 Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change to physical health and an understanding of emotional health is a day people’s intentions and behavior? A meta-analysis of experimental stud- one skill for the veterinary profession just as much as it is for medical ies. Psychol Bull. 2014;140(2):511-543. professionals. 5 Sheeran P, Webb TL. The intention-behavior gap. Soc Personal Psychol Emotional health issues are addressed using a combination of approach- Compass. 2016;10:503-518. es and consideration of food impacts on these: 6 Michie S, Johnston M, Francis J, et al. From theory to intervention: Map- 1. Optimising the domestic environment in relation to providing for spe- ping theoretically derived behavioural determinants to behaviour change cies specific behavioural needs – consideration of natural species-specific techniques. App Psychol. 2008;57:660-680. feeding behaviour 7 Michie S, Richardson M, Johnston M, et al. The behavior change tech- 2. Identifying underlying emotional motivations and determining if they are nique taxonomy (v1) of 93 hierarchically clustered techniques: building justified by the context – consideration of the emotional impact of food an international consensus for the reporting of behavior change interven- and the feeding process and the impact of emotion on responses to food tions. Ann Behav Med. 2013;46(1):81-95. 3. Addressing learning theory issues in terms of the acquisition of unwant- 8 Pearl RL, Wadden TA, Bach C, et al. Who’s a good boy? Effects of dog ed behavioural responses – consideration of the use of food to specifical- and owner body weight on veterinarian perceptions and treatment recom- ly facilitate behavioural change through learning mendations. Int J Obes. 2020;44(12):2455-2464. 4. Using medication, pheromones and nutraceuticals – consideration of 9 Gino F, Coffman, K. Unconscious bias training that works. Harvard the therapeutic use of food Business Review. 2021. The relevance of food to the caregiver-pet relationship 10 Webb TL, Krasuska M, Toth Z, et al. Using research on self-regulation to understand and tackle the challenges that owners face helping their Humans are a nurturing species. They like to take care of others and feed- (overweight) dogs to lose weight. Prev Vet Med. 2018;159:227-231. ing others is a very important part of that nurturing process. Feeding pets is a major activity within the caregiver role and one that most caregivers 11 Gollwitzer PM. Implementation intentions: Strong effects of simple gain a great deal of pleasure from. Understanding species specific differ- plans. Am Psychol. 1999;54(7):493–503. ences in feeding behaviour and in the relevance of food in a social context is important in optimising the feeding experience for pet and caregiver 12 Gollwitzer PM, Sheeran P. Implementation intentions and goal achieve- alike. Issues related to food and feeding can impact on the emotional ment: A meta‐analysis of effects and processes. Adv Exp Soc Psychol. health of the pet and can be involved in the initiation, management and 2006;38:69-119. resolution of unwanted behaviours in dogs and cats. The importance of emotion In order to understand the role of food and feeding in the initiation, man- agement and resolution of unwanted behaviours in dogs and cats we need 147

13–15 NOVEMBER, 2021 to understand the principles of emotional health and the link between With whom – are any people or other animals in the vicinity when the pet food and emotion. There are two main ways in which consideration of eats? food impacts on emotional health. The question about the proximity of people when the pet is eating is im- • Influencing or being influenced by emotional motivation – positive (en- portant in a number of ways. The presence of people may be coincidental gaging) / negative (protective) and be most relevant in terms of the contribution to the level of emotional arousal for the animal when it is eating. In other cases proximity of people • Influencing emotional arousal level may be deliberate and may be linked to a desire for the caregiver or others to be involved in the feeding process, to assist the pet in eating or to Emotional capacity reduce the potential for conflict between animals while they are eating. If there is more than one pet in the household it is important to determine The sink model of emotional health created by Heath in 2010 illustrates whether they are expected to eat together. If that is the case then ques- emotional capacity through the image of a sink. Emotional stability tions about each individual’s response to that arrangement will also be relies on an appropriate balance between sink size, emotional input and necessary. Questions about the reaction of each animal to the food and emotional output. Emotional resilience is important to ensure optimal the likelihood of any of the pets helping themselves to the food intended emotional drainage after a trigger has been encountered in order to main- for others will also be beneficial. tain a low level of residual emotion and thereby maximise the availability of emotional capacity. How is the food delivered? The risk of overflow The next line of questioning in relation to food concerns the style of delivery. It is important to determine whether this is fulfilling natural spe- Emotional overflow is most likely if: cies-specific behaviour for the pet in terms of both social behaviour and feeding behaviour. Managing the style of food delivery can be important The sink is small (low emotional capacity) in determining feeding time budgets both in terms of the overall amount of time the pet spends engaging in the feeding process and in terms of The tap is hot when this is not justified (emotional disorder) speed of direct ingestion of the food provided. In addition, the manner in which food is delivered may influence emotional health both through The tap is hot when justified (inappropriate physical or social environ- its effect on emotional motivation and on levels of emotional arousal. ment) Questions about anticipation of feeding times and whether these are spontaneous or encouraged can provide helpful information. The tap (hot or cold) is turned on full Positive use of food for behavioural purposes There was a high level of residual water in the sink at the time (poor emotional resilience) In addition to providing useful information during the history taking process food can also play an important role in dealing with behavioural The people around do not recognise or act on species specific signs of issues. It can be used in a range of ways including: impending overflow 1. As a reinforcement for appropriate behavioural responses The importance of food in behavioural history taking? 2. As an occupation tool When animals are presented with behavioural change questions about food are an important part of the history taking process 3. As a tool to encourage emotional drainage Fundamental questions can reveal crucial information and they should 4. As a cue for positive emotional state include the following: Negative influence of additional food use on emotional state • What does the pet eat? Food is a trigger for the engaging (positive) emotional motivation of • Where is the food delivered? desire-seeking and is usually thought of as a thoroughly positive influ- ence. This is not necessarily true and there are potential pitfalls of using • With whom – are any people or other animals in the vicinity when the pet food in the context of behavioural modification. Considering the emotional eats? responses of the individual is vital as food has the potential to induce frustration, anxiety and emotional conflict if used inappropriately. In • How is the food delivered? addition, food can lead to unintentional reinforcement of behaviours and establishing or maintaining of unwanted behaviours as a result. Where is the food delivered? Conclusions House plans can be a very useful tool when taking behavioural histories and one area in which they can be helpful is for noting the locations for The role of food in the initiation, management and resolution of unwanted food delivery. It is important to assess these locations in relation to behaviours in dogs and cats is complex. The key to understanding it is levels of activity (human or related to other pets) and in relation to other to consider the effect of food and its method of delivery on emotional important resources (such as entry and exit points, toileting facilities etc). state and on the level of emotional arousal. Feeding interactions need The location in which food is delivered may be more readily thought to be to respect the natural behaviour of the species and strive to ensure that relevant in feline behaviour cases but it is equally important to assess the positive (engaging) emotional motivation predominates. location of food delivery in canine cases. Further reading Once the place of delivery has been ascertained the next question is whether the pet actually eats the food where the caregiver provides it, or Dantas L M S, Delgado M M, Johnson I et al (2016) Food puzzles for cats: does the pet move its food to another location before consuming it? If feeding for physical and emotional wellbeing Journal of Feline Medicine this is the case it will be important to determine why the pet is not willing or able to consume the food in the location where it is delivered and what that tells the clinician about the location and about the pet’s emotional and behavioural responses. 148 WSAVA GLOBAL COMMUNITY CONGRESS

and Surgery (2016) 18, 723–732 0091 Panksepp J (2004) Affective Neuroscience : The Foundations of Human SIX FUNDAMENTAL NEEDS - NEW GRADUATE and Animal Emotions Published by Oxford University Press MENTORSHIP PROGRAM EXTRACT FROM SOUTH AFRICA. Sedek T, Hamper B, Horwitz D et al (2018) Feline Feeding Programs: M. Abatzidis Addressing behavioral needs to improve feline health and welfare Journal of Feline Medicine and Surgery 20, 1049–1055 Johannesburg/South Africa Qualifications: Dr Mats Abatzidis B. Sc (Phys & Micro) B.V.Sc. (UP) Certified VIP Life Coach Founder of Influential Life Coaching [email protected] Whether we choose to admit it or not, you and I do everything we do for emotional reasons. At some level you are choosing to do what you do because you believe it will make you feel good about yourself. This has been happening throughout your life and your behaviours are derived from the associations you have with pain and pleasure. Your values and beliefs shape your behaviours too. Inasmuch as we are different because of our experiences, values, and beliefs, we are also all human beings with core needs. That is why you experience problems and challenges in your life that are much the same as other people around you. Regardless of nation- ality, culture and origins, the problems faced are amazingly similar. The bad news is that our obstacles are not only derived from our values and beliefs, but also from a more general all-encompassing source that we all share. The good news is we all share it. So, what is it? Our Six Human Needs. Everything we do in life we do to meet one of the following Six Human Needs: 1. Immediate physiological needs 2. Self-protection 3. Affiliation 4. Status/Esteem 5. Growth 6. Contribution Immediate physiological needs & self-protection Your need for certainty represents a fundamental requirement for your survival encompassed by immediate physiological needs (food, water, sex, sleep, elimination) and self-protection (shelter, safety, finances, and in today’s times this has become all about the basic rules of COVID – social distancing, wearing masks, sanitising, etc). Whenever you lack certainty in your life, you will experience problems until proven otherwise. Due to the crucial nature of this need, your brain will constantly be directing you to do anything you can to get this need met. In life, your ability to succeed will be partially determined by your ability to cope with uncertainty in various situations. The way you seek certainty can vary: You might use food. Uncertainty will stimulate you to eat something, which may relax comfort you. That’s why they call it comfort food. That’s a survival mechanism kicking in, where your body tells your brain to start stocking up ahead of tough times. Other examples: having enough money in the bank, cleaning up by sorting out your home or working desk? You might have a very important task at hand, and you start by rearranging your desk, following a routine, seeking out stable relationships, etc. More complex in cases of addiction to drugs, alcohol, tobacco, and other 149

13–15 NOVEMBER, 2021 substances. Especially, if an individual uses alcohol or drugs to assuage the human desire to feel fulfilment at the deepest level. When was the last their fears, aggression may turn into physical violence to family members, time you felt totally and deeply fulfilled? women, children, and pets. There are increases in the incidence of homi- cides and suicides. Whatever your answer may be, at that time, you were either growing or contributing or both. For that to take place, you must generally have your Affiliation other four needs (immediate physiological needs, self-protection, affilia- tion, and status) met first. We know from documentaries about famous people from top executives to actors, artists, and diplomats, that one of the major challenges they For instance, growing and giving back to others is not usually a high face is feeling too unique. They feel lonely and isolated. Here is the priority if you are uncertain if you will eat tonight. However, if you are in a paradox: Too much uniqueness feels bad. This is where the human need strong and supported position, your ability to contribute is much greater. for affiliation comes in. We all need to connect with others. This is why we It isn’t always the case that one cannot contribute greatly without one’s are so attracted to groups. It satisfies our need for connection. base needs being fully met. Some leaders live without certainty and still contribute greatly, such as think Mahatma Gandhi or Nelson Mandela. Overachievers and achievers experience loneliness and lack of fulfilment Generally, though, it is very difficult to create meaningful ideas when one a lot, because it is their uniqueness that makes them stand out. Yet most is in a state of great uncertainty, feeling insignificant or experiencing no societies covet and reward conformity, which is an interesting paradox. love and connection. • Connecting with others normally helps individuals to regulate their • Growth is essential to life: Feeling totally at peace, entails growing and emotions, cope with stress, and remain resilient. giving back. There is a rule in nature that says if something is not growing, it’s dying. • Loneliness and social isolation, however, worsen the burden of stress, and often produce deleterious effects on mental, cardiovascular, and • Growth and Contribution builds your happiness: Everything in this world immune health. serves some purpose including each and every one of us, whether we are consciously aware of that purpose or not. • Intergenerational social support, self-esteem and loneliness are all strongly associated with subjective well-being. • Growth and Contribution builds the happiness of others: I believe that as humans, our primary purpose is to help others. It isn’t just you who benefit • Among adolescents, loneliness is associated with physical inactivity. from your gift of contribution because you become part of a cycle of giving (contribution) and receiving (growth) from which everyone benefits. • People with unmet needs for affiliation are also at risk of failing to meet needs for status and self-esteem New Graduate Mentorship Program Extract from South Africa Status / Self-esteem The introduction of Compulsory Community Service (CCS) for veterinar- ians commenced in January 2016. This requires of all newly qualified The need for status / self-esteem is really a need to feel important, need- veterinary graduates to perform one (1) year of community service. CCS ed, different or unique and to feel a sense of meaning. Remember, this veterinarians are placed in employment by the Department of Agriculture, is a fundamental need that we all have and has nothing to do with being Land Reform & Rural Development (DALRRD), the employer. CCS veterinar- arrogant. We all experience the need to feel significant. It starts from the ians are placed in various national and provincial state veterinary services, day we begin competing with our siblings for attention. On a more basic veterinary laboratories, research facilities and in animal welfare services. level at a very young age, attention meant food, warmth, and protection, representing survival. If we apply the same principle to the animal king- The local veterinary association, veterinary council and DALRRD have dom, if one isn’t noticed, one dies. How’s that for a motivating factor? teamed up to ensure that a mentoring process is in place as the first step in developing newly qualified graduates into skilled and professional veter- You only have to look at children to see some of the unique ways that they inarians in the field. There will be 169 graduates that enter the CCS year in come up with to gain recognition and attention within the family dynamic. 2022. Plan was rolled out to 30 Mentors and 53 Mentees participating in Some children are brilliant at sports, others at drama, while others remain 2020. In 2021, the Mentoring programme continued with 65 Mentors and introverted and invariably there are the loudest and most demanding of 81 Mentees throughout all provinces in South Africa - all Mentors submit children. monthly reports on the interaction with Mentees • Status and self-esteem needs are vulnerable if needs at Levels 1–3 are The 2022 mentorship programme: unmet. a) Using experienced veterinary professionals to support new graduates to • The pandemic is producing huge increases in unemployment and pover- ensure a smooth transition into the profession. ty, vulnerability factors for lowered self-esteem and social status. b) The program assists towards job satisfaction and reaching their full • Self-esteem is associated with responses to success and failure. potential. • Low self-esteem also creates a vulnerability to depression. c) Retention for the veterinary profession • Low self-esteem also creates a vulnerability to drinking alcohol – if d) Using mentor access to skills & practical knowledge from senior veter- affordable. inarians • Self-esteem moderates the associations between body-related self-con- e) Encourage knowledge transfers to assist the mentee to develop trust in scious emotions and depressive symptoms. their own abilities and boost confidence and self-esteem • Self-esteem also appears to be an important antecedent of the develop- f) Prepare veterinarians when entering the veterinary industry after CCS, ment of self-compassion. which may include private practice, state veterinary services, animal welfare and industry Growth and contribution References available on request The need to grow as a person and the need to contribute are borne out of 150 WSAVA GLOBAL COMMUNITY CONGRESS