WSAVA Nov 2021 Proceedings

0092 • What if they say ‘no’ to my recommendation? OVERCOMING THE FEARS & FRUSTRATIONS • What if they don’t like me? THAT IMPACT THE RESILIENCE OF VETERINARY PROFESSIONALS • What if they say ‘yes’ but can’t afford it? G. Turnbull • What is they think I am over-servicing? Wahroonga/Australia • What if they choose to go elsewhere for a second opinion? Qualifications: From a practical perspective these fears, and frustrations will play out on a day-to-day basis is a variety of ways. Typical behaviours include: Dr Gary Turnbull • Purposefully omitting fee items on estimates or invoices to limit the BVSc (Hons) financial burden placed on pet owners. [email protected] • Applying discounts to completed work because of inaccurate estimating The veterinary profession faces a global challenge. A shortage of vet- in the first place. erinarians (and in many instances support staff) has been identified in Australia, Canada, Europe, New Zealand, USA, UK, SE Asia, and South Af- • Offering clients multiple options that include a ‘best care’ and basic ‘low rica. Recent reports indicate further pressure has been applied by a surge cost’ option in the same sentence and before the client has declined the in pet ownership associated with the COVID-19 pandemic. This shortage best care option. is not a result of reduced graduate numbers from veterinary schools but rather an unprecedented rate of premature departure of veterinarians from • Use of inferential language to avoid asking for a ‘sale’ thus leaving the clinical practice. client confused about what to do next. Challenges associated with veterinary recruitment first came to the • Failing to offer a diagnostic or therapeutic option based on the assump- attention of the Lincoln Institute in 2018. A rapid increase in the number tion that the client will not be able to afford it. of positions vacant and time required to fill said positions was reported by veterinary business owners across Australia and New Zealand. This fear-based mindset tends to steer veterinarians away from a primary focus on patient advocacy and toward a desire to find ‘affordable’ To better understand the state of the industry workforce we conducted solutions. Of course, ‘affordable’ is completely subjective and based on a survey of veterinarians across Australia and New Zealand in 2019. judgements made by the practitioner about what the client can afford and Participants included 543 practice owners/managers and 958 employed is willing to spend of their pets’ healthcare needs. In many instances, this veterinarians. Over 200 pages of personal commentary was collected and adjustment in clinical approach will ultimately compromise standards collated in addition to the direct survey data. of patient care, clinical outcomes, client satisfaction and professional fulfilment. Most alarming of the results was the indication that 30% of respondents were giving consideration to leave clinical practice within the next 12 More broadly, compromising standards of care exposes the clinician to months. The most common reason cited for professional dissatisfac- both informal and formal complaint from the public as well as exerting tion was ‘stress and anxiety associated with their role’. Importantly, this a detrimental effect on the financial performance of veterinary business, related to behavioural issues (communication with clientele, interpersonal which ultimately limits the scope to be appropriately remunerated. relationships in the workplace and time management) more so than clini- cal or technical competency. The purpose of this presentation is to highlight three proven strategies by which veterinarians can successfully manage financially related fears This should come as no surprise. The authors of the so-called KPMG and frustrations resulting in a far more satisfying and optimistic daily ‘Mega Study’ published in 1999 deemed business acumen, leadership, experience. and interpersonal and communication skills as crucial for success. In subsequent reports from the Bayer-Brakke and the Personnel Decisions • Recalibrate intrinsic sense of purpose International (PDI) studies, as well as individual commentaries, business acumen, self-management, and interpersonal skills have repeatedly been For more than a decade the field of social science has recognised sense identified as key determinants of success and personal satisfaction. of purpose as a key intrinsic motivator in the workplace. Employees will (Burns et al., 2006) be more productive, engaged, and resilient when they identify meaning and a sense of contribution to the work they undertake. Based on existing research, our survey results and anecdotal enquiry of hundreds of practising veterinarians, bridging the gap in non-technical For many veterinarians, their fundamental sense of purpose appears skills appears to represent an exciting opportunity to not only, improve the to progressively shift over time from one of advocacy to affordability. resilience of veterinarians but also greatly enhance professional satisfac- The ‘pursuit of affordable solutions’ becomes the over-arching priority, tion and career longevity. potentially compromising standards of care. This is not surprising con- sidering the high degree of empathy and compassion integral to the work Accumulated feedback suggests conversations with pet owners of a of veterinary professionals. Couple this with a tendency toward Imposter financial nature represent a constant and ongoing source of stress, anx- Syndrome (lack of self-confidence when levelled against competence) iety and frustration for practising veterinarians. It is our conjecture, that and consequent poor sense of self-worth, and a focus on affordability this correlates with a poor sense of self-worth, experience of guilt when becomes the path of least resistance. When practitioners recalibrate their charging appropriately for services rendered and fear of how a client will intrinsic sense of purpose from a focus on affordability to that of patient respond to an estimate or invoice. advocacy, uncompromising, ethical recommendations ensue. This leads to superior standards of clinical care and better patient outcomes. The typical internal dialogues that veterinarians grapple with at a subcon- scious and often conscious level include: • Change perspective On the study of veterinary client compliance or adherence, published re- search examining the propensity of a pet owner to accept a veterinarian’s recommended approach to diagnostic, surgical and dental intervention is 151

13–15 NOVEMBER, 2021 limited. Based on data available and extensive anecdotal evidence, there 0093 appears to be a significant misconception amongst veterinary profession- als. A compliance study commissioned by the American Animal Hospital IS BIGGER BETTER? CHOOSING THE RIGHT SIZED Association (AAHA) in 2002 found that the vast majority of veterinarians IMPLANT considered cost to be the biggest barrier to client compliance. However, the same study found that cost was a limiting factor for only four to seven C. Tan percent of pet owners. The pet owning public cited issues with commu- nication as the biggest barrier to following clinical recommendations. Sydney/Australia Specifically, being unaware of, or failing to remember a recommendation made by their veterinarian. Qualifications: Perception of value, clarity of information, convenience and patient safety Christopher John Tan all play an integral role in the clients’ decision-making process. These factors are frequently misinterpreted by the clinician further exacerbating BVSc BSc (vet) PhD FANZCVS Diplomate ECVS (small animal surgery) the misconception relating to affordability and compliance. [email protected] Assumptions made by veterinarians about the receptivity of a client to As outlined in the previous lecture, a systematic approach to fracture professional advice will frequently limit the number of recommendations a management is always recommended. Following description of the clinician will provide in any given interaction. To this end, the AAHA com- fracture and assessment of the biological and mechanical environments, pliance study again identified a marked contrast between the perceptions the clinician must decide if surgery is indicated for management of the of veterinarians and pet owning families as they relate to the motivations fracture. of the clinician. Seventy-five percent of pet owners agreed or strongly agreed that veterinarians make recommendations because they feel it is The aim of surgery will always be to create the optimal mechanical and bi- good for their pets. Only ten percent agreed or strongly agreed that the ological environment in which the bone can heal. It must be remembered recommendations are motivated by profit. that bone healing occurs in two ways: Given the regularity of financially based client interactions, clarifying the Direct (primary) bone healing refers to the direct formation of bone across priorities of the pet-owning public will positively influence the daily experi- the fracture line without the formation of callous. For this to occur, there ence of the veterinary professional. Accurate identification of client objec- must be absolute stability and direct apposition of bone ends. Techniques tions and conscious recognition that cost is a limiting factor infrequently that support direct bone healing all involve implants which produce inter- can be liberating for the clinician suffering from conscious discomfort fragmentary compression, such as lag screws (supported by a neutrali- relating to the economic aspect of veterinary healthcare delivery. sation plate), cerclage wire (supported by an intramedullary pin) or plates with a dynamic compression unit. • Practise Patient Advocacy Indirect (secondary) bone healing refers to the uniting of the fractured Price based discomfort exposes clinicians to both conscious and uncon- bone ends by the progressive transformation of the fracture haematoma scious biases in the decision-making process for clinical recommenda- to fibrous tissue, fibrocartilage and eventually bone. This form of healing tions. Implementation of a ‘systematized’ personal approach to client still requires stabilisation of the bone ends but is more tolerant of small interactions can facilitate habit formation in specific steps that support amounts of motion, as the initial tissues (haematoma and granulation tis- a focus on patient advocacy and minimize the risk of succumbing to the sue) are able to undergo greater deformation compared to bone. Perfect inner dialogue that frequently compromises clinical standards to reduce anatomical reduction of the individual fracture fragments are not required treatment costs. Such a system includes the critically important steps of but it is essential to restore the anatomical relationship of the joint above mindful transitioning between cases, rapport building to develop trust and the fracture to the joint below the fracture for an optimal clinical outcome. likeability, emphasising value, handling client objections, and addressing the phenomenon of “Buyer’s Remorse”. Therefore, the surgeon must decide on what form of bone healing they will support with their chosen repair technique recognising that there are Targeted non-clinical training and development that addresses gaps in advantages and disadvantages of each approach communication skills and financial mindset/self-worth allows veteri- narians to approach client interactions in a more sophisticated fashion The Carpenter achieving better patient outcomes and greater client satisfaction The techniques which support primary bone healing are often referred Objective measurement of individual veterinary performance demon- to as the carpenter’s approach. If this approach is taken, perfect recon- strates that implementation of the three strategies presented greatly struction of the bone column will ensure that the anatomical relationship enhances a veterinarians’ propensity to make best ethical recommen- of the joint above and below the fracture is restored, in terms of re-es- dations and follow through with highest standards of clinical care. This tablishing limb length and ensuring no angular or torsional abnormalities maximizes commercial productivity of the veterinarian and leads to an are induced. The other major advantage of the carpenter’s approach is improved subjective experience for veterinary professionals as they enjoy that the implants will share the load with the reconstructed bone column, improved patient outcomes, and greater professional fulfilment with less protecting them from premature failure during the healing period. daily stress and anxiety. However, in order to achieve perfect anatomical reduction, much soft References tissue (including the fracture haematoma) must be removed from the bone ends, damaging the precious biological environment and potentially American Animal Hospital Association ed., 2003. The path to high-quality delaying the healing process. Furthermore, if perfect anatomical reduc- care: practical tips for improving compliance. American Animal Hospital tion is not achieved intraoperatively, then we will not only create some Association malalignment, but the surgical implants will no longer share the load with the bone column, making premature implant failure more likely. It is for Burns, G., Ruby, K., DeBowes, R., Seaman, S. and Brannan, J., 2006. Teach- this reason that anatomical reconstruction is only recommended in two ing Non-Technical (Professional) Competence in a Veterinary School (possibly three) piece simple fractures where the surgeon is confident that Curriculum. Journal of Veterinary Medical Education, 33(2), pp.301-308. they can achieve anatomical reconstruction intraoperatively. 152 WSAVA GLOBAL COMMUNITY CONGRESS

The Gardener great variations in the resistance to bending. For example, the 2mm LCP plate is produced with two different plate heights (1.2mm thick and The techniques that support secondary bone healing are often referred 1.5mm thick). Both plates are 5.5mm in width but the additional thick- to as the gardener’s approach. The aim of these bridging techniques is ness of the longer plates increases their resistance to bending by almost to provide “relative” stability, which allows formation of a soft callous twice (Area Moment of Inertia (AMI) of the 1.2mm thick plate = 0.79mm4, which will later transform into bone. The relationship of the joint above AMI of the 1.5mm thick plate = 1.55mm4). The surgeon must be familiar and below the fracture must be re-established but no attempt is made to with these subtle differences to ensure the most appropriate implant is perfectly reconstruct the individual bone fragments. This means surgi- selected for each case. The anticipated rate of bone healing, owner com- cal implants can be inserted with less disruption to the biology of the pliance and patient behaviour are all additional variables that must also be fracture. An open but do not touch approach is commonly employed and considered when selecting implants for osteosynthesis. more recently, minimally invasive approaches have been described for the long bones of dogs and cats, further reducing disruption to surrounding soft tissues. As these techniques do not aim to re-establish the load bearing ability of the bone column, it must be recognised that there is increased risk of implant failure when compared to load sharing implants. To reduce the risk of implant failure, many bridging techniques involve a combination of implants to ensure success. Larger plates are often utilised or alter- natively, they can be combined with an intramedullary pin (known as a plate-rod construct), or an orthogonal plate. External skeletal fixation can be applied in multiple planes, such as the type 1b configuration, to ensure adequate stability. A gardener’s approach is recommended for all frac- tures that cannot be perfectly reconstructed. In simple fractures, bridging techniques may also be employed but it should be recognised that this will produce a high strain interfragmentary environment, which may result in prolonged healing times as resorption of the bone ends will often occur prior to callous formation. Implant selection Once it has been decided what form of bone healing the surgeon will sup- port (direct or indirect), the surgeon must select the implant design and size. If the implant is undersized, there is the risk of implant failure, whilst oversized implants may weaken the remaining bone leading to further fracture or in some cases, result in stress protection. This is particularly true for radius and ulna fractures in toy breed dogs. There are a number of charts available to provide some guidance on im- plant selection based upon the bone involved and the body weight of the animal, however, these charts serve only as a very rough guide as they do not take into account factors such as the function of the implant. For ex- ample, a single bone plate could be applied to serve a variety of functions. If used as a neutralisation plate, this implant will serve to protect the pri- mary fixation (usually lag screws or cerclage wires) and is considered load sharing. This same plate could also be applied as a compression plate if the fracture had a transverse configuration, which would also share the load with the reconstructed bone column. However, if used as a bridge plate, the same implant would be considered load bearing and would be subjected to far greater loads and hence failure would be considered more likely. In order to minimise the risk of failure, the surgeon may elect to use a larger plate or supplement the fixation with another implant such as an intramedullary pin or orthogonal plate if appropriate. The ability of an implant to resist a bending moment is related to the size and shape of the cross-sectional area, its location relative to the neutral axis of the bone and the material from which it is made. Titanium is more flexible than 316L stainless steel but not as malleable, meaning it will undergo less plastic deformation before failure. Intramedullary devices, such as IM pins and interlocking nails are located closest to the neutral axis of the bone, meaning they have a great ability to resist bending, whilst external skeletal fixation has the connecting bar a considerable distance from the neutral axis, producing a less advantageous biomechanical scenario. This potential weakness can be combatted by the use of larger and stronger connecting bars or the addition of a frame in the orthogonal plane if bone stock and anatomy permit. In regard to bone plates, small variations in plate dimensions can produce 153

13–15 NOVEMBER, 2021 0094 has been incorporated into the design). If locking and non-locking screws are used in the same construct, the non-locking screws must always be TIPS AND TRICKS FOR LOCKING PLATES applied first. C. Tan The importance of plate contouring Sydney/Australia Unlike non-locking plates, tightening of the screws in a locking plate will Qualifications: not result in a primary loss of reduction if plate contouring is poor. In this Christopher Tan regard, the surgeon may deliberately undercontour the plate; providing the BVSc BSc (vet) PhD FANZCVS Diplomate ECVS off set distance is small. However, plate contouring is extremely important [email protected] in the flared metaphysis as changes in plate contouring result in a change in screw direction (for monoaxial locking plate systems, where the screws must be inserted perpendicular to the plate). In other words, plate con- touring will determine the screw direction in monoaxial plate systems. Locking plates Number of screws Locking plates differ from traditional non-locking plates by the way the Unlike non-locking plates, where a minimum of 6 cortices (3 bicortical screw interacts with the plate hole. In a non-locking bone plate, the screw screws) is recommended, locking plates can be applied with a minimum can toggle within the screw hole, allowing some ability to angle the screw of 2 locking screws per fragment. However, it is important to note that in relation to the plate. This permits interfragmentary compression during this configuration should be reserved for animals with a high fracture as- screw tightening. Stability is only achieved when the screw is fully tight- sessment score, where rapid healing is anticipated. In general, 3 bicortical ened, thereby compressing the plate to the underlying bone. In locking screws are recommended in most configurations with 4 bicortical screws plates, the screw head tightens, or “locks” into the plate hole, creating an in animals with anticipated prolonged healing. angle stable construct. The bone plate is therefore not compressed to the underlying bone. Insertional torque Biomechanics of non-locking and locking plates Unlike non locking plate designs, where overtightening of a screw will result in stripping of the threads in the bone, overtightening of locking To reduce the interfragmentary strain (and hence promote bone healing), screws may result in cold welding, a process that makes screw removal bone plates must stabilise the two bone fragments relative to each other. very challenging. For this reason, the use of a torque limited is recom- In non-locking plates, each fragment is independently drawn up and mended in some locking plates. Conversely, inadequate insertional torque compressed to the overlying bone plate with stability reliant on the friction may result in inadequate coupling of the locking mechanism. This is created between the bone and plate. Non-locking plates can therefore be particularly important in the polyaxial locking systems, where the harder used as bridging plates (where no load sharing is achieved with the bone metal of the screw head must cut a thread in the softer metal of the bone column), neutralisation plates (which serve to protect a primary anatom- plate2 ical repair using lag screws or cerclage wires) or compression plates (which produce interfragmentary compression. Various locking plate designs In contrast, locking plates achieve stability without compression of the There is an ever increasing range of locking plate designs available to the plate to the bone. Force is transmitted through the screws to the bone veterinary surgeon. Some of the most popular designs include: plate through the angle stable “locking” mechanism of the plating system. Biomechanically, this construct acts much the same way as external skel- Synthes LCP etal fixation and is the reason that locking plates are sometimes referred to as internal fixators. The Synthes locking compression plate (LCP) has the Combi-hole as it’s distinguishing feature. This figure of eight shaped hole comprises a The stiffness of the resultant locking construct is dependent on a number threaded section, which accepts the corresponding threads found on the of variables that are under the control of the surgeon. The greater the dis- head of the locking screws, and a non-threaded section, which accepts tance between the plate and underlying bone, the longer the unsupported cortical bone screws. The non-threaded section included the traditional length of the locking screw. This distance is known as the working length dynamic compression unit, allowing screws to be placed in the load of the screw. Greater stiffness is achieved with a reduction in screw work- position, which will produce interfragmentary compression, or the neutral ing length and some studies suggest this offset distance of the plate and position when used as a neuralisation or bridging plate. The locking bone should be no greater than 2mm.1 screws of the LCP have a reduced thread depth, producing a wider core diameter when compared to a non-locking screw with the same outer Clinical application of locking plates thread diameter. This produces a screw which has a greater resistance to bending compared to non-locking screws, an important feature if the plate Drill guides is offset from the bone. The LCP is therefore a very versatile plate and can be used as a dynamic compression plate, neutralisation or bridging plate To ensure that the locking mechanism between the plate and screw head with a combination of locking and non-locking screws is properly engaged, most locking plate systems incorporate a drill guide that facilitates the correct orientation of the bone tunnel created with the SOP drill bit. For threaded coupling mechanisms, cross threading of the screw head into the plate hole will reduce the mechanical stability of the con- The String of Pearls (SOP) plate comprises a series of spherical “pearls” struct. Some locking plates may also allow the use of non-locking screws separated by thinner “internodes” which allow contouring in “6 degrees of which can allow the placement of lag screws, allow the non-locking screw freedom”. The pearls accept standard non-locking cortical screws using a to hold the plate to the bone (reducing screw working length) or allow combination of a tapering hole and thread to produce a locking mecha- the plate to act as a compression plate (if a dynamic compression hole nism and angle stable construct. Plates are available for 2.0mm, 2.7mm 154 WSAVA GLOBAL COMMUNITY CONGRESS

and 3.5mm cortical screws and are produced in both stainless steel and 0095 titanium. There is no ability to utilise the screws to create interfragmen- tary compression. THERAPY OF ATOPIC DERMATITIS: DOG Advanced Locking Plate System (ALPS) C. Noli Produced in titanium, the ALPS plating system allows great versatility CN/Italy with each screw hole accepting both locking and non-locking screws, which can be angled relative to the plate (30 degrees in longitudinal plane Qualifications: and 5 degrees in the transverse plane), and monoaxial locking screws which have a larger core diameter but must be inserted perpendicular to Chiara Noli the plate. The plates range in size from the mini ALPS 3.5/4.0mm plates (which accept 1mm non-locking screws and 1.6mm locking screws) up to DVM, Dip ECVD the ALPS 10/11mm plates (which accept 2.7mm non-locking screws and 4mm locking screws). The locking mechanism utilises a tapered screw [email protected] head and partially threaded hole. Introduction Fixin Atopic dermatitis is a chronic inflammatory skin disease, which will need This locking plate system was developed in Italy and utilises two differ- life-long therapy. It is thus essential to chose safe, effective and sustain- ent materials in the fixation constructs. The original plates, known as able treatment protocols, which the owner can follow with full compli- supports, are made of 316 LVM stainless steel and have threaded plate cance over the years. Recent therapeutical protocols include both reactive holes. Titanium inserts known as “bushings” fasten into the threaded and proactive interventions. The former ones are used to get pruritus holes and receive the locking screws. The bushings have a conical hole and lesions in complete remission and the latter to keep the disease in which corresponds to a conical screw head, allowing locking of the screw remssion with time, and avoid a new flare. into the bushing via a Morse taper. The standard series plates have blue bushings that accept either 3mm or 3.5mm screws (which can be made Reactive interventions from either titanium alloy or stainless steel). The mini series have yellow bushings that accept both 1.9mm and 2.5mm screws. The newest micro Glucocorticoids are very effective in suppressing the symptoms of atopic series utilise 1.7mm screws. Like the SOP plates, the Fixin system does dermatitis. Prednisolone is given at 1mg/kg daily in dogs until remission not allow interfragmentary compression across the fracture line. of pruritus and complete disapperance of all lesions (generally for a couple of weeks). It is not necessary to taper the corticosteroid dose after References such a short administration period, and also side effect, which can be diverse and profound if given for a longer period of time, are usually not Baroncelli AB, Reif U, Bignardi C et al. effect of screw insertional torque on severe. Steroids, even if for such a short period of time, are contraindicat- push out and cantilever bending properties of five different angle stable ed in dogs with renal disease, diabetes or Cushing’s syndrome. systems. Vet Surg 42 (2013) 308-315 Oclacitinib is a Janus-kinase inhibitor able to suppress the production Stoffel K, Klaue K, Perren SM. Functional load of plates in fracture fixation of several proinflammatory cytokines. At the dose of 0,4-0,6mg/kg twice in vivo and its correlate in bone healing. Injury 31 (2000)37-50 daily for two weeks it is able to suppress pruritus and obtain remission of lesions in dogs with allergic dermatitis, with efficacy similar to that of corticosteroids. Side effects are not frequent and usually mild, however, it should be avoided in animals with malignancies, kidney and liver insuffi- ciency and in dogs younger than one year of age. Systemic proactive interventions Oclacitinib can be continued as a long term maintenance therapy at the dose of 0,4-0,6 mg/kg once daily and used as proactive therapy. Ciclosporin is an antiinflammatory drug able to inhibit the enzyme calcineurin. It has a variety of immunological effects on multiple players of the skin immune system and is as efficaceous as prednisolone in the control of symptoms of atopic dermatitis. Due to a lag period of about 2-3 weeks, in which no response is seen, it cannot be used as a reactive therapy. However, ciclosporin is suitable to be used as proactive therapy, especially in severe cases that need permanent systemic antiinflammato- ry drugs. Side effects reported are transitory vomiting, reversible gingival hyperplasia, hyperkeratosis and hirsuitism (excessive growth of hair). The initial daily dose is 5mg/kg for a period of four weeks then tapered to every other day or 2.5mg/kg per day if results are obtained. In the first two or three weeks of administration, ciclosporin may be associated to corti- costeroids or oclacitinib (as reactive therapy) with no particular concern regarding safety. Lokivetmab is a caninized monoclonal antiIL-31 antibodiy. As IL-31 is the main mediator of pruritus it is a potent antipruritic drug with concurrent antiinflammatory effect, able to suppress itch and lesions in allergic dogs for about 1 month (1-2mg/kg SC). Lokivetmab is extremely safe in every 155

13–15 NOVEMBER, 2021 dog of every age and health condition, with no known contraindication or Antimicrobials and parasiticides pharmacological interaction. This makes lokivetmab very sutable to be used as proactive therapy for very long periods of time. Efficacy is similar Infection control is very important, as atopic skin is predisposed to colo- to that of ciclosporin, with a 75-85% response rate. nization and infection by bacteria and yeasts (mainly Staphylococcus and Malassezia spp). These microorganisms increase pruritus and inflamma- Antihistamines inhibit the action of histamine by competitively blocking tion, and can also act as allergens themselves and form part of the patho- H1 receptors. In the dog, chlorpheniramine, diphenhydramine, hydroxyzine, genesis of the chronic phase of atopic dermatitis. Any such infection can clemastine and cyproheptadine are the more commonly used agents, be dealt with by systemic and/or topical medication. Topical therapies, however response is very individual and variable. based on chlorhexidine shampoos 3-4% once or twice weeksly should be preferred over systemic antibiotics, in order to decrease development of Palmitoilethanolamide (PEA) is a naturally occurring lipid with anti-in- antibacterial resistance. In case a systemic therapy is the only option, flammatory properties. It down-modulates mast cell degranulation, which then first choice antibiotics are clindamycin (5-10mg/kg bid), cephalexin proved to be effective in the treatment of cutaneous hypersensitivity (25-30mg/kg bid), cephadroxil (30-40mg/kg sid) or amoxicillin-clavulanic disorders in humans and animals. A study conducted on 160 atopic dogs acid (20-25 mg/kg bid), given for 3-4 weeks or until 7 days after complete showed that at the dose of 10 mg/kg q24h for 56 days it was able to remission of signs of pyoderma. Systemic therapy of Malassezia relies on significantly improve pruritus, lesions and quality of life of dogs and their itraconazole (5 mg/kg sid) for 2-3 weeks. Proactive maintenance therapy owners. This product has the advantage of an excellent tolerability and may be based on regular (every 1-4 weeks) desinfecting shampoos, to can be used in mild to moderate cases and as proactive therapy. prevent relapse of the bacterial/yeast overgrowth and/or infection. Topical therapy proactive interventions If otitis externa is part of the clinical presentation, this must be treated, depending on the microorganism involved and on the severity, with topical Hydrocortisone aceponate topical spray is useful to treat localized pruri- or systemic corticosteroids, antibiotics or antifungal agents, as well as tus and reduce the need for systemic medication. This product has been with daily ear washing until normalization is achieved of the self-cleaning proven to cause minimal thinning of the skin, local immunosuppression or corneocyte migration which is typical of the healthy external ear canal. systemical absorbtion, and was considered effective as proactive therapy Proactive maintenance therapy may be based on the twice weekly admin- when administered twice weekly. istration of hydrocortisone aceponate in the ear canals, in order to prevent relapse of the otitis in recurring cases. Topical tacrolimus, a calcineurin inhibitor with similar properties to cyclosporine, has been used with some success in dogs as a 0.1% lotion especially those with localised disease. Studies have shown greater than 50% improvement in lesional scores in 58-75% of dogs treated. Topical humectant agents, emollients and antipruritic agents (such as ophitrium or adelmidrol) are of value as proactive agents. They decrease epidermal water loss and form a barrier between the skin and potential allergens, and/or decrease pruritus sensation on the skin. These agents are used as a post-bath conditioners, sprays, lotions or mousses. Recently topical spot on barrier restorers containing polyunsaturated fatty acids and lipid barrier components, such as ceramides (found in high concentration in the stratum corneum and can influence the permeability of membranes) and phytosfingosine (considered to be part of the skin’s natural defence system), have been released on the market with the aim of topically normalise protective epidermal barrier defects typical of atop- ic skin and decrease transepidermal water loss. Nutritional management Omega-3 and omega-6 fatty acid supplementation is useful as a proactive intervention to control pruritus and allergic inflammation. Supplemen- tation with the parent eighteen carbon omega-6 linoleic acid (LA), while improving the coat gloss, reducing seborrhea and possibly enhancing the epidermal barrier, has little effect on reducing pruritus. Supplementation with gamma-linolenic acid (GLA), a metabolite of LA, or with omega-3 fatty acids, such as alpha-linolenic acid (ALA) and eicosapentaenoic acid (EPA), are effective in reducing pruritus in some patients. A lag period of 6-12 weeks occurs before which any benefits are seen. Only a small mi- nority of patients can be controlled with fatty acid therapy alone, however they can be useful in association to ciclosporin as they permit a reduction of 50% of the ciclosporin dosis. Dietary manipulation. Some patients with atopic dermatitis benefit from a dietary change (special dermatological diets). Several publications have reported that veterinary diets with high omega-6 and omega-3 fatty acids, as well as certain aminoacids and vitamins important for skin helth, can result in a significant improvement of pruritus and erythema scores in allergic dogs, as well as a significant improvement of skin and coat condition. 156 WSAVA GLOBAL COMMUNITY CONGRESS

0096 Antihistamines inhibit the action of histamine by competitively blocking H1 receptors. Chlorpheniramine, diphenhydramine, hydroxyzine, cetirizine, THERAPY OF ATOPIC DERMATITIS: CAT clemastine and cyproheptadine are the more commonly used agents. The response to antihistamine therapy is variable and it may be necessary C. Noli to trial several different agents for a period of 15 days each to deter- mine which, if any, is more efficient. The conclusion of the International CN/Italy Committee on Allergic Diseases of Animals was that there is “insufficient evidence to recommend for or against” the use of antihistamines in Qualifications: allergic animals. Chiara Noli Oclacitinib is a JAK1 inhibitor registered for dogs, able to block intracellu- lar metabolic pathways leading to the allergic activation of inflammatory DVM, Dip ECVD cells and keratinocytes and to the elicitation of pruritus in neural fibers. Given at 1 mg/kg every 12 hours has an efficacy similar to that of meth- [email protected] ylprednisolone given at the same dose, albeit with no obvious advantage, and with minimal or no toxicity.6 Please be aware that oclacitinib is Introduction not registered in cats and that its long-term safety is not known in this species. Regular haematology and biochemistry monitoring is advised for Feline atopic dermatitis is a chronic disease. The clinician must make the long-term maintenance therapies. client understand that unless the offending allergen(s) are identified and removed a cure is not possible. The keys to the successful management Palmitoylethanolamide (PEA) is a natural occurring bioactive lipid present of atopic dermatitis are client education and a combination of aetiologic, in both animals and plants. PEA is produced by several different cell types symptomatic, topical, antimicrobial and nutritional therapy. in response to tissue damage and acts by controlling the functionality of mast cells (it inhibits degranulation) and other inflammatory cells such Immunotherapy as macrophages and keratinocytes. Consequently, PEA decreases skin inflammation and nerve sensitization in animals with allergic dermatitis. A Immunotherapy aims at correcting the immunological response to multicentre, placebo-controlled, randomized trial determined a glucocorti- allergens. I should be considered if the duration of pruritus is more than coid sparing effect of PEA-um (15 mg/kg q24h) in cats with non-seasonal four months of the year. Success rates are similar to those of dogs. This allergic dermatitis. In the same study, PEA-um was showed to be able to therapy will be described in another lecture. prolong the effects of a short-course of oral glucocorticoids with virtually no significant adverse effects.7 Symptomatic therapy Maropitant Maropitant is a neurokinin-1 receptor antagonist, able to block Glucocorticoids are very effective in suppressing the symptoms of atopic the interaction of substance P, a pruritogenic neurokinine, to its receptor. dermatitis. Prednisolone or methylprednisolone are given at 1-2mg/kg In an open pilot study at the dose of 2 mg/kg, it has been reported to be daily in cats until remission of pruritus (usually a few days), then the dose effective against pruritus and lesions in 11/12 allergic cats. Maropitant is reduced to every other day and then further reduced to the lowest dose was well tolerated if administered once daily for 2-4 weeks. There is no that will control the pruritus (generally 0.25-0.5mg/kg every other day ). information about its safety for a long-term treatment.8 Prednisone should be avoided, as it is not well metabolized by cats.1 Al- ternative steroids are triamcinolone and dexamethasone at 0,1-0,2mg/ Other drugs described to be anecdotally effective, particularly in idiopath- kg/day. Unfortunately, corticosteroids have diverse and profound side ic self-induced neck ulceration, are gabapentin and topiramate. effects, such as polydipsia and polyuria, induction of liver enzymes, mus- cle atrophy and increased susceptibility to skin and bladder infections, Topical therapy diabetes and skin fragility syndrome.2 For long term treatments it is thus advised to reach for alternative, non steroidal antipruritic and antiinflam- Hydrocortisone aceponate topical spray is useful to treat localized pruri- matory drugs. tus and reduce the need for systemic medication. This product has been proven to cause minimal thinning of the skin, local immunosuppression or Ciclosporin is a polypeptide derived from the fungus Tolypocladium infla- systemical absorbtion. 9 tum. Its mode of action is by inhibiting the enzyme calcineurin. It has a variety of immunological effects on multiple members of the skin immune Other over-the-counter topical antipruritic products available for cats are system and is active in the acute and chronic phase of atopic dermatitis. based on ophitrium and adelmidrol. Ciclosporin has the same efficacy rate as prednisolone in the control of symptoms of atopic dermatitis.3 A lag period of about 2-3 weeks, in Think out of the box which no response is seen, occurs after ciclosporin treatment is started. During this time frame, prednisolone or methylprednisolone can be given A recent article proposed that cats with self-inflicted head and neck concurrently at 1-2mg/kg per day and interrupted without tapering after lesions may in reality suffer of a welfare (and not dermatological) 2-3 weeks. Significant reduction in pruritus is expected in 75-85% of problem.10 All cats in which the environmental conditions and welfare cases within one month of treatment. To maximize absorption, ciclospo- could be improved stopped scratching and the lesions healed within two rin should be administered two hours before a meal. However, there has weeks. Consideration of behavioural problems and cooperation with a been recent data suggesting that giving ciclosporin with food does not behaviourist is advised in selected cases. alter clinical outcomes. Side effects reported are transitory vomiting, diarrhes, reversible gingival hyperplasia, and rare weight loss and haepatic References lipidosis. The initial daily dose is 7mg/kg for a period of four weeks, then tapered to every other day and then twice weekly if results are obtained. 1. Graham-Mize CA, Rosser EJ, Hauptman J. Absorption, bioavailability Cats should be FIV-FeLV negative, and if toxoplasmosis negative should and activity of prednisone and prednisolone in cats. In: Hiller A, Foster not be allowed to eat raw meat or hunt and eat their prays. For intractable AP, Kwochka KW, eds. Advances in VeterinaryDermatology, Vol. 5. Oxford: cats that will not take oral ciclosporin, the drug can be injected subcutane- Blackwell, 2005: 152–8. ously at 2,5-5mg/kg every 24-48h.4 2. Lowe AD, Campbell KL, Graves T. Glucocorticoids in the cat. Vet Derma- 157

13–15 NOVEMBER, 2021 tol 2008; 19: 340-347. 0097 3. Wisselink MA, Willemse T. The efficacy of cyclosporine A in cats with HOW TO APPROACH THE TRAUMA PATIENT presumed atopic dermatitis: a double blind, randomized prednisolone-con- trolled study. Vet J 2009; 180: 55-59. M. Hickey 4. Roberts ES, Tapp T, Trimmer A et al. Clinical efficacy and safety follow- Camperdown/Australia ing dose tapering of ciclosporin in cats with hypersensitivitydermatitis. J Feline Med Surg. 2016; 18: 898-905. Qualifications: 5. Scott DW, Miller WH Jr. Antihistamines in the management of allergic Mara Hickey pruritus in dogs and cats. J Small Anim Pract. 1999; 40: 359-364. DVM DACVECC 6. Ortalda C, Noli C, Colombo S, Borio S. Oclacitinib in feline nonflea-, non- food-induced hypersensitivity dermatitis: results of a small prospective [email protected] pilot study of client-owned cats. Vet Dermatol. 2015; 26: 235-e52. Many factors from human trauma care can be applied to veterinary medi- cine to ensure practitioners can follow a clear algorithm when faced with 7. Noli C, Della Valle MF, Miolo A, et al. Effect of dietary supplementation injured dogs and cats. with ultramicronized palmitoylethanolamide in maintaining remission in cats with nonflea hypersensitivity dermatitis: a double-blind, multicentre, Primary Survey & Resuscitation: randomized, placebo-controlled study. Vet Dermatol. 2019; 30:387-e117. A primary survey is first performed so the practitioner can identify life 8. Maina E, Fontaine J. Use of maropitant for the control of pruritus in threatening injuries, quickly followed by resuscitation. The mnemonic non-flea, non-food-induced feline hypersensitivity dermatitis: an open ABCD provides the guide for this primary survey: label uncontrolled pilot study. Journal Feline Medicine and Surgery 2019; 21:967-972. A: Airway – air needs a clear pathway into the lungs – evaluate for intralu- menal and extraluminal airway obstruction 9. Schmidt V, Buckley LM, McEwan NA, Rème CA, Nuttall TJ. Efficacy of a 0.0584% hydrocortisone aceponate spray in presumed feline allergic B: Breathing – determine if the patient is able to ventilate and oxygenate – dermatitis: an open label pilot study. Vet Dermatol. 2012; 23: 11-6, e3-4. watch for chest wall excursion with spontaneous breaths, auscult for lung sounds, try to get a SPO2, look for cyanosis, use capnography to measure 10. Titeux E, Gilbert C, Briand A From Feline Idiopathic Ulcerative Der- ETCO2 if able matitis to Feline Behavioral Ulcerative Dermatitis: Grooming Repetitive Behaviors Indicators of Poor Welfare in Cats. Front Vet Sci. 2018, 5:81. C: Circulation – identify if perfusion parameters are consistent with shock, cardiovascular collapse, massive haemorrhage, cardiac arrest – tachycar- dia or bradycardia, pale mucus membranes, prolonged capillary refill time, weak or absent pulses, decreased mentation; measure blood pressure; perform FAST scan to identify pericardial, pleural or peritoneal haemor- rhage; look for external haemorrhage; measure lactate, PCV/TP, glucose D: Disability – evaluate for central nervous system injury – look for altered mentation, calculate a modified Glasgow coma scale score, identify spinal cord injury Responses to any threats to life follow the same pathway: A: Airway - suction the oropharynx, establish a patent airway through intubation or temporary tracheostomy if indicated B: Breathing – provide supplemental oxygen; thoracocentesis if indicated +/- place a chest tube; manual or mechanical ventilation C: Circulation – gain veinous access or place an intraosseous catheter; fluid resuscitation with balanced crystalloids or blood products (caution with volume of fluid therapy if active haemorrhage present); haemorrhage control with pressure, antifibrinolytic therapy, vessel ligation or emergency surgery; cardiopulmonary resuscitation D: Disability – traumatic brain injury treatment includes oxygen supple- mentation, supporting perfusion with fluids, elevation of the head to 30 degrees and hyperosmolar therapy; spinal injury immediately requires immobilization on a solid surface Be prepared to repeat the primary survey until you are confident all immediate threats to life have been addressed. Note that no diagnostics should move the patient away from your initial stabilization location nor should the majority of resuscitation treatments. Once you have responded to abnormalities found in the primary survey, it is then time to move on to your secondary survey. 158 WSAVA GLOBAL COMMUNITY CONGRESS

Secondary Survey & Diagnostics: 0098 Before the secondary survey is started, administering adequate analgesia HOW TO APPROACH TREMORGENIC TOXINS is imperative. Pure mu opioids are the analgesic of choice and micro- doses of ketamine can be helpful for multimodal analgesia. Nonsteroidal M. Hickey anti-inflammatory drugs should never be given to a patient in shock but may be appropriate for long term analgesia after the patient has been Camperdown/Australia stable for more than 24 hours. Qualifications: A secondary survey starts with a complete physical exam with initial focus on identifying any urinary tract injuries, orthopaedic injuries, or significant Mara Hickey wounds. Injuries to the urinary tract and other abdominal organs may not be immediately identifiable, so repeating a full examination should be DVM DACVECC planned several times over the first 24-48 hours. [email protected] For moderately to severely traumatized patients, survey radiographs of The most common toxins leading to muscle tremors include metalde- the thorax and abdomen, haematology and a full biochemical blood panel hyde (snail/slug bait), organophosphates and carbamates (insecticides), are indicted. Additional imaging may be needed to identify fractures or methylxanthines (chocolate’s theobromine and caffeine), mycotoxins and luxations, and repeated FAST scans are suggested over the first 24 hours bufotoxins (cane toads). All lead to neurotoxic signs (muscle tremors, to monitor for fluid production. ataxia, hyperexcitability, seizure activity) after being ingested, often within a short period of time, but additional clinical abnormalities may help Wound care and bandaging can be performed during or after the sec- differentiate some tremorgenic toxins from others. ondary survey – specific recommendations are beyond the focus of this module. Antimicrobial stewardship is recommended when determining How to differentiate between common tremorgenic toxins: if antibiotics are indicated for superficial wounds. Patients with deep soft tissue wounds or open fractures should be given antibiotics with an Metaldehyde will lead to early neurologic abnormalities within 30 minutes appropriate spectrum of coverage. of ingestion. As the majority of sources are molluscicides, the presence of bait granules in vomitus and/or faeces can point to this toxin. References: Organophosphates and carbamates can show acute signs within 10-30 Aldrich J. Global Assessment of the Emergency Patient. Vet Clin Small minutes of exposure. Muscarinic receptor activation leads to a con- Anim 2005; 35:281-305. stellation of clinical signs (SLUDD – salivation, lacrimation, urination, defecation, dyspnoea) which are nearly pathognomonic for this toxicity. Drobatz KJ, Beal MW, Syring RS, editors. Manual of Trauma Management Treatment with a normal dose of atropine (0.02 mg/kg IV) will not lead of the Dog and Cat. 2011. Hoboken: John Wiley & Sons. to resolution of SLUDD signs – this is called the atropine response test which will further confirm the clinical diagnosis. In addition, patients ingesting organophosphates can develop an Intermediate Syndrome 1-3 days after acute toxicity, which leads to gastrointestinal signs and flaccid paresis. Methylxanthines may take up to 2 hours before clinical signs develop in a patient, with most patients first having gastrointestinal signs before neuroexcitation develops. Hypertension and severe tachycardia can occur with large doses. Cane toads cause neurologic and cardiac effects due to the complex na- ture of the toxins they secrete, developing within seconds to minutes after exposure. Oral irritation with hyperaemic mucus membranes and marked hypersalivation can be seen immediately. Due to serotonin effects, dogs can have abnormal mentation not associated with neuroexcitation. Gastrointestinal signs, hyperthermia and tachypnoea are also possible. Death can occur within 60 minutes of exposure if a large dose of toxin is ingested. Mycotoxicosis may occur when patients get into old/mouldy food, com- post piles, or other sources of decomposing plant material. Neuroexci- tation occurs within a similar timeframe as seen with metaldehydes. It can be difficult to differentiate mycotoxins from metaldehyde. Luckily, both are treated in a similar fashion. General treatment recommendations: Gastrointestinal decontamination is the first line of treatment for tremor- genic toxins. For those patients with recent ingestion and no significant clinical signs, emesis induction is appropriate. For those patients which ingested large doses or that are already sowing moderate to severe clin- ical signs, gastric lavage is an appropriate choice. The majority of these toxins can be adsorbed by activated charcoal, with some undergoing enterohepatic recirculation, meaning that repeated doses of charcoal in 159

13–15 NOVEMBER, 2021 those cases. 0099 Muscle relaxants and antiepileptic medications are very important to con- HOW TO APPROACH PARALYSIS TOXINS trol of clinical signs. Getting excessive muscle activity under control can help prevent some of the secondary clinical issues including hyperthermia M. Hickey which may lead to dysfunction of any or many organ systems. In severe cases, short-term anaesthesia may be the only way to fully control clinical Camperdown/Australia signs. Qualifications: Fluid therapy is indicated in most clinical cases, both to help with thermo- regulation and the ensure hydration/perfusion. Mara Hickey Toxin-specific treatments: DVM DACVECC Metaldehyde doesn’t require any special therapy. Follow general treatment [email protected] recommendations. The most common toxins leading to paralysis include tick paralysis, tetrodotoxins, and elapid snake envenomation. Botulism and ionophore Organophosphates should be treated with Pralidoxime (2-PAM) if it has ingestion are less common but still important causes of paralysis. All lead been less than 24 hours since ingestion as this prevents “aging” which to ascending flaccid paralysis, but timing of onset, geographical region, occurs when permanent inhibition of neurotransmitter recycling, therefore and the presence of other clinical signs may help differentiate between preventing prolonged signs of toxicity. Carbamates don’t undergo “aging”, these toxins. so 2-PAM is not required. Therapy for SLUDD signs with 0.1-0.5 mg/kg atropine IV or IM is appropriate, even in the face of tachycardia. How to differentiate between common paralysis toxins: Chocolate has a prolonged gastric dwell time, indicating that induction Tick Paralysis is noted in specific regions of the world including but not of emesis is suitable to perform up to 6 hours after ingestion. Methylxan- limited to the east coast of Australia, the southeast and pacific northwest thines undergo enterohepatic recirculation, so massive doses are appro- regions of North America, and south Africa. Variations in clinical onset, priate to be treated with repeated doses of activated charcoal. clinical signs and clinical recovery are dependent on the tick species at fault, with the majority of cases having clinical signs start more than 24 Treatment for bufotoxicosis depends on if the patient ingested the cane hours after attachment of the tick. In general, cats are relatively resistant toad or not. Those without ingestion of the toad are treated symptomat- to paralysis ticks, with the exception of the Australian Ixodes tick. ically. Atropine is not recommended for these patients, even if profuse hypersalivation is present. Oral rinsing with large quantities of water can Patients with tetrodotoxicosis have recently been to the waterfront as the help instead. For patient ingesting a toad, the animal must be removed majority of fish, cephalopods and molluscs with this toxin are oceanic from the patient’s gastrointestinal tract as soon as possible, through or coastal. Onset of clinical signs is rapid, usually within 30-60 minutes. induction of emesis, gastric lavage or endoscopy. Activated charcoal is Hypotension and bradycardia can be seen with this toxin due to toxin-as- unlikely to help with this toxin. sociated downregulation of the sympathetic nervous system. Mycotoxins don’t require any special therapy. Follow general treatment Elapid snake venom contains a variety of neurotoxins and haemotoxins, recommendations. with clinical signs including any combination of paralysis and haemor- rhage, with possible muscle damage. Onset of clinical signs is usually within minutes but can be delayed up to 24 hours. Preparalytic signs – acute collapse with SLUDD (salivation, urination, defecation, etc) signs which apparently self-resolve – are associated with a lethal dose. Botulism occurs 12-24 hours after ingesting decomposing material (usual- ly flesh) containing Clostridium botulinum. Botulinum toxin causes a pure lower motor neuron (LMN) disease. Ionophores such as monensin are a feed additive for cattle and poultry, used as a growth promotor and to control coccidiosis. Ingestion leads to LMN signs with cardiotoxicity rhabdomyolysis and hyperthermia due to ef- fects on intracellular calcium and magnesium levels. Acute clinical signs may develop within 6 to 24 hours from ingestion, but for animals ingesting lower doses, signs may be delayed for 2 weeks or longer. General treatment recommendations: As most patients don’t present to hospital until clinical signs have developed, and because several of the toxic causes of LMN paralysis are not ingested, administration of emetic agents is usually contraindicated. Instead, the primary aspects of treatment include stress reduction, recum- bent patient care and monitoring/supporting respiratory status. Patients with toxin-induced flaccid paralysis are commonly anxious and stressed, so sedatives are imperative to decrease anxiety and prevent struggling. Butorphanol and low-dose alpha-2-agonists are the sedatives of choice, with benzodiazepines and acepromazine as potential secondary options. 160 WSAVA GLOBAL COMMUNITY CONGRESS

For recumbent patients, nursing care is of paramount importance to focus on nursing care and respiratory support. prevent secondary issues. Using a nose-to tail approach may be helpful to ensure all appropriate care is ordered: Due to decreased blink reflexes, frequent eye lubrication and daily fluores- cein staining will help prevent/detect corneal ulcerations. Dysphagia and oesophagel dysfunction may increase oropharyngeal fluid, so careful suctioning/wiping should be performed as needed. Patients should be NPO (nil per os) until oesophageal dysmotility resolves, so nutritional support via enteral feeding tubes or parenteral routes should be started in patients which require NPO orders for more than 48 hours. Passive range of motion (PROM) exercises, limb massage, changing recumbency positions, provided padded bedding and examining skin for the development of pressure sores are indicated for any patient with tetraparesis. Urinary bladder management (frequent expression, passage of temporary or placement of indwelling urinary catheters) will decrease the risk of overflow incontinence, detrusor muscle atrophy and urinary tract infec- tions for urine retention. Patients may also require enemas to facilitate passage of faeces if flaccid paralysis persists for more than 2-3 days. Finally, temperature management is needed – many paralysed patient require heat support but hyperthermia can be found in some patients. Monitoring respiratory function (both ventilation and oxygenation) can be performed with repeated physical exam, blood gas analysis, pulse oximetry and capnometry. Patients may require oxygen supplementation via nasal insufflation or flow-by/mask supplementation if mild hypox- emia or mild hypoventilation is identified. Endotracheal intubation may be helpful for patients with toxin-induced laryngeal paralysis – oxygen supplementation may or may not be needed once the patient’s airway is secured. Indications that the patient requires ventilator support includes a venous CO2 or end-tidal CO2 level greater than 60 mmHg, hypoxemia re- fractory to oxygen supplementation (PaO2 < 60 mmHg or SPO2 < 90%, or unsustainable respiratory efforts. When it comes to deciding to ventilate a patient with flaccid paralysis, if you are deeply uncomfortable with how the patient is breathing, that indicates you need to secure their airway and take over ventilation. Specific toxin treatments: With the exception of the Australian Ixodes tick, removal of paralysis ticks will lead to a resolution of clinical signs within a short period of time. Ixodes tick anti-serum is required for clinically affected dogs and cats in Australia, even once the tick has been removed. Patients with tetrodotoxicosis due to swallowing an oceanic creature need to have this source removed from the body. As most are already showing clinical signs at presentation, emesis is inappropriate, but gastric lavage and/or gastroscopy can be successful at removing the source of the toxin. Elapid snake envenomation required appropriate antivenin therapy, with the amount of antivenin based on the severity of clinical signs and antici- pated total amount of venom within the patient. Botulism has no antidote and antimicrobial therapy will not have any beneficial effect. Ionophore toxicosis has no antidote. IV lipid therapy theoretically may help but consistent results have not been reported. Conclusion: For the majority of toxicities leading to flaccid paralysis, treatment should 161

13–15 NOVEMBER, 2021 0100 gy). Cats can present in respiratory distress. EVERY BREATH YOU TAKE: RESPIRATORY DISEASE Importantly cats with lower airway disease can make fragile patients, IN CATS decompensating and suffering a respiratory arrest if handled inappropri- ately. Although diagnostic tests are important, emergency treatment of S. Taylor dyspnoeic cats should be ‘hands off’ and tests requiring restraint such as radiography postponed until the cat is more stable. Veterinary nurses play Tisbury/United Kingdom a vital role in the careful and calm handling of dyspnoeic cats to avoid deterioration. Qualifications: Diagnostic tests Samantha Taylor Clinical signs and physical examination findings may be consistent with BVetMed(Hons) CertSAM DipECVIM-CA MANZCVS FRCVS lower airway disease, but differential diagnoses such as congestive heart disease, lungworm, pleural space disease or upper respiratory disease [email protected] must be excluded. Tests will be dictated by the individual case but blood Every breath you take: lower airway disease in cats tests are generally unremarkable, with circulating eosinophils found in around 20% of cats with asthma. Faecal analysis may be indicated to Introduction exclude feline lungworm (Aelurostrongylus abstrusus). Never rush to perform radiographs in tachypnoeic/dyspnoeic cats. First minimise stress Lower airway disease, and specifically bronchial disease, is common and perform s TFAST ultrasound to exclude pleural effusion. in cats, and a cause of significant morbidity and even mortality. The predominant presenting sign is a chronic cough, which may be mistaken Radiography is important in the diagnosis of lower airway disease and by owners for ‘furballs’, as the cat may retch during a coughing episode. usually reveals a diffuse bronchial, or bronchointerstital pattern, although Inflammatory bronchial disease is the most common lower airway disease radiographs may be normal. Other abnormalities include lung hyperinfla- in cats and is frequently termed ‘feline asthma’. However, feline asthma tion, hyperlucency, right middle lung lobe collapse and aerophagia. likely represents just one end of a spectrum of non-infectious, inflam- matory, lower airway diseases seen in cats, with chronic bronchitis also Thoracic CT is growing in popularity in veterinary medicine and in cases of associated with significant respiratory morbidity in this species. lower airway disease it can reveal airway thickening, lung lobe consolida- tion and mucous accumulation, and exclude other differential diagnoses. Pathophysiology CT can be performed in conscious dyspnoeic cats if stress can be mini- mised (using a ‘mousetrap’ perspex chamber). In feline asthma it is generally accepted that a type 1 hypersensitivity reaction occurs within the airways, where sensitised cats react to repeat Bronchoscopy with BAL is useful in the diagnosis of lower airway disease exposure to an antigen with mast cell degranulation. Histamine and in cats, as collection of BAL samples allows cytology and testing for leukotrienes result in increased vascular permeability and smooth muscle infectious agents to be performed. BAL samples can be collected via the contraction (acute airway narrowing), eosinophils are recruited and bronchoscope, or blindly. Contraindications include severe dyspnoea/ worsen the inflammation and tissue damage. This inflammation results hypoxia, coagulopathy or cats with very unstable asthma. Bronchos- in airway hyper-reactivity, smooth muscle hypertrophy and excessive copy of asthmatic cats is associated with severe bronchospasm, but mucus production. The condition is seen more commonly in young to pre-treatment with terbutaline (a bronchodilator), and using saline at body middle-aged cats, with Siamese and other Oriental cats overrepresented. temperature for the wash may help prevent this complication. Blind BAL Multiple triggering allergens are implicated, including dusty cat litter, can alse be performed and adequate samples obtained. house dust mites, strong chemical smells, building dust, perfumes, hair- spray, cigarette smoke and pollens. Therapy In chronic bronchitis neutrophilic inflammation predominates, with Emergency treatment excessive mucous production and airway remodelling and narrowing. This condition does not seem to be acutely triggered by allergens or result in As mentioned, dyspnoeic cats are prone to decompensation so a ‘less is bronchoconstriction, but the causes are not fully understood. more’ approach should be adopted and thought given to stress reduction. Treatment may include injectable bronchodilators and corticosteroids. Reduced airflow occurs in both conditions due to oedema, mucus, inflam- Note that other common causes of dyspnoea such as congestive heart mation and epithelial alterations, with bronchoconstriction occurring in failure and pleural effusion should be excluded. cats with asthma. These changes in airway diameter, even if small, result in significant reductions in airflow. Over time changes become permanent Chronic therapy including fibrosis and emphysema. The mainstay of treatment of lower airway disease is corticosteroid treat- The role of Mycoplasmas (small bacterial organisms) in feline respiratory ment, but bronchodilator therapy can be helpful for cats with bronchoc- disease has been studied in cats and remains unclear. The organisms are onstriction. As treatment is life-long and potentially associated with side found as commensals in the upper respiratory tract, but have been associ- effects, other causes of airway disease should be excluded and treated ated with lower airway disease, where they may not be the primary cause, empirically if necessary, such as antiparasitic treatment for lungworm. but are likely an exacerbating factor. Testing for, and treating Mycoplasma Clients should also be counselled as to maintaining their cat at a healthy spp infection is therefore generally advised for cats with lower airway weight and overweight or obese cats should be seen in a weight-manage- conditions. ment clinic at the practice to encourage slow, healthy weight loss. Chronic stress may also worsen respiratory disease and should be avoided. Clinical signs • Removal of triggers: cigarette smoke and dusty or scented cat litters We will discuss clinical signs in the talk, coughing is common but also should be avoided, owners should vacuum daily to remove house dust tachypnoea, exercise intolerance (eg mouth breathing after playing, lethar- mites, and high-efficiency particulate air filters may be helpful for indoor cats. 162 WSAVA GLOBAL COMMUNITY CONGRESS

• Corticosteroid therapy: forms the mainstay of management of affected 0101 cats. Oral prednisolone is used initial in most cases, using dosages to control clinical signs (0.5-1.0mg/kg BID), but tapered to avoid side effects INTRODUCING INHALERS: TRAINING TO CATS FOR such as polydipsia and insulin resistance resulting in diabetes melli- COMFORT WITH INHALED THERAPY tus. Injectable corticosteroids are the least desirable option due to the potential for severe side effects, but maybe the only option for some cats. L. Ryan Inhalational corticosteroids are an effective way to manage lower airway disease in cats, although they can take 1-2 weeks to become effective. An New Forest/United Kingdom initial course of oral corticosteroids is appropriate, with a view to using inhaled medications once clinical signs are controlled. Inhaled therapy Qualifications: should be given using a device such as an Aerokat (Trudell Medical). Training to tolerate the inhaler is vital. Inhalational therapy is provided LINDA RYAN via a metered dose inhaler (MDI) attached to a chamber and facemask. Inhaled corticosteroids and bronchodilators are used, although none are BSc (Hons) VTS (Behaviour, Oncology) DipAVN KPA-CTP RVN CCAB licensed for cats. Inhaled medications provide local drug distribution into the lungs, and are associated with fewer side effects than oral medica- iCatCare: [email protected] / Inspiring Pet Teaching: linda@inspir- tion. Fluticasone is used widely as an inhaled corticosteroid at a starting ingpets.com dose of 125-250μg BID and salbutamol is used as a bronchodilator at Training cats for comfort with inhaled therapy 100μg every 30 minutes during an acute episode. Both are available from human pharmacies. Chronic use of salbutamol is not recommended as it Linda Ryan BSc (Hons) VTS (Behaviour, Oncology) DipAVN KPA-CTP RVN may exacerbate airway inflammation. CCAB • Bronchodilators: may be useful in asthma cases with bronchoconstric- Cat Advocacy Programme Manager, International Cat Care (www.icatcare. tion. Inhaled salbutamol be useful in an acute episode at a dose of 100μg. org) Other bronchodilators used in cats with lower airway disease include other beta2-receptor antagonists such as terbutaline and methylxanthines Certificated Clinical Animal Behaviourist and animal trainer, Inspiring Pet such as propentofylline. Teaching (www.inspiringpets.com) • Other therapies: antibiotic therapy should be based on culture and Introduction sensitivity results, although scant growth due to contamination is not unusual. Results should be interpreted with cytology findings and how Treating feline respiratory conditions, such as asthma, with inhaled heavy the growth is. Mycoplasma infection is treated with doxycycline or medication is common. Inhaled therapy, using bronchodilator and/or fluoroquinolones. Ciclosporin has been used successfully to treat a cat anti-inflammatory medications, is considered to be the optimum method with asthma but further study is required before it can be recommended. of medicating cats with asthma, chronic bronchitis and other respirato- Omega-3 polyunsaturated fatty acids and allergen specific immunotherapy ry conditions. While this is effective in terms of treatment, some cats show promise and further publications are awaited. may not comfortable with the inhaler and can become sensitised to its frequent use, making ongoing treatment difficult and distressing for both Conclusions cat and caregiver. This, in turn, may result in cats being medicated with systemic medication, such as corticosteroids, which may cause short- and Lower airway disease is common in cats and can be life-threatening. long-term adverse effects. Investigations include imaging and bronchoalveolar lavage. Management is based on the use of corticosteroids, but in inhaled form they are asso- To avoid the negative health effects of longer-term systemic treatment, ciated with fewer side effects. Bronchodilators, allergen avoidance and the potentially deleterious effects on mental wellbeing of enforcing more recently therapies such as allergen specific immunotherapy may be inhaled therapy, and to protect the human-cat bond, well-planned positive other treatment options.The prognosis for cats with inflammatory lower teaching for comfort with inhaled treatments is ideal. Careful introduc- airway disease is generally positive. Although life-long therapy is required, tion and positive reinforcement training can lead to acceptance of and response to treatment is usually good. Deterioration or failure to respond comfort with inhaled therapy. Training with the cat goes hand in hand with should prompt reassessment of diagnosis, assessment of compliance, or caregiver education and support, which veterinary professionals are well a search for complicating factors such as infection. placed to provide. aThe veterinary nurse plays an important role in the care of affected Training can take time, which will be cat-dependant, and should not be cats, at initial presentation, during the investigation and crucially during rushed. Investment of time, care and commitment at the beginning can treatment, when time spent with owners explaining and demonstrating the set cats and caregivers up for lifetime success with optimal care for use of inhaled medication can make a great difference to compliance in respiratory conditions. During the training phase, the client is encouraged the long term. not to try to use the inhaler/spacer device, but instead to liaise with the veterinary team on the safe use of short-term systemic therapies, so as to keep the cat’s medical condition stable until such a time as it is comfort- able with inhaled therapy. The training process Step 1: Mastering the training techniques for comfort inhaled therapy and equipment. Cats, in the context of their individual and species-specific natures, and - like all other lifeforms - learn through processes of association, and of “performance-feedback-revision” (or trial and error/success). Creating positive associations with inhalers, chambers/spacers, and all related equipment and contexts, is the first step. 163

13–15 NOVEMBER, 2021 Conditioning positive and calm emotional responses in relation to the for a short time, and with little pressure – mark whist the item is on the inhaler/equipment is important, and first impressions matter! The inhaler/ body, remove it, then reinforce. Repeat with varying pressure and duration chamber must not be perceived as a threat, and ideally cats will habituate (independently of each other initially), in different body parts, working up to its presence (whereas using force, rushing the training process, or at- to longer times prior to the marker, more pressure, or both simultaneously. tempting inhaled treatment too early will like cause distress and sensitise This may help to generalise the concepts being taught. the cat). Step 5: Teaching cats to be comfortable inhaling medication. Teaching caregivers these concepts, how to build positive predictions related to the inhaler/chamber, and how to give the cat choice and control Once all of the previous steps have been mastered, always monitoring and are vital. This may be taught and supported via in-house knowledge and responding to the cat’s emotional state, and ensuring they have control skill, external video resources, and/or by referral to an appropriately qual- of their bodies and actions, and working in short sessions often, it’s time ified and experienced trainer +/- behaviourist (particularly important if the to start putting everything together. This entails emulating an entire treat- cat has already had negative experiences). The mechanics of mark and ment sequence in incremental chunks, building up to the whole thing and reinforce training should also be taught to fluency. with the cat holding still for seven-ten breaths. Reinforce the cat for calm behaviour while the medication is shaken, attached and dispensed (prac- Step 2: Introducing cats to the inhaled therapy and equipment. ticing with a dummy inhaler for training) – this should initially be done away from the cat. Then let the cat approach and put their nose in the Habituation may occur through simply leaving the inhaler/chamber around mask – mark and reinforce. Repeat, building up to closer proximity, longer in the environment, in a non-threatening way. Positive associations may durations, more pressure of the nose in the mask, etc. Do not always be created by the inhaler/chamber predicting reinforcers the cat val- make sequences longer and more difficult – work back and forth between ues, e.g., stroking, food, treats, and so on – all dependant on the cat’s shorter and easier, marking and reinforcing, with occasionally more being preferences. Ideally play or high-energy reinforcement strategies should asked from the cat, until the goals are achieved. be avoided, as this may condition high-arousal with the inhaler/chamber, which may lead to frustration if expectations are not met. Conclusion It is also recommended to habituate the cat to a variety of sounds and Training slowly, in an environment that they feel safe, monitoring their scent, and pair these with positive outcomes, so as to prepare them for emotional state and putting the cat in control, comfort with inhaled the “hiss” of the inhaler and unfamiliar scent of medication, which may be therapy can be taught positively and in a welfare-centred way. At no aversive, without careful preparation. time should the cat be rushed, should they have the mask or treatment enforced upon them, or should any kind of reprimands, punishment or Step 3: Teaching cats voluntarily place their nose in the chamber/mask. physical restraint be used. Each cat is an individual, and training should be at their pace, with veterinary support throughout the process, to ensure Operant teaching is used to encourage the cat to cooperatively take part health and wellbeing. Reinforcement should continue long-term, and care- in their inhaled therapy, by shaping for voluntary approaches to the mask. giver should continue to be supported by the vet-led team. This is best done by initially using a variety of objects, so as to generalise the concepts, making it easy for the cat (e.g., by using large/open items). For further depth, detail and instructions, please see International Cat Gradually, the cat can be reinforced for placing their nose into smaller and Care and Trudell Animal Health’s collaborative video project to train cats more enclosed objects, such as the mask. The process of approach can for comfort with inhaled therapy. be kick-started by luring the cat’s interest and reinforcing near/in the ob- ject, e.g., with a tasty treat. Initially the food or treat is given in the object, Further reading and resources then – after a few repetitions – a marker signal (e.g., a clicker) is used to pinpoint the desired behaviour of nose-in-mask, and the treat is given Bradshaw JWS and Ellis S (2015) The Trainable Cat. A practical guide to outside the mask (after the marker). making life happier for you and your cat, Aleen Lane, UK. When the mask is easy for the cat to approach and put their nose it, attach International Society Feline Medicine (2016) ISFM guide to feline stress the chamber, and repeat these steps. and health: managing negative emotions to improve feline health and wellbeing. Ellis, S. and Sparkes, A. (Eds.) ISFM/CEVA Animal Health. Step 4: Teaching cats to hold their nose in the mask/chamber for the duration of their treatment. Asthma in cats: https://icatcare.org/advice/cat-health/asthma-cats Once the cat is completely comfortable with the inhaler/chamber near its Training cats for comfort with inhaled therapy: https://icatcare.org/inhal- body/face, and they are making voluntary approaches and putting their er-training/ noses in the mask, it is time to build duration of this behaviour. This is achieved by withholding the marker signal fractionally when the cat puts Cat Handling Video: Recognising and responding to signs of a happy cat: its nose in the mask, e.g., by 1-2 seconds initially (then feeding outside https://www.youtube.com/watch?v=KSXjLgTUbzAandfeature=youtu.be the mask). Gradually, over many short repetitions, the time the marker is withheld while the cat’s nose is in the mask is lengthened – but not in a Nagel, Sartori, and Rozanski. (2020). Impact of Spacer Design on Respira- way that is always getting longer. The interval prior to the marker should tory Drug Delivery and Potential Drug Cost Implications. American College be random – sometimes a few seconds longer, sometimes a few seconds Veterinary Internal Medicine and Trudell Animal Health. shorter, while the average builds to the time that is needed to hold still for treatment. As this becomes easy for the cat, watch the breath indicator to Finding appropriately qualified trainers or behaviourists: www.abtc.org.uk/ ensure a good seal, and count breaths, rather than seconds, thus reinforc- practitioners ing more and less breaths prior to marking and delivering the reinforcer. In addition to this, it may be helpful to teach the cat the concept of com- fort with duration and pressure of an object on their body (but not their faces – this should always be the cat’s choice, and the mask should never be placed over the cat’s nose). This entails brief placement of a hand, training prop or the mask on an easy, well-accepted part of the cat’s body 164 WSAVA GLOBAL COMMUNITY CONGRESS

0102 Number of the litterboxes MANAGEMENT OF INAPPROPRIATE URINATION IN Problem with the litter CATS Location M. Irimajiri Cleanliness Tokyo/Japan Stress Qualifications: The size of the litterbox should be large enough. We usually recommend Mami Irimajiri that the box should be at least one and a half times the length of the cat (from the tip of the nose to the end of its rump). This size can give the cat BVSc, PhD, Dipl.ACVB enough room to sniff, dig, posture, and cover its excretes. [email protected] We usually recommend an uncovered litterbox but in case the cover is necessary, big size box with a cover should be OK 1. Generally speaking, Management of inappropriate urination in cats the number of litterboxes should be equal to the number of cats in the household plus one. In doing so, the cats can choose to use the clean box Feline inappropriate elimination (periuria and/or perichezia) or unwanted and if the cat likes to urinate and defecate in different boxes, more than toileting behavior is a very common behavioral complaint of cat owners. the number of cats can accommodate. We may get as a general question from the cat owners that their cat has been urinating or defecating outside of the litterbox. This problem may Research has shown that most cats prefer fine-grain, clumping slays frustrate the owners and it is serious enough that those cats may be at litter 2. Domestic cats are descendent from desert-dwelling ancestors risk for abandonment. that are eliminated on fine dry sand or soil. Try to educate the owners to choose fine grain litter for the cats. However, there are always exceptions When we receive a cat with an inappropriate elimination case, the that some cats have a litter preference. Some may choose soft materials differential diagnosis flow should start from thinking if the behavior has or others may choose larger grains. For less dusty litter, there is litter developed from medical issues. DDx list may be as below but not limited made from corn, grass, and tofu beans. Those are non-toxic and natural, to those. biodegradable, and gentler on your cat’s feet. If your clients are choosing those litter, make sure to tell them to monitor their cats first. Some cats Crystals or stones in the urinary tract cab ingests those litter. Cystitis including FIC Location for those litterboxes should not be too far from their core area and they should be kept clean since cats like to eliminate on clean litter- Kidney diseases box. Endocrine diseases (diabetes, hyperthyroidism, etc) If the owners are trying everything possible and the cats are still urinating at unwanted places, stress should be considered. Pain that might cause the cat not to be able to get into the box For spraying behavior, as well as unwanted toileting behavior due to Liver problem stress, medication is another choice you can make3. Make sure that physical checkups including urine examination and blood Fluoxetine 0.5-1mg/kg Q24H tests (if needed) should be done. Paroxetine 0.5-1mg/kg Q24H Then we need to discuss if unwanted toileting behavior is by urine mark- ing (spray) or urinating outside the litterbox. Make sure to ask the owner For cats’ environment, make sure that all cats have multiple soft beds to what the cat’s behavior looks like when depositing excretes outside of the sleep and rest. They should have places to hide and climb. Playtime with litterbox. the owners is important. If the household with multiple cats, their social relationship should be considered. If the cats are sleeping together, they Urine marking is the act of depositing urine usually spraying on vertical are good buddies but if cats may have some distance to each other, that surfaces with intention of leaving urine marks with smell and its pher- distance shall be respected. So their food bowls and resting places should omone. Usually, they stand, keep their tail up with its tip quivering, and get privacy. spray urine on the vertical surface but sometimes cats may squat to mark on a horizontal surface. Urine spray is normal behavior for intact cats. References They use urine to communicate their sexual status so if the client is intact both male and female, neutering them as one of the treatments should be 1 GRIGG, E. K., PICK, L. & NIBBLETT, B. (2013) Litter box preference in considered. Neutering may not stop spraying behavior. If that is observed, domestic cats: covered versus uncovered. J Feline Med Surg 15, 280-284 stress surrounding the cat may be the cause of this problem. In order to reduce cats’ stress, we need a multimodal approach to fight against it. 2 NEILSON, J. (2004) Thinking outside the box: feline elimination. J Feline What we need to tell the owner to reduce cats’ stress in the house and Med Surg 6, 5-11 keep them happy and healthy will be discussed. 3 PRYOR, P. A., BENJAMIN L HART, MELISSA J. BAIN, KELLY D. CLIFF Urinating outside the litterbox means that the cat is emptying its bladder (2002) Causes of urine marking in cats and effects of environmental but not in the litterbox. Behavior itself is normal but there could be rea- management on frequency of marking. Journal of the American Veterinary sons that the cat is avoiding the litter that the owner provided. When there Medical Association 219 (2), 1709-1713 are problems with the litter, there are points that we need to be aware of. Size of the litterbox Style if the litterbox 165

13–15 NOVEMBER, 2021 0103 0104 HOW TO TRAIN CATS TO GO INTO THEIR CARRIER IS THIS A BEHAVIOR DISORDER OR NOT - TIPS FOR DIFFERENTIAL DIAGNOSES M. Irimajiri M. Irimajiri Tokyo/Japan Tokyo/Japan Qualifications: Qualifications: Mami Irimajiri Mami Irimajiri BVSc, PhD, Dipl. ACVB BVSc, PhD, Dipl. ACVB [email protected] [email protected] Cats are becoming more popular as a pet worldwide. Compare to keeping If a client asks you what to do with his dog being aggressive to his chil- dogs as a family pet, cats do not need regular walks and baths. They are dren, what can we do to make a diagnosis of behavior disorder? small so it is easy to keep them even in a small apartment. They do not bark so for the people living in a big city who has neighbors only “a wall” Even if the main concern was a behavioral problem, a road to make a away. diagnosis is the same as other medical problems. First, list up the main problem list that you got from the owner. Because we do not take cats out to walk and take them to “dog parks”, they can be too comfortable in the house and not having enough chance Let’s diagnose one example case. The main concern is “aggression to get out from their habitat, they can end up being shy to the carrier. towards children in the household.” When we want cats to visit the veterinary hospital, the owner suddenly realizes that putting them in the carrier is difficult. Main concern: Aggression at children Being able to get cats into their carrier is very important so cats can visit Make differential diagnosis the clinic but also this can help their lives when disaster hits. Sebastian et all reported that those who had difficulty evacuating were with cats who Ddx list couldn’t get into the carrier1. This talk will show step by step how to teach the owner to get ready to put D Pain induced cats into the carrier without big hassles. Those are the desensitization A hydrocephalus techniques. Hepatic encephalopathy M hypothyroidism Step 1: get the carrier out from the closet and let the carrier be one of the Cushing cats’ beds or hiding place Step 2: Play with cats with food treats so the cat will be comfortable being around the owner and getting treats from them Step 3: Let the cat go in and out of the carrier as fun games Step 4: When the cat gets into the carrier, start to close the entrance but N Renal disease do this process slowly so the cat will not feel that it will be confined I Neoplasia (nerve system) T Nutrition (luck of thiamine from intake) Step5: Provide treats while the cat is resting in the carrier Infection (brain, CNS) Infection (other parts) Step 6: Start to pick up the carrier and move them Trauma that can cause pain Step 7: Bring the cat with the carrier to your car and get engines on or bring them to walks Step 8: Take the cats to the vet clinic, the staff will give food treats to cats and the cat goes home. Important points are to go through each step slowly. Always have fun with V PTSD cats so they will not get stressed. Any staff members can shoot video Not enough circulation in the brain clips of how to desensitize cats to the carrier so the owners can watch them and try the same things at home. Reference Do a physical exam, blood exams, urine exams if needed. 1 SEBASTIAN E. HEATH, P. H. K., ALAN M. BECK, LARRY T. GLICKMAN If no medical problem was found or, there are medical problems but the ( 2001) Human and Pet-related Risk Factors for Household Evacuation behavioral problem seems to be happening, the behavioral differential can Failure During a Natural Disaster. American Journal of Epidemiology 153, be listed. 659–665 Behavioral Ddx Fear aggression (being afraid of children) Learned aggression (using aggression can shoo the child away) 166 WSAVA GLOBAL COMMUNITY CONGRESS

Conflict aggression (fear, frustration and the dog did not know what to do) 0105 Lack of socialization (missed socialize with children so the dog does not EMERGENCY CARE AND TRIAGE OF BIRDS AND know how to interact with children) EXOTIC ANIMALS Play induced aggression (playing with children and got excited) D. Elliott Redirect aggression Pretoria/South Africa Maternal aggression (the dog is raising puppy) Qualifications: Protective aggression (dog is protecting its toy from the child) Dr Dorianne Elliott To understand what is the underline cause of aggression towards children Dip Vet Nur BVSc ask for detailed history to make behavioral history [email protected] History taking/consultation Emergency care and triage of birds and exotic animals Ask about each aggressive incident in detail: where, when, how, who Elliott DL. Dip Vet Nur BVSc. Bird and Exotic Animal Hospital, Onderste- poort, South Africa. Extraordinary Lecturer, Dept of Companion Animal Ask the first incident Clinical Studies, University of Pretoria. [email protected] Ask about if the dog has ever been to socialization class, where the dog INTRODUCTION: The veterinarian plays a critical role in the speedy rec- came from ognition and stabilisation of emergencies in the avian or exoticl patient. Non-traditional species are often very stressed by handling and hospital- How did the incident end? isation and signs of deteriorating condition can be very subtle. Because many exotic animals are only a generation or two removed from their What kind of training that the dog is receiving? wild ancestors, they still display marked fight or flight behaviours and will mask clinical signs of disease to avoid becoming a target for predators. The goal for the treatment GENERAL SUPPORTIVE MEASURES: Birds and many small mammals have Detail history can lead you to a decent diagnosis and if knowing the goal very fast metabolic rates and quickly become hypoxic when dehydrated for the owner is understood, the clinician and the client may be able to or hypovolaemic. Reptiles with their slower metabolisms take longer to discuss the goal so the prognosis will be better. become ill but are often presented in a compromised condition due to the owner’s inability to recognise the signs of deterioration. Most compro- mised patients will benefit from supplemental oxygen. A dedicated oxygen chamber is ideal but even a box sealed with tape or a bag placed over a small birdcage will work in an emergency. The administration of crystalloids (eg Ringers Lactate) and colloids is a critical part of resuscitative, emergency and supportive care. With small mammals and birds we use 60 to 100ml/kg/day with shock rates being given at up to 10ml/kg/hr. Reptile daily requirements are much lower at 20-30ml/kg/day. Ringers Lactate with 50% dextrose added at 1ml per 20ml Ringers is a good general fluid mixture that can be safely admin- istered subcutaneously or intraperitoneally in the majority of species. Reptiles have lower plasma osmolarity than birds and mammals and an isotonic fluid solution for reptiles can be made either by using 1 part Lactated Ringers to 2 parts 0.45% saline with 2.5% dextrose. Alternately a 50% Ringers to sterile water solution is effective. Due to their small size (large surface area to volume ratio) and high metabolic rates, small exotic patients are particularly susceptible to hy- pothermia. Normal hospital room temperatures are far too low to properly support the critically ill exotic patient and incubators or brooders set to between 28 and 32⁰C are invaluable. Supplemental heat should always be provided during anaesthesia. Bair huggers or even heating pads (properly insulated to prevent thermal burns) or heat lamps may be used. To summarise - the three most important aspects of emergency support- ive care are: OXYGEN, FLUIDS and WARMTH Even if no diagnosis has yet been made, providing these three treatments will save many exotic patients. STABILISATION OF AVIANS: The basics of emergency care include supple- mental Oxygen (by mask or in an induction chamber), fluid therapy (pref- erably intravenous but intraosseous or subcutaneous administration can 167

13–15 NOVEMBER, 2021 also be useful) and warmth. Intracoelomic fluids cannot be given to birds offered tempting foods to encourage eating. as the fluids will be injected into the airsacs, causing the bird to drown.1 An ill bird will often refuse to descend from the cage perch to feed from a We will typically place a compromised bird into an oxygen chamber for food bowl placed on the floor. Favourite food items should be offered and 10-15 minutes before performing a clinical exam. Covering the oxygen food and water bowls should be elevated to the level of the bird’s perch to chamber to provide a secluded environment is also beneficial to reduce encourage feeding. stress1. Anorexic avian patients should be assist-fed sooner rather than later. The initial examination should be hands off. The birds posture, ability to Gavage feeding with purpose made steel crop needles (in hard billed spe- ambulate, interest in the environment and respiratory status as well as any cies such as parrots) or with standard feeding tubes in species incapable signs in the cage of vomition, diarrhoea, haemorrhage or sources of lead of biting through the tube is indicated. Useful gavage feeding products or zinc can be assessed1. include avian handrearing formulas and canine recovery diets, depending on species requirements (carnivore During the clinical examination care should be taken not to place any pressure over the ribs or sternum. Having no diaphragm, birds ventilate In an adult Psittacine (parrot type bird) approximately 3-5% of body mass the lungs and airsacs by expansion of the chest and it is easy for an may be gavage fed 2-3X daily. Neonates have larger crops and can be fed inexperienced handler to accidentally compress the sternum to the point up to 10% of body mass per feeding. where hypoventilation occurs. A dyspnoeic bird should also not be placed in dorsal recumbency. Many birds with respiratory tract disease will have Crop feeding should be performed after any other planned procedures to fluid in their airsacs and dorsal recumbency could potentially allow fluid to minimise the chances of regurgitation and subsequent aspiration1. drain from the airsacs into the lungs, thus effectively drowning the bird. A thorough hands-on clinical exam should be performed only once the bird STABILISATION OF SMALL MAMMALS AND PRIMATES: Return to first has stabilised1. A suitably sized towel is used to gently enfold the bird principles. Fluids, warmth, caloric and pain support. for examination. Towel handling is minimally traumatic for the bird and does not predispose them to hand-shyness. The towel also protects the FLUID THERAPY: Intravenous access is difficult in many small mammals, feathers and is perceived as less traumatic by the owner. but possible with experience. S/Q fluids or intraperitoneal fluids are frequently used and intraosseous access is achieved via the tibial crest or ROUTES FOR FLUID THERAPY: A small (22-26g) gauge intravenous cath- the femur. eter is used to cannulate the basilic vein in most species. The catheter is secured in place by using cyanoacrylate glue on an elastoplast butterfly. HYPOTHERMIA: Occurs quickly and a warm environment (30+ degrees C) The drip line is secured to a few wing feathers to prevent movement of the is critical. catheter. In larger and long legged species the medial metatarsal vein is used. The jugular vein is easily accessible in many species but is not an CAGING: As they are prey species, a hiding area must always be provided effective site for cannulation due to the flexibility of the bird’s neck. The as the increased stress of constant exposure to “predators” adversely jugular is however commonly used for blood collection and for emergency affects their recovery.2 boluses of dextrose/colloids etc. FEEDING: Err on the side of caution and feed patients quickly even if they Intraosseous cannulation into the distal ulna or proximal tibia can be are eating a little. Carnivores can be given canine recovery diets. Fibre- used in cases where intravenous access is difficult, as in very small or vores such as rabbits and guinea pigs do very well on purpose made high collapsed patients. The humerus and femur of many species are pneu- fibre gruels. Soaked and ground up pellets or vegetable purity can also be matised and connect directly to the airsac system. For this reason these used. bones should be avoided. Primates need human supplements such as Ensure mixed with baby por- HOUSING: Birds have a much higher core temperature than mammals ridge. Gluten intolerance is common so gluten free foods should be used. (40-42°C) and can become hypothermic very quickly. After warmed fluid administration has been begun we will place the patient in an incubator at CONCLUSION: A return to first principles is needed for supportive care approximately 29-32 C. of critical exotic patients. They deteriorate quickly and aggressive action must be taken if a patient is compromised. The client should be warned Post-surgical patients are kept in incubators for recovery as hypothermia that the animal is critically ill as many clients fail to identify the signs of ill develops quickly during anaesthesia and surgical procedures (especially health until very late in the disease process. where alcohol is used to prep the bird and when the coelomic cavity is exposed). REFERENCES A dimly lit, quiet environment away from potential predator species such 1. Wilson H. Avian Emergency and Critical Care. In: Proceedings of the as dogs and cats is needed to minimise the stress associated with hospi- Association of Avian Veterinarians. Pittsburg; 2003. p. 261. talisation. 2. Meredith A, Flecknell P. BSAVA Manual of Rabbit Medicine and Surgery. PAIN MANAGEMENT is important. A bird in pain will often present Gloucester; 2006. 37–44. depressed and immobile. Increased aggression, guarding of the painful body part, tachycardia and tachypnoea are also common indicators of pain. Meloxicam at 0.5 to 1mg/kg once to twice daily is an effective Non-Steroidal Anti Inflammatory and Butorphanol at 0.5-1mg/kg q8hrs1 is an effective opioid. Buprenorphine has not proven to provide analgesia in the bird1. MAINTENANCE OF CALORIC REQUIREMENTS: Hypoglycaemia is common, especially in smaller patients. Parrots are only starved for a maximum of 4 hours prior to general anaesthesia and are encouraged to eat as soon as possible on recovery. Ill or compromised avian patients should also be 168 WSAVA GLOBAL COMMUNITY CONGRESS

0106 One of the most common underlying causes of anorexia in the domestic rabbit is dental malocclusion. The rabbit has aradicular hypsodont teeth THE APPROACH TO THE ANOREXIC RABBIT that grow approximately 2mm per week. Pet rabbits commonly develop dental malocclusion due to genetic factors, inadequate bone minerali- D. Elliott sation (due to a Calcium deficient diet or inadequate access to UV light) and inadequate wear of the teeth commonly due to a diet low in fibre. A Pretoria/South Africa dental exam is a requirement for any rabbit workup. Sharp spurs common- ly develop on the cheek teeth that cause pain on mastication and thus Qualifications: secondary anorexia and ileus. Dr Dorianne Elliott Rabbit dentistry is a speciality on its own so we will cover it only briefly here. Ad-lib access to high energy foods such as pellets often cause the Dip Vet Nur, BVSc (Pret) rabbit to eat insufficient amounts of hay as they preferentially select out the most palatable food. [email protected] The rabbit’s dentition is designed for a diet of hard grasses and the con- AN APPROACH TO THE ANOREXIC RABBIT stantly growing teeth need to be worn down by the grinding mastication of hay. Elliott DL. Dip Vet Nur BVSc. Bird and Exotic Animal Hospital, Onderste- poort. Extraordinary Lecturer, Dept of companion animal clinical studies, With inadequate wear, the cheek teeth become overgrown and devel- University of Pretoria. [email protected] op sharp spurs which can cut the tongue or gums. The roots will also proportionately elongate which can cause exophthalmos, sinusitis and ABSTRACT: A history of anorexia is a common clinical presentation in the lachrymation. pet rabbit. Anorexia can be caused by any number of conditions including medical conditions, trauma and simple stress. Discerning the cause of Overgrown cheek teeth are corrected by burring them down to a normal the anorexia requires a detailed history, a thorough physical examination flat occlusal plane. and potentially a variety of diagnostic procedures. Common underlying conditions include dental disease, gastrointestinal disorders, urogenital Anorexia will result in a reduction of first the volume and then the size disease, hepatic disease, renal disease, respiratory disease, neoplasia, of the hard faecal pellets. We often try to offer tempting food to rabbits severe pododermatitis, arthritis, fractures and ingested toxins. Nutritional during the clinical examination. A rabbit that shows interest in the food support of the rabbit during the diagnostic phase is vitally important to but then ignores it or mouths and then drops the food is often a rabbit prevent or reverse hepatic lipidosis and to re-establish proper gastrointes- with a painful oral condition. A sick rabbit presents immobile, hunched tinal tract (GIT) motility. over and oblivious to its surroundings. Abdominal auscultation may be used to evaluate borborygmus.1 RELEVANT PHYSIOLOGY AND ANATOMY: The rabbit is an obligate herbivore and a hindgut fermenter. The digestive system is adapted for a Diarrhoea is also a common presenting complaint. True diarrhoea is a fibrous diet. Digestion in the stomach and small intestine is similar to that serious condition, no solid faeces are produced and the rabbit is typically of monogastrics and the remaining food reaching the hindgut consists very ill. These animals need aggressive therapy. Causes of true diarrhoea mainly of fibre which can be divided into two portions: fermentable and include intestinal parasites, sudden diet change and bacterial dysbiosis indigestible fibre. Both are important for proper gastrointestinal function. from incorrect use of antibiotics. Antibiotics including Penicillins (espe- (Excess carbohydrate reaching the caecum predisposes the rabbit to cially if dosed orally), Cephalosporins, Tetracyclines and Clindamycin can bacterial dysbiosis).1 cause dysbacteriosis. Enrofloxacin, Trimethoprim Sulphas and Metronida- zole are listed among the safer antibiotics.3 The fibre that passes into the proximal colon is divided into two separate portions. Fibres of a greater length than 0.5cm are directed distally and Owners often mistake uneaten caecotrophs for diarrhoea. These cae- are excreted as hard faecal pellets. These fibres stimulate healthy gut cotrophs may be found in piles in the cage or may be found tangled in the motility. Smaller particles are directed in a retrograde fashion into the perineal hair. Soiling of the perineum with also predispose the rabbit to fly caecum. This phase of colonic motility is named the “hard faecal phase”. strike. Animals with caecotrophic disorders will typically still pass solid The caecum functions as a bacterial fermentation vat and has a complex faeces intermittently and will be bright, alert and responsive, often with a and delicate microflora. Bacteroides spp predominate in a mixed microflo- good appetite. Commonly, a gradual increase of good quality fibre (grass ra including aerobic and anaerobic bacteria, both gram positive and gram hay) in the diet will encourage caecotropy, improve gut motility, control negative. Small numbers of potential pathogens such as Clostridium spp obesity (which can make it impossible to assume the correct position for may be present but are not harmful unless changes in caecal conditions caecotroph ingestion) and make the gut flora more resistant to sudden allow their proliferation.1 stressors. Volatile fatty acids are synthesised by the caecal microflora. These are Abdominal palpation and radiography may reveal a distended stomach absorbed by the rabbit as an energy source. The fermentation in the cae- with gas surrounding a firm (sometimes palpable) mass. Many normal cum reduces the fermentable fibre to a soft paste containing amino acids, rabbit stomachs contain hair ingested while grooming. In the past it was enzymes, microorganisms and volatile fatty acids. thought that gastric trichobezoars were a primary cause of anorexia in the rabbit. We now understand that the hard mat of fur and fibre sometimes Twice daily, the motility of the proximal colon reverses direction and the palpable in the stomach is simply dehydrated normal stomach content caecal contents are expelled and directed towards the anus. This phase and is a sequel to, rather than a precipitating cause of anorexia.3 Occa- is known as the “soft faecal phase”. The caecal contents are excreted as sionally a rabbit (especially a long-haired breed such as the Jersey Woolly) soft, odorous clumps of material with a thick covering of mucus. These will develop a true pyloric obstruction. Both gastric and intestinal obstruc- caecotrophs are re-ingested by the rabbit directly from the anus and are tions are emergencies and typically present with an acute abdomen and further digested in the stomach and small intestine. The mucus coating a collapsed rabbit. Gastrointestinal surgery on the rabbit is fraught with protects the many beneficial bacteria from destruction in the extremely complications and is considered a last resort. low pH (1-2) of the stomach.1 Anorexia in the rabbit quickly leads to multiple metabolic derangements. 169

13–15 NOVEMBER, 2021 Rabbits are unable to vomit and constantly produce saliva. During normal 0107 digestion water is also secreted into the stomach and proximal colon. Re-absorption of water occurs in the caecum and distal colon. For this EXOTIC ANIMAL EMERGENCIES reason any type of intestinal ileus or obstruction rapidly results in dehy- dration, electrolyte imbalances and distension of the gut with fluid cranial G. Fitzgerald to the site of obstruction. Gatton/Australia Early in the course of the illness rabbits may appear bright and alert but they are predisposed to the development of hepatic lipidosis. During Qualifications: periods of anorexia glucose absorption by the gut falls and there is a decrease in the amount of volatile fatty acids produced by the caecal mi- Gary Fitzgerald croflora. This results in hypoglycaemia which stimulates lipolysis and the production of ketones. Rabbits do not have effective metabolic pathways BAppSC VT, RVT to correct acidosis and are particularly susceptible to the effects of keto- acidosis. Hepatic lipidosis occurs most readily in already obese animals.1 [email protected] Begin assist feeding in the initial phases of the illness. (Approximately EXOTIC ANIMAL EMERGENCIES 10ml/kg of pureed vegetable baby food/soaked complete rabbit diet or purpose-made critical care diets for herbivores 4-5x daily.) Naso-oesopha- In recent years non-traditional pet ownership has increased dramatically, geal tubes may be placed if necessary (8FG works well) but are only used with many owners opting to own exotic pets such as reptiles, birds, small in patients that resist syringe feeding. mammals, fish, and amphibians. As husbandry plays a significant role on the health and wellbeing of these pets it is inevitable that they will present Although the rabbit may not seem to be losing fluids via vomition or to veterinary clinics for care. This creates a unique challenge for the emer- diarrhoea, a rabbit with anorexia and gut stasis should be considered gency team as exotic pets contain a huge diversity of species which vary dehydrated. Subcutaneous or intravenous fluids should be administered. greatly in their husbandry, anatomy, physiology. However, many approach- es to stabilisation can be extrapolated from canine/feline emergency Analgesics are indicated as gas distension of the inactive bowel causes medicine successfully if clinical techniques are adapted to exotic species. pain. Opioids such as Buprenorphine (0.03mg/kg bid) are regularly used. The first difficulty you will be faced with is the Preservation Reflex. As the NSAIDS such as Meloxicam (0.5mg/kg – 1mg/kg once to twice daily) are majority of these species are prey animals, they will regularly mask signs also used for pain control. of illness to reduce the risk of predation. Symptoms noticed by the owner may not be apparent at time of consultation, demonstrating the impor- Anti-ulcerogenics such as Ranitidine (5mg/kg p/o) and Omeprazole are tance of accurate history taking. If the patient fails to mask the severity of indicated as gastric ulceration may occur rapidly in a stressed rabbit. its illness it requires immediate intervention. It is important to house ill rabbits correctly. They need quiet quarters, To effectively triage such a diverse number of species it is important for away from possible predator species such as dogs. A bed of hay is often the veterinary technician to be knowledgeable in commonly kept exotic useful both as a good fibre source and as a familiar environment. A hiding species in their area, and be familiar with husbandry and care require- box or a covered area should be offered. Anorexic rabbits will often be ments for these species. This could feel overwhelming but separating the tempted to take fresh growing grass before any other foodstuffs. species into family groups can be useful, for example the Central Bearded Dragon family Agamidae contains numerous species of “dragons” CONCLUSION: An anorexic rabbit should be treated quickly and aggres- which will have significant overlap in husbandry requirements, anatomy, sively to prevent dehydration, hepatic lipidosis, acidosis and death. It is physiology, and clinical techniques. This can help the technician critically imperative to discover the underlying cause of the anorexia and address apply information known about a common species when presented with a this while supportive care is administered. Owners should be made aware species they are unfamiliar with. of the severity of the condition and should be educated on proper rabbit care and nutrition as many of the predisposing causes are prevented by To assess the urgency in which a patient needs to be seen an initial good husbandry. assessment of three major body systems should occur: the respiratory, circulatory and neurological systems. REFERENCES Airway: Is the patient breathing? Is the airway obstructed? In avian and Harcourt-Brown F. Textbook of Rabbit Medicine. 1st ed. Butter- small mammal patients respiratory arrest is quickly followed by cardiac worth-Heinemann, editor. Oxford; 2002. 19–51. arrest, so removal of the obstruction or gaining airway access via intu- bation or tracheostomy is critically important. Advantageously avian and reptilian/amphibian airways are easy to visualise as they lack an epiglot- tis, rather they have a glottis that sits caudal to the base of the tongue or tongue sheath. Intubation can be achieved with an un-cuffed endotracheal tube of an appropriate diameter. If the patient is very small intravenous (IV) catheters can be used with needle removed and connected to a 3.5mm ET tube connector. Unfortunately, small mammals particularly the small herbivores such as guineapigs, chinchillas and rabbits can be noto- riously difficult to intubate and even visualising the airway may be impos- sible without specialised equipment. If intubation is not possible in these patients, as they are obligate nasal breathers, ventilation may be achieved with a tight-fitting oxygen mask and positive pressure ventilation. Another useful piece of equipment for rabbits and soon to be guineapigs is the v-gel® advanced supraglottic airway device. In avian patients that present with a tracheal foreign body or granuloma 170 WSAVA GLOBAL COMMUNITY CONGRESS

and intubation is not possible, a catheter can be placed into the caudal air the back of the bird. Pulses can be digitally palpated in medium to large sac. Allowing the bird to ventilate, bypassing the trachea. birds feeling for the superficial ulna artery which runs parallel between the ulna and radius on the ventral aspect of the wing. MM and CRT are not Breathing: Assess rate and effort. Stressed or anxious patients will likely normally assessed in birds but in some species such as the chicken the be tachypnoeic. In reptiles sever respiratory distress may be seen with comb can be an indicator of perfusion. the animal lifting its head vertically with open mouth and exaggerated intercostal movement. This can be accompanied by noise and mucous Assessing circulation in our small mammal species is very similar to that production. Reptiles lack a diaphragm, have a primitive mucociliary lining of dogs and cats. Heart rates are varied depending on the species but are and primitive lungs with pythons only having a single developed lung. normally increased compared to dogs and cats due to high metabolism, Auscultating the lungs is difficult but vibrations can often be felt or heard and where bradycardia can be an indicator of decompensated shock. while examining the reptile. Small mammals have small thoracic cavities Normal rates for some commonly kept species are; rabbits: 130-325bpm, often with a large gastrointestinal tract. Any distension or pressure on the guinea pigs: 230-380bpm, chinchillas: 200-350bpm, and rats: 250- abdomen can place excess pressure on the diaphragm and reduce the an- 500bpm. The femoral pulse can be digitally palpated in most species and imal’s tidal volume. Most of the species are obligate nasal breathers, any MM and CRT can be assessed using oral mucosa. disease process that obstructs the nasal cavities can cause respiratory distress. If open mouthed breathing is observed immediate oxygen ther- Mentation: Assessing mentation is a very important aspect of triaging apy should be administered. Obstructed breathing patterns present like exotic pets. A scale ranging from BAR, QAR, obtunded, stuporous, and dogs and cats. Avian patients have an array of air sacs, pneumatic bones comatose is used to assess the level of responsiveness. Due to the and lungs allowing for unidirectional ventilation. Air will typically pass preservation reflex they may present with an improved mentation and through the nares into the trachea to the caudal air sacs, pass through the may deteriorate further when the patient is placed in a calm stress-free lungs and further into the cranial air sacs before being expelled via the environment. Although these patients may not respond in the same way a trachea and nares. For this reason, respiratory distress may present as dog or cat would to our presence or our voices, mentation can still be well open mouth breathing, a tail bob as the patient increases effort to draw assessed. Firstly, by a distanced exam, followed with interactions such air into the caudal air sacs and/or exaggerated movement of the cranial as handling for the physical exam to assess how they move, their body air sacs which in a healthy bird would usually be unnoticeable. If any signs conformation and reactions to their environment. In reptiles you may wish of respiratory distress are detected the animal should be supplied with to assess the righting reflex by placing the animal in dorsal recumbency. supplemental oxygen and placed in a calm stress-free area away from The animal should move to right itself quickly, if the reflex is sluggish or noise of traffic, dogs, and cats. absent then the mentation is poor. Circulation: Assess the patient’s heart rate and rhythm and further Reference list supplied on request. perfusion parameters: pulse quality, MM, CRT and extremity temperature. Assessing circulation in reptiles is particularly difficult. Firstly, auscul- tating the heart with a stethoscope is often unsuccessful due to the rigid scales and pockets of air between the scales and heart position. This is best done with a doppler as it can be utilised to evaluate flow of blood in multiple locations in the body. Reptiles have a three chambered heart con- sisting of two atria and one ventricle but under normal circumstances the heart can act like a four chambered heart with pressure differences and muscular ridges keeping oxygenated and deoxygenated blood separate. This unique anatomy does allow right to left and left to right shunting. A right to left shunt can affect pulmonary blood flow. Pulmonary pathology will predispose a patient to shunting due to an increase in pulmonary resistance. In many species of dragon and skinks the heart is located in the axillary region. Doppler position is best placed in the armpit directed toward the opposing ear or in what would be considered the “thoracic” in- let directed caudally. In monitors and turtles the heart is located centrally within the coelom, caudal to the forearms (Music & Strunk, 2016). In mon- itors probe placement directly over the heart is achievable but in turtles/ tortoises probe placement is achievable at the base of the neck directed centrally. In snakes the heart is located approximately 1/4 to 1/3rd of the snout to vent length. Probe placement can be placed directly over the heart which can be palpated easily in a debilitated snake. Normal heart rates will vary between species and also with body size and temperature. The presence of an audible heartbeat does not always indicate adequate circulation as a reptile heart will often continue to beat well beyond a patient’s compatibility with life. A better indicator of adequate circulation is to use the doppler to obtain distal pulses. Assessing mentation is helpful as many species have pigmented MM making assessing MM & CRT difficult. The Avian heart is larger than in mammalian species and the expected heart rate is often significantly higher. Heart rates are species depen- dent, determined by size and metabolism. For example, an ostrich heart rate is ~60bpm, while a sulphur crested cockatoo is 120-150bpm and a hummingbird is >1000bpm. Auscultating the heart is performed with a stethoscope with the bell positioned over the keel/pectoral muscles or on 171

13–15 NOVEMBER, 2021 0108 analgesic agents for the type and location of the pain. Reducing fear and stress, could be as simple as housing the animal in a warm private cage, EXOTIC ANIMAL ANALGESIA removed from other predator species. These patients may also benefit from an anxiolytic drug in addition to the analgesic protocol. Removing G. Fitzgerald the source of pain is often impossible but reducing an injury such as splinting a fractured limb can have a significant positive effect for the pa- Gatton/Australia tient. Lastly utilising a combination of drugs to fight pain and its effects. Drugs can be used to reduce inflammation and block or dull nociceptive Qualifications: impulses peripherally and centrally. We can achieve this with Opioids, Local Anaesthetics, NSAID’s, Alpha-2 agonists and NMDA-antagonistic Gary Fitzgerald drugs. In cases where we intend to cause the noxious stimulus i.e. surgery the patient should receive pre-emptive, perioperative and post operative BAppSc VT, RVT analgesia. [email protected] Opioids remain the mainstay of analgesic therapy in exotics. Opioids pro- duce analgesia by binding to opioid receptors within the central nervous EXOTIC ANIMAL ANALGESIA system. Analgesia is an often-neglected topic for exotics due to lack of informa- Reptiles have had limited research regarding opioid receptors. Aquatic tion and historical misinformation. Comparably with canine and feline turtles were shown to have Mu and Delta opioid receptors throughout the medicine, there is very little literature for the diversity of species. We un- brain with Delta receptors found to be more abundant. Kappa receptors derstand that all vertebrates have specialised sensory receptors (nocicep- were not identified anywhere in the CNS (Xia & Haddad, 2001). There is tors) capable of detecting noxious stimulus and initiating a physiological also limited pharmacokinetic/dynamic studies and we are only beginning response to the noxious stimulus. This process involves the peripheral to understand the efficacy of common opioid analgesics. Butorphanol, a nociceptors, a sensory pathway to the spinal cord dorsal-horn where it can kappa agonist and mu antagonist has been a long standing first choice be modulated and ascending and descending pathways to and from the opioid for reptiles, without any clinical evidence that it is an effective brain. In general people have a reduced ability to recognise pain in exotics analgesic agent. In recent studies Butorphanol was determined to have no due to behavioural adaptations and reduced anthropomorphic characteris- analgesic efficacy in a number of papers, using different methodologies, tics. Although, how exotic species perceive pain is unclear. Neuroanatom- including the species, red eared slider turtles, bearded dragons, green ic, neurophysiologic and behavioural data suggest they are physically and iguanas and ball pythons (Mader & Divers, 2013). While on the other hand functionally capable of experiencing pain. As veterinary professionals we Morphine (Mu agonist) had promising results in bearded dragons, turtles, therefore have, not only a moral obligation to provide effective analge- tortoises and anoles. Fentanyl patches have been shown to readily absorb sia, but also sound medical reasoning to do so. Uncontrolled pain has through reptiles skin with high plasma levels during patch application far-reaching consequences for our patients. Including adverse effects (Kharbush et al., 2017) but analgesic efficacy was not definitive. Tramadol on wound healing and the immune system but also reduced survival and has shown promising analgesic properties in turtles with higher range recovery rates. doses offering analgesia for up to 96 hours with seemingly no respiratory depression as seen with both mu and kappa opioids. Local anaesthetics Recognising pain is very subjective, in dogs and cats interpreting pain can have been successfully utilised in reptiles to perform ring and splash be more objective by following pain scoring guidelines. Unfortunately the blocks. Intrathecal administration between the coccygeal vertebrae has majority of exotic species, outside of research models (Rats, Mice, Rab- also been demonstrated in turtles for procedures of the tail, phallus, bits), standardised pain scoring charts are not available. Pair this with the cloaca or hind limbs (Mader & Divers, 2013). The diversity of species is a preservation reflex, diagnosing, treating and assessing the treatment of significant limitation for evidence-based analgesia of reptiles. Continued pain becomes very challenging. Due to the preservation reflex the species research is required to identify effective drugs, doses and duration for the will mask outward clinical signs of illness or pain to prevent predation. many species. This has been demonstrated in a research setting where some exotics species will display increased signs of pain when the researcher is not An early study found in pigeons a distribution of opioid receptors within observing within the room. Although the preservation reflex makes recog- the fore and midbrain of mu, kappa and delta similar to that of mammals nising pain more complex, these patients will often have altered or absent with the exception that 76% of the opiate receptors within the forebrain behaviours considered normal for that species. These include increases were kappa. Unfortunately there have been species dissimilarities noted of decreases in social interactions, guarding behaviours, aggression, therefore investigation is required. This may be why some avian patients grooming or appetite. When witnessing these behaviours they are very do not respond to mu agonists in the same way as mammals. It has also subtle until the patient passes a threshold where they can no longer mask been postulated that birds may not have distinct mu/kappa receptors or their pain making the behaviours far more obvious. that the receptors may have similar functions (Paul-Murphy & Hawkins, 2012). Morphine investigations in chickens have been clinically inconclu- This emphasises the need for veterinary professionals to remain well-in- sive, it was noted that the morphine was rapidly cleared and required high formed regarding new research in this area. Although research is limited doses to reach plasma concentrations expected to produce analgesia. due to the diversity of species, many of the commonly seen exotic pets A typical mammal dose of 0.5mg/kg IM was found to be cleared within have had pharmacokinetic and pharmacodynamic studies performed 10mins (Singh et al., 2010). Another mu agonist, Fentanyl a short acting for commonly used opioids. This research plays a significant role as a opioid, has shown promise as a CRI in red-tailed hawks but less promising starting point for analgesic planning for species within the same “family” in white cockatoos that only produced a analgesic response at high doses with multi-modal protocols assisting to prevent “break through” of pain. also causing hyperactivity in the patients (Paul-Murphy & Hawkins, 2012). Multi-modal analgesic plans can successfully dull or block nociception at Butorphanol has demonstrated reduced withdrawal effects in multiple multiple locations within the pain pathway as well as providing synergistic companion parrot species but with rapid elimination identifying the need effects between medications. for frequent dosing intervals or administration via CRI. NSAID’s are a very commonly utilised analgesic agent in avian patients, meloxicam is likely Controlling pain in exotics involves more than supplying analgesic agents. the most frequent due to its COX2 selectivity. These are also rapidly elimi- We need to focus our efforts on reducing the fear and stress of the patient, if possible, remove the source of pain and administer appropriate 172 WSAVA GLOBAL COMMUNITY CONGRESS

nated requiring a higher dose and more frequent dosing than in mammals. 0109 The main negative side effect reported is on renal tissues and function. Regional anaesthesia with local anaesthetics shows promise particularly ADVERSE REACTIONS TO FOOD for distal limb procedures. M. Chandler In small mammals butorphanol is still the most frequently used opioid even with its recent questionable efficacy and is considered a poor Glasgow/United Kingdom choice for moderate to severe pain. Pure mu agonists having proven to be excellent analgesic agents for moderate to sever pain but can cause dose Qualifications: dependent hypoventilation and reduced gastric transit time. NSAID’s are also commonly utilised with dose rates often higher then in dogs and cats Marjorie L Chandler due to the high metabolism and clearance by small mammals. DVM, MS, MANZCVS, DACVN, DACVIM, MRCVS As there is evidence of differing efficacies of analgesic agents in classes of species, or even sub species, it is impossible to confidently extrapolate [email protected] this data for the tens of thousands of species under the banner of exotics. Adverse reactions to food in dogs and cats most frequently present with In many cases veterinary professionals rely on anecdotal experiences to dermatological signs (cutaneous adverse food reactions or CARF) or gas- guide analgesic choices. This presents a unique challenge for the veteri- trointestinal (GI) signs. Adverse food reactions include food poisoning, nary professional food aversion, and non-immunological food intolerances (including dietary indiscretion) as well as true food allergy. ‘Food allergy’ is often misused to Kharbush, R. J., Gutwillig, A., Hartzler, K. E., Kimyon, R. S., Gardner, A. describe any reaction. True food allergy is a reproducible adverse reaction N., Abbott, A. D., Cox, S. K., Watters, J. J., Sladky, K. K., & Johnson, S. M. to a specific food, or less likely in pets, a food additive, with a proven (2017). Antinociceptive and respiratory effects following application of immunological basis. Food allergies or intolerances will both respond to transdermal fentanyl patches and assessment of brain μ-opioid recep- dietary manipulation. tor mRNA expression in ball pythons. Am J Vet Res, 78(7), 785-795. doi:10.2460/ajvr.78.7.785 Chronic small intestinal GI signs are common in dogs and cats. The term chronic enteropathy (CE) is commonly used now; with “inflammatory bow- Mader, D. R., & Divers, S. J. (2013). Current Therapy in Reptile Medicine el disease” (IBD) reserved for case with chronic GI signs and histopatho- and Surgery. Saint Louis: Elsevier. logical evidence of inflammatory cells in the GI tract (GIT). The underlying cause is not fully understood and is likely due to complex interactions Paul-Murphy, J., & Hawkins, M. G. (2012). Chapter 41 - Avian Analgesia. among genetics, diet, and the intestinal microbiome. In humans it is In R. E. Miller & M. Fowler (Eds.), Fowler’s Zoo and Wild Animal Medicine thought there is a dysregulation of the mucosal immune response to the (pp. 312-323). Saint Louis: W.B. Saunders. intestinal microbiome or to food antigens. Singh, P. M., Johnson, C., Gartrell, B., Mitchinson, S., & Chambers, P. A dietary aspect to CE is recognized; about 2/3 of the cases will respond (2010). Pharmacokinetics of morphine after intravenous administration to a diet change1,2,3,4. Many clinicians recommend a diet trial be per- in broiler chickens: Pharmacokinetics of morphine in broiler chickens. formed before using antibiotics or immunosuppressive medications, and Journal of veterinary pharmacology and therapeutics, 33(5), 515-518. often prior to endoscopy in cases with milder signs and serum albumin doi:10.1111/j.1365-2885.2010.01182.x within the reference range. Some clinicians feel that patients with food responsive disease are in a different category from those with true IBD, Xia, Y., & Haddad, G. G. (2001). Major difference in the expression of delta- however, dietary antigens may play a role in IBD. and mu-opioid receptors between turtle and rat brain. J Comp Neurol, 436(2), 202-210. doi:10.1002/cne.1061.abs Dietary proteins are the major source of food antigens. The inflammation in IBD likely increases intestinal permeability and contributes to antigenic exposure; however, the GIT is impacted directly by diet more than any other body part. It is affected by nutrients, frequency and timing of meals, and effects on the microbiome. In addition to allergens, diet may contain toxins, nutritional excesses or deficiencies. Diet also has a direct effect on GI physiology, affecting motility, cell renewal rate, enzyme production, immune functions, ammonia production, and volatile fatty acid content. Gastrointestinal signs did not recur after challenge with previous diet in 20% of cats which had resolution when fed an elimination diet5. One study proposed that antibiotic residue in foods may cause signs of otitis, diarrhoea, generalised anxiety, and dermatitis6. Therefore, factors other than food allergy or intolerance may affect clinical improvements often seen with a diet change. Diagnosing adverse reactions to food (ARF) Many clients request homemade diets or diet recommendations based on blood antigen tests for food allergy. These tests, including the saliva test, food specific IgA and IgM and ELISA serum test for food specific IgE are not reliable diagnosing canine ARF7.8. Due to false positives, these tests can make finding or formulating an appropriate diet more challenging as they erroneously limit ingredient choices. Diet trials with elimination diets remain the reference standard for ARF diagnosis. 173

13–15 NOVEMBER, 2021 Diet trial containing a variety protein sources had ~ 88% initial response to either diet. Of the dogs challenged with their original diet. about 2/3 relapsed. Dietary trials confirm or rule out ARF but do not establish an immune me- While the diets showed similar initial responses, at a long term follow up diated basis, although that does not affect case management. Previously (median 3.5 years), the dogs on the hydrolysed diet (13/14 dogs) were fed ingredients should be avoided or a hydrolyzed protein diet fed. more likely to in be remission compared to those on the intestinal diet (1/6 dogs). The dogs on the intestinal diet may have become sensitized to Absolutely no other foods or ingredients should be fed during the diet trial diet ingredients, as four improved when put on the hydrolysed diet4. as this makes it impossible to confirm that diet is part of the problem. Counselling the owner on feeding management, including the feeding In eight cats with IBD, a hydrolysed protein diet resulted in resolution of treats, snacks, or food to give medications is a key to success. Unlike clinical signs within 4 to 8 days; a challenge with a previous diet resulted patients with CARF where the diet should be fed for 6-12 weeks, pets in recurrence of the clinical signs3. with gastrointestinal signs that respond to elimination diets usually do so within 2 weeks, although rare patients may require 4-6 weeks. Diet Challenge Which diet– novel protein/ingredients, hydrolysed protein, To confirm an adverse reaction to food a re-challenge/provocation is nec- or homemade? essary. The initial food is re-introduced or individual ingredients from the initial diet are added singly. Gastrointestinal disease cases usually react There are generally two diet trial methods: “novel” ingredient or hydrolyzed within several days; pets with CARF may take longer. Many clients do not protein diets. In cases where neither commercial diet option will work, want to challenge; the pet can stay on the test diet if it is complete and a homemade diet formulated from novel ingredients, especially a novel balanced, or another novel protein complete diet can be tried. protein source, can be used. Unless formulated by a veterinary nutritionist, these are likely to be incomplete and unbalanced. Long term use is not Long Term Management recommended without formulation for nutritional completeness. In dogs with protein losing enteropathy (e.g. lymphangiectasia), a low fat diet While each pet and owner should be treated according to their needs, it should be fed. Some cases may require a homemade diet if novel ingredi- is reasonable to use hydrolysed diets as a diagnostic tool to determine if ents are also required. there is a dietary component to the disease. There is evidence of better long term control with a hydrolysed diet in dogs with food responsive CE, A good commercial diet is usually preferable to a homemade diet as it is although these diets can be expensive and the owner may not wish to not possible to replicate the quality control of a good commercial diet. continue them. The feeding trial of a homemade diet is also on that patient, whereas many good commercial diets have undergone feeding trials and research As noted in the Guilford et al., 2001 cat study5, some patients may be able trials. Further, many owners do not stick to the diet formulation of a to return to a previous diet. While no studies have provided good evidence homemade diet, termed recipe drift, which may result in a previously well when the diet may be changed, one recommendation is to feed the diet formulated diet being incomplete or unbalanced. which has resulted in clinical improvement for 6 to 12 months, then add a single protein source. If a protein is found which the pet tolerates, select a Novel protein diets commercial diet accordingly. In 50% of cats with CE, clinical signs improved, usually within 4 days, after Chronic enteropathies are a heterogeneous group of disorders, so man- being fed a highly digestible novel protein diet. In 20% of these cats the agement recommendations need to be individualized. Similar individual signs did not recur after challenge with their previous diet5. In 65 dogs management is recommended for CARF. The use of a hydrolysed diets with chronic GI signs, 60% responded to a novel protein diet fed for 10 trial is recommended as a diagnostic tool and first therapy in less severe days9. Many pets with CE respond to highly digestible novel protein diet. GI cases, and long term management with them may provide better quality Some may be able to return to a previous diet, perhaps due to a resto- of life and longer survival time. ration of normal mucosal immunity or other beneficial changes in the intestinal environment. References available upon request Hydrolysed protein diets The protein in these diets has been hydrolysed enzymatically to small peptides, which are less allergenic than entire proteins. Available diets include hydrolyzed chicken, soy protein, potato, feather or a combination of these. Development of an antigenic response to a small part of the peptides may still be possible; some diets are formulated with very small peptides and/or amino acids to minimize this. As many pets have been exposed to a variety of dietary proteins, feeding hydrolysed diets overcomes the challenge of finding a novel protein source. It is still possible, although uncommon, for a pet sensitive to the protein source in the hydrolysate to have an adverse reaction. In one study, 3 of 14 soy sensitive dogs fed a hydrolysed soy diet showed a dermatological reaction10. In some cases using a diet with a very small particle size or avoiding the previous dietary protein may be necessary. There have also been cases which failed an elimination diet with intact protein diets which then did respond to a hydrolysed protein diet2. In patients with severe intestinal disease hydrolyzed diets may improve nutrient absorption as well as decrease antigenic exposure11. In 26 dogs with CE signs fed a hydrolysed diet or a highly digestible “intestinal” diet 174 WSAVA GLOBAL COMMUNITY CONGRESS

0110 1. Food intake: days of inadequate nutrition, as defined by < 80% RER intake for > 3 days NUTRITIONAL SUPPORT IN THE HOSPITALIZED PATIENT 2. Presence of anorexia, as defined by zero voluntary food intake for 24 hours or at first feed each morning M. De Scally 3. ≥ 10% weight loss from original weight prior to illness Hilton/South Africa 4. Severe vomiting or diarrhoea Qualifications: 5. Body condition score ˂ 4/9 Martin Patrick de Scally 6. Muscle condition score ≤ 2/3 BVSc MMedVet(medicine) Onderstepoort 7. Hypo-albuminemia [email protected] Nutrition of in hospital patients 8. Estimated length of expected course of illness likely to affect any of the above 7 parameters for > 3 days Introduction What does the score mean? This lecture will introduce a tool to help alert care givers of the need for a nutritional intervention for their in-hospital patients. The tool is called a A score of 1 is designated 1 to each abnormal parameter. The range of Nutrition Severity Index (NSI) and is an indicator of risk of malnutrition in NSI would be 0-8. Two or greater indicates that a nutritional intervention hospitalised veterinary small animal patients. of some sort is indicated. The score is monitored to assess the effective- ness of the intervention. A decreasing score indicates the intervention or Why do we need a tool for this? disease resolution is successful. A score of 0 and 1 indicates mild risk of in hospital malnutrition, and 2 or greater indicates increased risk. An Nutrition is listed as the fifth vital assessment in all patients by the increasing NSI could indicate disease progression, inadequate, or even ex- WSAVA5. Nutrition tools have been published describing standardised cessive nutritional intervention. Excessive nutrition can lead to increased nutritional assessments and nutrition planning5. Despite this, publications vomiting, diarrhoea, hyperglycaemia, and, or refeeding syndrome4 have documented malnutrition in hospitalised patients6. In an online survey conducted in 2018 in Clinicians Brief only 4.1% of respondents . (98 of 2388) used a systematic nutritional assessment in hospitalised patients. In the same survey only 54.7% of respondents (1339 of 2390) How does a veterinary hospital practically introduce the did any form of nutritional assessment in hospitalised patients7. These score? suboptimal findings indicate that a more objective assessment of risk of malnutrition is necessary for veterinary as has been attempted in human Adequate, and accurate in hospital nutrition records are necessary. Cur- medicine2. rent diet, prescribed diet, amount to be fed, method of feeding and when, are essential. We use the formula RER (kcal/day) = 70 X BM (kg)0.75 to In hospital nutrition is simple and effective if it gets the determine RER. Secondly the 8 parameters making up a NSI are scored attention it deserves and documented. If the score is 0, the patient is merely monitored for a change. If the score is 1 appropriate nursing is implemented to en- A tool cannot replace common sense. Animals with the inability to courage eating. If the score is 2 or greater a nutritional intervention is prehend food and water or an animal with hypoglycaemia would need implemented. In these patients the score is monitored, and appropriate appropriate, immediate interventions. Unless starvation is planned for further action is initiated. The patient is offered food at the first feed of surgical reasons all hospitalised animals should have their resting energy each morning to establish anorexia or hyporexia. Once RER is met by a requirements (RER) calculated, an appropriate diet prescribed and feeding nutritional intervention, for example a feeding tube, the patient scores 0 instructions written for them on their hospital chart4,5,9. Actual amount for parameter number one, but may still score for anorexia if they refuse eaten must also be recorded, and if insufficient, an assisted feeding plan their oral food offering. The decision to remove the tube is based on the should be implemented5. Importantly total water intake is also monitored patient’s ability to meet RER voluntarily. to avoid over or under hydration. Assessing a critical care patient for risk of malnutrition: What sort of nutritional intervention is appropriate? Proposed NSI The simplest form of a nutritional intervention is increasing diet palatabil- Eight parameters that potentially place in hospital patients at risk of mal- ity, nursing and hand or syringe feeding. Food aversion and inadequate nutrition are listed below3. It is suggested that if any two of these parame- nutrition are potential problems with this technique. The WSAVA nutrition ters are present in a diseased patient, they should have a formal nutrition committee has published tools that are available on the WSAVA website assessment performed on them and a formal nutrition plan instituted and that guide veterinary care givers on the selection of tubes for patients monitored3. Omited markers of malnutrition, such as serum transferrin, at risk of in hospital malnutrition, as well as videos demonstrating tube are not readily available in practice8. The eight parameters considered are insertion. There are some intricacies in selecting the exact tube type and shown in table 1. technique (https://wsava.org/wp-content/uploads/2021/04/WSAVA-Glob- al-Nutrition-Toolkit). The simplest and most common tubes used in hos- Table 1 The eight parameters making up an NSI pital are naso-gastric or naso esophageal-tubes. They are the simplest to place, have low complication rates, and are easy to use with liquid diets. Upper respiratory tract disease and an unresolved bleeding tendency may be the most important concern for a nasogastric tube. If indicated, the 175

13–15 NOVEMBER, 2021 distal end can be inserted through the lower oesophageal sphincter for Plasma Transferrin Concentration as a Nutritional Marker in Malnourished gastric suctioning. Nasal tubes can be uncomfortable for some patients Dogs with Nutritional Treatment. J Vet Med Sci. 76:539–543 and their diameter is limiting. They are usually only used for short term intervention with a functional intestine from the oesophagus down. Be 9. Chan DL 2004 Nutritional requirements of the critically ill patient. Clini- warned a tube can enter the trachea even in an intubated animal with the cal Techniques in Small Animal Practice 9:1-5 cuff appropriately inflated. The author only considers a feeding tube safe for use after radiographic evidence of correct placement. Oesophagosto- 10. Shigeyuki Nagata etal 2009 Comparison of enteral nutrition with com- my tubes or if gastric suction is indicated oesophageal-gastric tubes are bined enteral and parenteral nutrition in post-pancreaticoduodenectomy technically more difficult to place, require general anaesthesia and need patients: a pilot study. Nutr J.; 8: 24 to be maintained, but are usually more comfortable and can have a larger internal diameter and are therefore less limiting. Feeding tubes are used in diseases where vomiting is common and feeding through the vomiting has been shown to improve survival, such as canine parvo viral enteritis and pancreatitis. Naso-oesophageal, naso-gastric, oesophagostomy and oesophageal-gastric tubes are contraindicated in most oesophageal dis- eases. For selected cases where gastric bypass is indicated oesophageal jejunal tubes can be placed endoscopically. In the case of a non-functional oesophagus a gastrotomy tube is indicat- ed. These are technically more difficult than oesophageal entry tubes and have more complications if leakage occurs. In the right hands they are more useful than oesophageal entry tubes for some cases and can be inserted endoscopically. In some cases where gastric function is compro- mised, or gastric vomiting cannot be controlled, jejunal tubes are inserted. The placement of a jejunal tube is considered a specialist procedure. Gastrotomy and jejunal tubes have the highest price for leakage compli- cations. If a NSI is still increasing after appropriate tube feeding and appropriate treatment of the underlying disease, parenteral nutrition is indicated. In veterinary medicine this discipline usually attempts to meet 50% of the patient’s energy requirements with added benefit of containing lipid and some of the essential amino acids required for survival10. Due to high septic and thromboembolic complications of parenteral nutrition, the lack of researched veterinary dedicated products, and all the superior benefits of enteral nutrition, enteral nutrition is the preferred route where possible. The take home message is, develop a nutrition plan for every patient and monitor it. React to those that require so early, with appropriate interven- tions. Monitor these patients’ response and react accordingly. References: 1. Barker JP, Detsky AS, Wesson DE etal 1982 Nutritional assessment: A comparison of clinical judgement and objective measurements. New England Journal Medicine 306:969-972 2. Brunetto MA, Gomes MOS, Andre MR et al 2010 Effects of nutritional support on hospital outcome in dogs and cats. Journal of Veterinary Emergency and Critical Care 20:224-231 3. Chan D, Freeman LM. 2006 Nutrition in critical illness. Vet Clin North Am Small Anim Pract 36:1225 4. Dickerson RN 2011 Optimal caloric intake for critically ill patients: First do no harm. Nutrition in clinical practice 26:48-54 5. Freeman L, Becvarova I, Cave N etal 2011 WSAVA Nutritional Assess- ment Guidelines. Journal of Small Animal Practice 52:385-396 6. Heyland DK, Dhaliwal R, Wang M etal 2014 The prevalence of iatrogenic underfeeding in the nutritionally ‘at-risk’ critically ill patients: Results of an international, multicenter, prospective study. Clinical Nutrition doi: 10.10.16/j.clnu,2014,07.00 7. Lumbis R, de Scally MP 2020 Knowledge, attitudes and application of nutrition assessments by the veterinary health care team in small animal practice JSAP 60:494-503 8. Nakajima M, Ohno K, Goto-Koshino Y, Fujino Y and Tsujimoto H 2014 176 WSAVA GLOBAL COMMUNITY CONGRESS

0111 Firstly, there is a fundamental shift in the locus of responsibility for them. They need to have an overt appreciation that the solutions to adaptive ADAPTIVE LEADERSHIP FOR A HAPPY, HEALTHY & challenges reside in the collective intelligence of the team, not in their PRODUCTIVE WORKPLACE. mind or that of the most senior figure in the building. M. Powell Secondly, the veterinary leader needs to be comfortable with not reflexive- ly rescuing the team from uncertainty. This is a challenge for knowledge- Sydney/Australia able and caring medical professionals. In particular, leaders need to try to avoid entering the Drama Triangle, a social model of human interaction Qualifications: proposed by Stephen B. Karpman, where he describes our tendency in conflict to play one of 3 roles: Rescuer, Persecutor or Victim. Dr. Michael Powell 90% of us adopt the Rescuer role when we see the team around us Bachelor of Veterinary Science (First Class Honours) struggling. This involves stepping in, taking responsibility and resolving challenges or issues that may arise. A smaller percentage either start [email protected] pointing the finger and blaming people for not being able to find a solution quickly enough (The Persecutor) or play the Victim and refuse to accept WHAT IS ADAPTIVE LEADERSHIP? that a win-win solution to the challenge exists at all. Nothing tests leadership ability quite like navigating with a veterinary An adaptive veterinary leader lets the team around them also shoulder team through challenging and uncertain times. the responsibility of learning new relationships, new connections and new ways of working when a challenge requires it. In truth, adaptive leaders Every veterinary practice, and the team within it, goes through moments of speak less and instead, learn to ask better questions. As opposed to upheaval and uncertainty as they grow and evolve. Similarly, the veterinary instinctively quelling conflict, they use well-crafted questions to artfully industry itself goes through challenges and periods of significant change promote conflict to draw the issues out. at a regional, national and sometimes global level – complications arising from the COVID-19 pandemic as an excellent case in point. THE 6 STEPS FOR LEADING THROUGH AN ADAPTIVE CHALLENGE Research by leadership experts, professors and authors Ronald Heifetz and Marty Linsky formed the basis for the theory of Adaptive Leadership. Letting go of an authoritative leadership style in certain situations can be It is a practical leadership framework designed to help individuals and difficult. To assist with the transition it can be helpful to follow a 6-step organisations not just navigate uncertainty and change more effectively, framework, developed by Heifetz and Laurie, for more effectively leading but to embrace it. others through an adaptive challenge. Embracing this adaptive approach as a leader allows veterinary teams to 1. Go to the balcony more rapidly and successfully adapt to challenges, while staying true to their practice values and deeper purpose. Great leaders have to be able to view patterns as if they were on a balcony – this is a prerequisite for the next 5 steps. What this means to not be TECHNICAL VERSUS ADAPTIVE CHALLENGES swept up in the field of play. Rather, step back from the challenge, even if it’s temporarily, and develop a higher level perspective. In their work on adaptive leadership, Heifetz and Linsky made an import- ant distinction between technical and adaptive challenges. Having the capacity to move back and forth from the balcony to the “dancefloor” is critical to ensuring you don’t get caught up in the emotion Technical challenges can be straight-forward or complex, and they present and fine details. From a distance you can better spot emerging patterns, a clear problem that can be solved through existing knowledge and the such as dysfunctional reactions to the change. Rather than stepping in experience. They are typically addressed by application of authoritative and playing the rescuer, you can more effectively seize these perfect expertise and through utilisation of current procedures and organizational opportunities to coach team members through difficulties. structures. 2. Identify the challenge Adaptive challenges are complex, difficult to clearly define and often involve an organisational failure. They require solutions that are almost This is the often the hardest part of the process. The leader’s own expe- never found soley within the leadership structure, but rather the broader rience, biases, and pre-conceived notions so often stand in the way of veterinary team, including sometimes an amalgam of thoughts from every seeing a root problem for what it really is. level. If an organisation is repeatedly facing the same kind of upheaval, it is likely an indicator of an unresolved adaptive challenge. These challeng- Exploring where the conflict lies is the key to better defining the challenge es test our belief system, our values and lie at the heart of the philosophy with the team. It is also important for the leader to determine what part of ; “what got us here, won’t get us to where we need to be”. they themselves may be playing in the challenge. The best rule of thumb; If they are not part of the problem, they can’t be part of the solution. An excellent indicator of an adaptive challenge is recurring conflict in a practice. It’s this conflict that so often results from a failure to address 3. Regulate Distress the true nature if the issue. Adaptative challenges call upon true leader- ship, not just authoritative expertise. They are the ultimate test of the ego Step 3 refers to the skill in finding the right balance between ensuring of leader who either thinks they have the answer to everything, or at the people feeling motivated to change, without them feeling overwhelmed by least believes they need to. At it’s core adaptive leadership is about asking it. It can be a delicate balance to achieve. better questions. A leader must sometimes suppress their own sense of urgency and CHARACTERISTICS OF AN ADAPTIVE LEADER instead, carefully consider the sequence and pace of work being done by the team as they navigate through the process. It’s important that they Adaptive leaders have distinctive characteristics. also maintain productive tension at this time; think of it like a pressure cooker in which things won’t cook unless the temperature is dialled up a 177

13–15 NOVEMBER, 2021 little, occasionally letting off a bit of steam. 0112 After turning up the temperature, the adaptive leader needs to set the VETERINARY STUDENT WELLBEING & direction and protect the team by controlling the pace of change. It is TRANSITIONING INTO THE PROFESSION. important they keep the team orientated towards the practice’s priorities, manage conflict and help to shape new norms in the process; all of which M. Peterson can be achieved by framing questions more effectively. Washington,/United States of America 4. Maintain Disciplined Attention Qualifications: This step refers to ensuring the team are disciplined around tackling divi- sive issues that arise over the period the change takes place. This process As a member of their senior leadership team, Makenzie Peterson serves will may involve facilitating difficult compromises in values, accepted as the Director for Wellbeing at the American Association of Veterinary procedures, and standards for many involved. Avoidance of laying blame Medical Colleges (AAVMC). She works to advance AAVMC’s strategic or denial is important. goal of fostering a culture of wellbeing throughout academic veterinary medicine by promoting preventative systems-based initiatives. Maken- The secret is to maintain beneficial tension by getting conflict out in the zie provides subject-matter expertise on the science and application open and use it as a source of creativity. The easiest way to do so is to of evidence-based wellbeing practices, as well as the development and continue to raise tough questions in order to sustain enough pressure implementation of strategic organizational changes to improve the overall to resist the tendency to slide back into the old, familiar ways of doing wellbeing of academic communities. She speaks on a variety of wellbe- things. ing-related topics, and also currently serves on the Board of Directors for the Women’s Veterinary Leadership Development Initiative. Born and 5. Give the work to the team raised in Alaska, Makenzie graduated from the University of Utah with a master’s degree in Health Promotion & Health Education and will complete The adaptive leader needs to ensure support of the team rather than her Doctorate of Social Work from the University of Southern California in control of them. They can enhance the development of their team through 2022. better self-regulation and remaining on the balcony. Makenzie Peterson: [email protected] When team members create their own solutions and see it through to a Veterinary Student Wellbeing & Transitioning into the Profession resolution, the collective self-confidence that results helps them to be- come more self-reliant. Encouraging them to take ownership of problems The student experience has its ups and downs – from their entrance into and the solutions, in an environment where it is safe to fail, also results in their medical training, the classroom and clinic experience, to graduation a team that embrace change rather than fearing it. and their debut into the profession. Students can experience a variety of stressors during their education, but there are stressors once they enter 6. Protect the voices from below. the profession that they may not anticipate. Does the curriculum ade- quately prepare students to enter the profession? How can the transition Giving a voice to all people is the mark of a practice that is willing to into the profession be better supported? Systemic barriers and solutions experiment and learn. Leaders need to be careful not to silence those will be discussed on how to improve the student experience and better prepared to call-out contradictions of values within the business, as their support new professionals. perspectives can promote fresh thinking and dialogue. This principle is also about acknowledging the power dynamic that exists within teams ; specifically, awareness of whether people at all levels are feeling psychologically safe to speak up. In other instances they may feel safe to share their view but may not be as articulate as others. Leaders need to resist any impulse to dive in and speak for them but rather be prepared to explore what this person is really trying to articulate. LEADERSHIP IS LEARNING Like any skill, adaptive leadership abilities can be developed. It requires repetition and constant learning on the part of the veterinary leader as well as the team they work alongside. REFERENCES Gilbert et al. (2006). Teaching Non-Clinical (Professional) Competence in a Veterinary School Curriculum. J Vet Med Educ. Summer 2006; 33(2):301-8. Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard Business Press. Karpman, S.B.. (2014) A Game Free Life. Drama Triangle Productions. 178 WSAVA GLOBAL COMMUNITY CONGRESS

0113 Animals (OIE) https://www.oie.int/en/what-we-offer/emergency-and-resil- ience/covid-19/ that are great for tracking the progress of the COVID-19 SARS-COV-2 UPDATE AND ONE HEALTH pandemic in both people and small companion animals. The OIE website COMMITTEE REPORT can be used to track cases in animals around the world. Worldwide health organizations like the CDC in the United States still report that the risk M. Lappin of animals spreading COVID-19 to people is likely to be low. Specific recommendations for handling animals during the pandemic are available Fort Collins/United States of America in some countries, including the CDC in the United States. https://www. cdc.gov/coronavirus/2019-ncov/daily-life-coping/animals.html?CDC_AA_ Qualifications: refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2F- animals%2Fpets-other-animals.html. Michael R. Lappin Using information from client-owned pets combined with information DVM, PhD, DACVIM (Small Animal Internal Medicine) gathered from a growing number of experimental infection studies, doc- ument that both dogs and cats can be infected by SARS-CoV-2. Clinical [email protected] signs in adult animals have been unusual. However, signs of respiratory  In the early part of 2021, COVID-19 continued to be a priority for the disease like sneezing or coughing of acute onset and acute vomiting or OHC and our committee members partnered with Dr. Mary Marcondes diarrhea in dogs or cats can occur. Myocarditis may also be a newly rec- of the Scientific Committee and Dr. Richard Squires of the Vaccination ognized clinical syndrome in animals. Most cases investigated in pets to Guidelines group to produce and number of webinars and updates for the date have been from homes with people showing signs of COVID-19 and WSAVA membership through the regular Eshots. signs in pets have been self-limited. In one experimental study of dogs, live viral shedding was not detected. Cats also limit infection very quickly In 2021, the OHC also had a focus on domestic violence as a key One (< 2 weeks) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585007/. Health issue. Dr Melinda Merck, forensic veterinarian and former Co-chair The data collected to date suggest that infected dogs or cats are unlikely of the WSAVA Animal Wellness and Welfare Committee lead this focus to be the source of SARS-CoV-2 that initiates infection in people. WSAVA with 2 lectures in the OH stream at #WSAVAPoland and a webinar. The recommends that our member associations work proactively with their OHC plans to continue this collaboration with a pre-Congress workshop regional and national Public Health groups to provide accurate informa- planned for Peru in 2022. tion concerning the low risk of transmission of SARS-CoV-2 from small companion animals to people. Small companion animals from homes with As we move towards 2022, the focus of the OHC will move back into people with COVID-19 should not be relinquished, euthanized, or otherwise zoonoses and infectious disease with the emphasis being placed on harmed. SARS-CoV-2 shedding will self-limited as in the owners. To date, finalizing the WSAVA Zoonoses Guidelines. These guidelines will follow no specific treatment of dogs or cats with SAR-CoV-2 has been reported. the format of the Vaccination Guidelines with a modular main document that contains the core messages and sections for different regions with Thankfully, over recent months many countries around the world have specific risks. The aim is to make the guidelines practical and easy to use made great progress in distribution and administration of SARS-CoV-2 and the OHC hopes to have the online posting by the end of 2021. Work vaccines to the owners of small companion animals. https://www.who.int/ will then start on the development of the related Small Companion Animal emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines. The Zoonoses phone app, to support physicians and primary care vets with administration of a booster vaccination to some groups of people is now accurate information, bedside. This launch is anticipated to be during approved or recommended for some of the SARS-CoV-2 vaccines (Pfiz- 2022. The OHC will maintain its focus on rabies control and SARS-CoV-2 er-BioNTech, Moderna and Johnson & Johnson) used in many countries. as always. https://www.fda.gov/emergency-preparedness-and-response/coronavi- rus-disease-2019-covid-19/covid-19-vaccines Having effective vaccines Dr Ben Young, a primary care physician and HIV specialist, plans to join Dr for people is great news for animals as it still appears that most new Lappin in writing a piece for American Family Physician on the impact of infections of small companion animals come from an infected person, pets on immune-suppressed people with an anticipated publication date usually presumed to be the owner. Vaccination of people should directly of early 2022. lessen the risk of SARS-CoV-2 in animals. Colorado State University has a new Fellowship in One Health to support Researchers announced the release of a vaccine for potential use in the Committee’s work in comparative gastroenterology. Dr. Alison Man- companion animals in Russia and this was discussed in the WSAVA Eshot chester is an ACVIM diplomate sponsored at CSU by Boehringer Ingel- in April https://www.reuters.com/article/us-health-coronavirus-russia-vac- heim. She will be welcomed to the OHC as an affiliate and is scheduled to cine-ani/russia-registers-worlds-first-covid-19-vaccine-for-animals-watch- lecture in the OH stream at this year’s virtual congress. dog-idUSKBN2BN0MY. Shortly thereafter, Zoetis Animal Health announced another experimental vaccine that could be used to potentially protect The One Health Certificate course that was one of Emeritus Professor multiple species against SARS-CoV-2. https://news.zoetis.com/press-re- Michael Day’s dreams was completed by Dr. Lappin and the OHC with out- leases/press-release-details/2021/Zoetis-Donates-COVID-19-Vaccines- side experts and is still available at (col.st/WSAVAOneHealth). The first 65 to-Help-Support-the-Health-of-Zoo-Animals/default.aspx Zoetis Animal certificates of completion have been awarded in 2021 and the course is Health has donated thousands of doses of the vaccine to zoos and animal now being refreshed and transferred to the WSAVA Academy website. sanctuaries around the world for administration to non-human primates as these species can develop severe COVID-19. The new focal points for the OHC in 2022 and 2023 will be nutrition issues, including comparative obesity, and an expansion into the environ- mental aspects of One Health. SARS-CoV-2 update. There are many websites around the world like the World Health Organiza- tion https://www.who.int/emergencies/diseases/novel-coronavirus-2019, the Center for Disease Control and Prevention (CDC) https://www.cdc. gov/coronavirus/2019-ncov/index.html, and the World Organization for 179

13–15 NOVEMBER, 2021 0114 is maintained in the environment by a wildlife cycle that includes canids as definitive hosts and rodents as intermediate hosts. E. multilocularis ENTERIC PARASITIC ZOONOSES causes alveolar echinococcosis in humans. V. Scorza Echinococcus granulosus, Echinococcus ortleppi, Echinococcus canaden- sis and Echinococcus intermedius have worldwide distribution and cause Fort Collins/United States of America cystic echinococcosis in humans and animals. Qualifications: Hookworm infections: Ancylostoma caninum, Ancylostoma braziliense and Uncinaria stenocephala are common parasites of dogs and cats. Andrea Valeria Scorza Hookworm infections are highly prevalent in low-income countries located in tropical and subtropical regions. In Asia, A. ceylanicum, is a common Medica Veterinaria, PhD. parasite of dogs and the second most common hookworm species infecting humans in Southeast Asia. Therefore, Ancylostoma ceylanicum [email protected] is considered an emerging parasite in the region. In humans the infection Cats and dogs are considered family members in the majority of the usually occurs after the larva penetrates the skin causing cutaneous larva industrialized countries. It is currently recognized that companion animals migrans but do not develop any further. Occasionally, in cases of massive have an important role in the psychological and physiological well-being infections, the larvae may migrate to the human intestine, causing eosin- of people. Regardless of these undisputable benefits, pet ownership may ophilic enteritis. The infection can also occur after ingestion of larvated be associated to potential health risks. Pets can act as reservoirs for zoo- eggs from the environment or by ingestion of other vertebrate hosts that notic pathogens that can be transmitted to people. The risk of becoming have consumed larvated eggs and have larvae in their tissue. In dogs, sick is variable and depends on the pathogen and the immune system of transmmamary transmission also happens. the host. People at high risk of infection are children under age of 5, older adults (age ≥ 65 yr), pregnant women, and people who are immunocom- Giardiosis: Giardia duodenalis is one of the most common parasites de- promised. Veterinarians and people working with animals are also at high tected worldwide and the species that infects most mammals. G. duode- risk of acquiring zoonotic infections. The most relevant enteric zoonotic nalis is considered a species complex that is comprised by several assem- parasitosis are toxocariosis, echinococcosis, giardiosis, hookworm infec- blages, some of them are zoonotic (A and B) and, some are host specific. tions, cryptosporidiosis, and toxoplasmosis. Most of these parasitosis Dogs, in general, harbor dog-specific assemblages C and D and cats are have global distribution and are considered neglected diseases. A sum- most commonly infected with the cat specific assemblage F. However, mary of each of these parasitosis in cats, dogs and humans, along with both cats and dogs can harbor zoonotic assemblages. A metanalysis preventive measures to avoid the transmission is described in this lecture. study reported a prevalence of 15 % and 12% of Giardia for dogs and cats respectively. In the case of dogs and cats, transmission of Giardia cysts Toxocariosis: Toxocara canis and Toxocara cati are common parasites in occurs by ingestion contaminated food and water, transport hosts, and dogs and cats that can also cause disease in humans. Infection occurs infected prey species. Humans usually acquire the infection by drinking after accidental ingestion of infectious eggs from contaminated soil, food contaminated water or performing recreational activities (swimming). or water. Ascarid eggs may remain infectious for years in an appropriate Therefore, the risk of zoonotic transmission from pets is low. Giardiosis environment and can cause infection to dogs, cats, and a wide variety of can be symptomatic or asymptomatic and treatment of infected dogs and vertebrate paratenic hosts, including humans. When larvae are ingested cats should be evaluated on an individual bases. by paratenic hosts, they are incapable of completing their life cycle and travel to different organs causing sometimes inflammatory responses or Toxoplasmosis: Toxoplasma gondii is considered one of the most import- remaining entrapped in the body for years. Infection can also occur after ant zoonotic pathogens. Cats are definitive hosts of T. gondii and only ingestion of undercooked meat or viscera with the infective larvae or after shed oocysts once in a cat’s life for a period of two weeks. Dogs, humans ingestion of infected paratenic hosts. Toxocariosis is more prevalent in and a large variety of animals are intermediate hosts. Clinical disease is tropical climates, and it is associated to poverty and is more common rare in cats, but can occur if immunosuppression occurs. Humans can ac- in children due to pica and coprophagia. In cats and dogs, prevalence is quire the infection after ingestion of contaminated meat, feces, soil, and higher in young animals and shelter animals. Toxocara spp. cause visceral water. Toxoplasmosis is a systemic disease that causes granulomatous and ocular larva migrans. An association between Toxocara seropositiv- inflammation in several organs. Immunocompromised individuals and ity and pulmonary disease (asthma and lung dysfunction) and Toxocara pregnant women must avoid infection. seropositivity and neurologic disease (epilepsy to cognitive delays) was reported in humans. Therefore, it is important to better comprehend the Cryptosporidiosis: Cats and dogs can harbor strains of Cryptosporidium connections between serological diagnosis of human toxocariasis and that are host specific and other strains that can be transmitted to humans. clinical findings Cats and dogs are usually infected with host-specific C. felis and C. canis respectively. Humans generally acquire Cryptosporidium spp. by drinking Echinococcosis is a severe zoonotic disease caused by several cestode contaminated water during recreational activities, or by direct contact species belonging to the genus Echinococcus. The genus Echinococ- with infected cattle. Humans are usually infected with C. hominis and C. cus is comprised of eight accepted species and one genotypic cluster parvum. Therefore, the risk of zoonotic transmission from pets is low. (Echinococcus canadensis cluster). Each Echinococcus species has its Cats and dogs can become infected by ingesting contaminated food own transmission cycle depending on the hosts available in a particular and water or by carnivorism; young and shelter animals are at higher risk geographic location. The definitive hosts are carnivores (dogs for Echino- of acquiring the infection. Cryptosporidiosis can cause diarrhea or be coccus granulosus and foxes for E. multilocularis), and the intermediate asymptomatic. Treatment of infected dogs and cats should be evaluated hosts are usually herbivores or humans. Infected dogs pass eggs in feces on individual bases. and the intermediate host acquires the infection by accidental ingestion of the eggs. Dogs are regarded as the source of human infection. Some Diagnosis: Cats and dogs should be screened for intestinal parasites Echinococcus spp. have transmission cycles that include for the most periodically considering pet’s health status and lifestyle. When animals part domestic animals (dog- livestock cycles), while others include wildlife have diarrhea, the risk of infection is higher since the parasite load is animals that may or may not interact with domestic animals. Echino- going to be higher as well. A fecal screening for diarrhea in dogs and cats, coccus multilocularis is distributed in the northern hemisphere, and it includes fecal flotation using zinc sulfate or Sheather sugar for detection of eggs, cysts and oocysts, wet mounts for detection of throphozoites, 180 WSAVA GLOBAL COMMUNITY CONGRESS

rectal cytology and immunofluorescence assay for detection of Giardia 0115 and Cryptosporidium. Echinococcus spp. eggs cannot be distinguished morphologically from taenia eggs. Therefore, taenia infections diagnosed INTRODUCTION TO THE WOW GLOBAL BIOPSY by microscopy should be considered as possible Echinococcus spp. GUIDELINES: HOW TO DO A PROPER BIOPSY infections. J. Kirpensteijn Recommendations: Parasite control should be done by periodical exam- inations of feces followed by anthelmintic administration and ectopara- Topeka/United States of America site control. Dogs and cats should be dewormed frequently considering pet’s health status and lifestyle. Hookworms and Toxocara eggs are not Qualifications: immediately infectious, they need a few days in proper environmental conditions to larvate and became infectious. Therefore, daily removal of Abbreviated CV Jolle Kirpensteijn DVM, PhD, Diplomate ACVS and ECVS feces from the environment will decrease the chances of environmental contamination and infection to animals and humans. Cryptosporidium Jolle Kirpensteijn, DVM, PhD, Diplomate ACVS & ECVS spp. oocysts are sporulated and immediately infectious after excretion thus, individuals with immunosuppression should be careful when han- Chief Professional Veterinary Officer, Hill’s Pet Nutrition US, Home ad- dling cats and dogs with diarrhea. It is also important to practice proper dress: 4501 Broadmoor Drive, Lawrence KS 66047, USA; jolle_kirpenstei- hygiene habits such as, washing hands after contact with feces, wearing [email protected] @jollenl @gvetsx @purrpodcast gloves when gardening, and rinsing fruits and vegetables. Sandboxes should be covered when not in use, and children and immunocompro- Jolle Kirpensteijn graduated from the Utrecht University Faculty of Veteri- mised individuals should avoid contact with feces. Cats and dogs should nary Medicine, Holland in 1988 and finished an internship in small animal be prevented to hunt and should be fed commercial diets or cooked meals medicine and surgery at the University of Georgia in the United States of to prevent raw meat transmitted infections. America in 1989. After his internship, he completed his residency training in small animal surgery and a master’s degree at Kansas State University, References USA. The residency was followed by a fellowship in surgical oncology at the Colorado State University Comparative Oncology Unit, USA. In 1993, Dubey JP, Cerqueira-Cézar CK, Murata FHA, Kwok OCH, Yang YR, Su C. Jolle returned to Europe to accept a position in surgical oncology and soft All about toxoplasmosis in cats: the last decade. Vet Parasitol [In- tissue surgery at Utrecht University. In February of 2005, he was appoint- ternet]. 2020 Jul;283. Available from: https://doi.org/10.1016/j.vet- ed Professor in Surgery at the University of Copenhagen and in August par.2020.109145 2008 Professor in Soft Tissue Surgery at Utrecht University. Jolle is a Diplomate of the American and European College of Veterinary Surgeons. Calero-Bernal R, Gennari SM. Clinical Toxoplasmosis in Dogs and Cats: An Jolle received the title Founding Fellow in Surgical Oncology (2012) and Update. Front Vet Sci [Internet]. 2019 Feb 26, 6:54. Available from: http:// Minimally Invasive Surgery (Small Animal Soft Tissue) (2017) of the doi.org/10.3389/fvets.2019.00054 American College of Veterinary Surgeons (ACVS). In September 2013, Jolle accepted the Chief Professional Relation Officer position at Hills Pet Stracke K, Jex AR, Traub RJ. Zoonotic Ancylostomiasis: An Update of Nutrition in the USA. Here, he played an integral role as the interface be- a Continually Neglected Zoonosis. Am J Trop Med Hyg [Internet]. 2020 tween the company and the profession at large. In 2018, he was promoted Jul;103(1):64-68. Available from: https://doi.org/10.4269/ajtmh.20-0060 to the Chief Professional Veterinary Officer position in the US, where he leads all professional activities in the United States. Jolle has published Ballweber LR, Xiao L, Bowman DD, Kahn G, Cama VA. Giardiasis in dogs over 120 peer-reviewed articles, given more than 250 lectures worldwide and cats: update on epidemiology and public health significance. Trends and has received the prestigious BSAVA Simon Award in 2007, Hills Parasitol. 2010 Apr;26(4):180-9. Voorjaarsdagen Excellence in Healthcare Award in 2009, WSAVA Presi- dent’s Award and honorary membership to the Netherlands Association Lucio-Forster A, Griffiths JK, Cama VA, Xiao L, Bowman DD. Minimal zoo- of Companion Animal Medicine (NACAM) in 2017. His main clinical and notic risk of cryptosporidiosis from pet dogs and cats. Trends Parasitol. research interests are professional social media and digital innovations, 2010 Apr;26(4):174-9. surgical oncology, and endoscopic & reconstructive surgery. Check out his podcasts at purrpodcast.net and globalveterinarysurgery.net Jenkins E. Echinococcus spp Tapeworms in Dogs & Cats. Clinician Brief. The ten steps for doing a proper biopsy 2017. Available from: https://files.brief.vet/migration/article/39726/echi- nococcus-spp-tapeworms-in-dogs--cats-39726-article.pdf European Scientific Counsel Companion Animal Parasites. https://www. esccap.org/guidelines/ Companion Animal Parasite Council. https://capcvet.org/ 181

13–15 NOVEMBER, 2021 0116 182 WSAVA GLOBAL COMMUNITY CONGRESS BIOPSY BASICS: GETTING THE MOST FROM A CYTOLOGY/HISTOLOGY REPORT A. Hohenhaus New York City/United States of America Qualifications: Ann Hohenhaus DVM, Diplomate, ACVIM (Oncology and Small Animal Internal Medicine) WSAVA Oncology Working Group [email protected] A histology or cytology report is part of a conversation between the clinician and the clinical pathologist or anatomic pathologist. To get the most from a cytology report, lesion selection and sample collection greatly influence the ability to obtain a diagnostic sample. The cytology report must be interpreted in the light of the accuracy of cytology for that particular organ or anatomic location. Interpreting a histology report requires understanding the information contained in the actual report as it is critical to developing an ongoing plan for the patient. Cytology report Sample collection Location Any skin mass or peripheral lymph node is an excellent lesion for cytolog- ical analysis. The results can help guide the need for antibiotic therapy, surgery, benign neglect, or cancer treatment. Fine needle aspiration of pleural effusion, peritoneal effusion or internal organs or masses is com- monly performed but may require ultrasound guidance. Common internal organs undergoing fine needle aspiration include liver, spleen, kidneys, intestinal masses, enlarged lymph nodes, lung masses and mediastinal masses. Aspiration of the spleen or liver is quite easy, but interpretation can be challenging because anatomic pathologists rely on tissue architec- ture to make a diagnosis and this feature is lost in cytology preparations. Despite concern about adverse events, pancreatic and adrenal gland aspiration can be useful. In about 15-20% of cytology samples, the sample is inadequate for diagnostic purposes. Firm masses and vascular lesions may not have adequate cell for interpretation. Necrotic lesions and lesions with signifi- cant inflammation are ones where cytology may not give accurate results because the secondary process can obscure the primary disorder. Low grade or well differentiated malignancies may appear benign on cytology. Fine needle aspiration of lymph nodes as part of tumor staging deserves special attention. Lymph nodes do not have to be enlarged to be contain metastatic cells. Oral tumors can have lymph node metastasis on the contralateral side to the tumor. Thus aspirating multiple lymph nodes, ipsilateral and contralateral to an oral tumor is recommended even if the lymph nodes are not enlarged. Technique Multiple techniques can be used to obtain a sample for cytologic analysis. Clinical pathologists prefer samples obtained via the non-aspiration technique where a needle is used to make multiple stabs into a lesion without an attached syringe or with an attached syringe filled with air. For soft lesions, use a 23-25g needle and a 22g for firm lesions. Syringe size for non-aspiration technique is not important, but for aspiration technique use a 3-6 cc syringe for soft lesions and 12cc for firm ones. Masses in the distal colon may be scaped using a cotton swab which can be useful to

identify infectious agents such as fungi or protozoa, inflammatory cells or Histology Report malignant cells. Like the cytology report, a histology report will include a description of Adverse events the tissue sample, a diagnosis, prognosis and the case of some tu- mors, tumor grade. Tumor grade is derived from histologic features that Hemorrhage from fine needle aspiration of a cutaneous mass of lymph influence prognosis. Two of the most commonly used grading systems in node is uncommon, but with ultrasound guided fine needles aspirates, veterinary oncology are for canine cutaneous mast cell tumors and soft thrombocytopenia appears to be associated with hemorrhage. Although tissue sarcomas. aspiration of adrenal gland masses and the pancreas seem risky, this belief has not been corroborated by some small studies. The report may also contain comments, references and further recom- mend diagnostic testing. In this section the pathologist explains unusual Submission form findings, gives references to support their conclusions and makes sugges- tions for additional testing. Recommendations for additional testing often The paper or electronic submission form is the clinician’s communication include immunohistochemistry as a method to further define the tumor to the pathologist regarding location, clinical findings and differential type. When a pathologist recommends immunohistochemistry to further diagnoses for the sample being submitted. This information is critical characterize a tumor, this testing should be performed if the pet owner to a pathologist’s ability to give an accurate interpretation of the sample desires further clarification of prognosis or the information gained from that is ultimately helpful to the clinician. For example, if a mandibular immunohistochemistry will alter treatment recommendations. lymph node is aspirated and the pathologist sees epithelial cells, they may conclude the salivary gland was aspirated. If the lymph node aspirated is When a pathologist includes a reference in the histology report, they not reported, the pathologist can only say epithelial cells. If the clinician provide the clinician with up to date information on some aspect of the has a specific question by the cytology report, it should be included on the reportWith the explosion of scientific literature, no one can keep up with submission form. Never submit a cytology sample in the sample transport all the latest findings. The addition of references to the histology report container as a tissue sample in formalin because the quality of the cytolo- helps the clinician ensure treatment recommendations are based on the gy sample will be negatively affected. most up to date information. Cytology Report Clinician to Pathologist The cytology report will contain three components: a description of the When the clinician reviews the histology report, questions may arise sample, a diagnosis and other information like a prognosis, references or about any aspect of the report. Pathologists welcome the opportunity to recommendations for additional testing. Examples of additional testing discuss the report and explain an unexpected diagnosis or explain the include a recommendation for flow cytometry or PCR for antigen receptor recommended testing. Second opinions on histology reports appear to rearrangement in a lymph node cytology suggestive of lymphoma or for a change the treatment recommendation in about 17% of cases referred to culture and sensitivity in a sample that contains bacteria. an oncology service at a veterinary teaching hospital. Clinician to Pathologist References The cytology report will contain contact information for the pathologist Avallone G, Rasotto R, Chambers JK, et al. (2021) Review of Histolog- issuing the report. This is extremely helpful if the clinician needs to clarify ical Grading Systems in Veterinary Medicine. Vet Pathol. 2021 Mar the diagnosis, understand the recommended additional testing, or discuss 26:300985821999831. doi: 10.1177/0300985821999831. Online ahead of the case further. Most pathologists welcome the opportunity to discuss print. cases with the submitting clinician. Soga I, Pohlman LM. Top 5 fine-Needle Biopsy Sample Collection and Diagnostic accuracy of cytology Handling Errors. Clinician’s Brief June 2021. Aspiration cytology results for cutaneous and subcutaneous masses is Veterinary Cancer Guidelines and Protocols Veterinary Cancer Guidelines quite reliable and agrees with histopathology over 90% of the time. One and Protocols (vcgp.org) aspect of cytology that can limit its usefulness is the highly focal nature of the sample obtained from large organs like the spleen and liver. The Pey P, Diana A, Rossi F, et al. (2020) “Safety of percutaneous ultra- architecture of the spleen and liver is important in determining the diag- sound-guided fine-needle aspiration of adrenal lesions in dogs: Perception nosis. These two aspects cytology may explain the low rate of agreement of the procedure by radiologists and presentation of 50 cases.” Vet Intern between fine needle aspiration cytology and histopathology of the liver Med. 2020 Mar;34(2):626-635. and the spleen. Mesenchymal tumors (sarcomas) tend not to exfoliate as well as hematopoietic tumors or epithelial tumors (carcinomas) and often Yankin I, Nemanic S, Funes S. (2020) “Clinical relevance of splenic several attempts must be made to obtain an adequately cellular sample nodules or heterogeneous splenic parenchyma assessed by cytologic from a tumor such as a soft tissue sarcoma. Overall, a diagnosis of can- evaluation of fine-needle samples in 125 dogs (2011-2015)”. J Vet Intern cer from a fine needle aspiration cytology is highly likely to be correct. Med 34(1): 125-131. Histopathology report Cordner AP, Sharkey LC, Armstrong PJ, et al. (2015) “Cytologic findings and diagnostic yield in 92 dogs undergoing fine-needle aspiration of the Biopsy Sample Collection pancreas”. J Vet Diagn Invest. 27(2): 236-40. Location and technique R Léveillé , B P Partington, D S Biller, et al. (1993). “Complications after ultrasound-guided biopsy of abdominal structures in dogs and cats: 246 Biopsy techniques are discussed in a presentation by Dr. Jolle Kirpensteijn cases (1984-1991)”. J Am Vet Med Assoc. 203(3): 413-5. at WSAVA 2021. Bigge LA, Brown DJ, Penninck DG. (2001) “Correlation between coagula- Submission form tion profile findings and bleeding complications after ultrasound-guided biopsies: 434 cases (1993-1996)”. J Am Anim Hosp Assoc. 37(3): 228-33. It is critical for the form to be completed in order for the pathologist to have adequate information to respond with an accurate histopathology Ghisleni G, Roccabianca P, Ceruti R, et al. (2006). “ Correlation between report. 183

13–15 NOVEMBER, 2021 fine-needle aspiration cytology and histopathology in the evaluation of cu- 0117 taneous and subcutaneous masses from dogs and cats”. Vet Clin Pathol. 35(1):24-30. HOW I TREAT LARYNGEAL PARALYSIS: UNILATERAL ARYTENOID LATERALISATION Skinner OT, Boston SE, Souza CHM. (2017) “Patterns of lymph node E. Monnet metastasis identified following bilateral mandibular and medial retropha- ryngeal lymphadenectomy in 31 dogs with malignancies of the head”. Vet Fort Collins/United States of America Comp Oncol. 15(3): 881-889. Qualifications: Eric Monnet, DVM, PhD, FAHA Diplomate ACVS, ECVS Professor Small Animal Surgery Colorado State University [email protected] The laryngeal functions are to regulate airflow, voice production and prevent inhalation of food. If the intrinsic muscles and/or the nerve supply of the larynx are not normal laryngeal function is not normal. The cricoarytenoideus dorsalis muscle abducts the arytenoid cartilages at each inspiration. The laryngeal recurrent nerve innervates this muscle. Le- sions to the laryngeal recurrent nerve or to the cricoarytenoideus dorsalis muscle result in laryngeal paralysis in dogs and cats. Laryngeal paralysis can be unilateral or bilateral. Medical treatment is necessary in an emergency situation however the surgical treatment is the definitive treatment. Laryngeal surgery is di- rected at removing or repositioning laryngeal cartilages that obstruct the rima glottidis. The four currently recognized surgical procedures used to correct laryngeal paralysis are (1) unilateral or bilateral arytenoid cartilage lateralization, (2) ventricular cordectomy and partial arytenoidectomy via the oral or ventral laryngotomy approach, (3) modified castellated laryngo- fissure, and (4) permanent tracheostomy. Arytenoid cartilage lateralization is currently the most common surgical treatment. Arytenoid Cartilage Lateralization This procedure has been used successfully to treat laryngeal paralysis in cats and dogs. Arytenoid lateralization has been performed bilaterally or unilaterally. Unilateral arytenoid lateralization is sufficient to reduce clini- cal signs of laryngeal paralysis. Unilateral lateralization can be performed through a lateral incision. The animal is positioned in lateral recumbency for unilateral lateraliza- tion, and a skin incision is made over the larynx just ventral to the jugular groove. The sternohyoid muscle is retracted ventrally to expose the lateral aspect of the thyroid and cricoid cartilages. The larynx is rotated to ex- pose the thyropharyngeal muscle, which is transected at the dorsocaudal edge of the thyroid cartilage. The wing of the thyroid cartilage is retracted laterally, and the cricothyroid junction may be incised. Incision of the cricothyroid joint gives a better exposure but it is not always needed. Its transection might reduce the diameter of the rima glottidis after arytenoid abduction. The cricoarytenoideus dorsalis muscle or the fibrous tissue left is dissected and transected. The cricoarytenoid articulation is open from caudal to cranial with Metzembaum scissors. Only the caudal part of the joint capsule is open to visualize the articular surface. The sesamoid band connecting the arytenoid cartilages dorsally is left intact. The arytenoid cartilage is sutured to the caudo-dorsal part of the cricoid cartilage. This provides an adequate laryngeal airway with only a unilateral tieback. Placement of the suture on the caudo-dorsal part of the cricoid provides a physiologic position of the suture. The suture is first placed around the caudo-dorsal border of the cricoid cartilage and it should exit the cricoid cartilage just caudal to the crico-arytenoid joint to limit the 184 WSAVA GLOBAL COMMUNITY CONGRESS

amount of abduction of the arytenoid cartilage. One 2-0 non-absorbable 0118 suture is placed in a simple interrupted suture pattern from the muscular process of the arytenoid cartilage to the caudo-dorsal edge of the cricoid HOW I TREAT TUMORS OF THE DIGITS IN DOGS cartilage and tightened to maintain the arytenoid in position. In cats, it is recommended to use small suture material 3-0 or 4-0 mounted on a N. Bacon pledget to prevent tearing through the cartilage. The arytenoid cartilage does not need to be displaced caudally. It is the authors’ impression that Guildford/United Kingdom the arytenoid cartilage needs only to be maintained in position and stabi- lized at inspiration. The wound is closed by suturing the thyropharyngeal Qualifications: muscle and routinely closing the subcutaneous tissue and skin. Nicholas James Bacon Complications associated with laryngeal lateralization include aspiration pneumonia, persistent cough exacerbated after drinking, seroma, breaking MA VetMB CertVR CertSAS DipECVS DACVS FRCVS of the suture, and fragmentation of the arytenoid cartilage. Breaking of the suture or fragmentation of the cartilage induces recurrence of the ACVS Founding Fellow (Surgical Oncology) clinical signs of laryngeal paralysis. Laryngeal lateralization should then be performed on the other side. If the procedure has been performed RCVS Specialist in Small Animal Surgery (Surgical Oncology) bilaterally a permanent tacheostomy needs to be performed. Seroma formation is very common and is self-limited. The incidence of aspiration [email protected] pneumonia is more common in bilateral laryngeal lateralization compared Tumours of the digits commonly encountered include melanoma, to unilateral. In a study, 42% of the dogs with bilateral lateralization experi- osteosarcoma, squamous cell carcinoma, mast cell tumour, haemangio- enced an episode of aspiration pneumonia. Water and food should be pericytoma, and other malignancies. It is normally only affecting one toe, completely withdrawn after surgery for 24 hours. Two or three meatballs but very occasionally several can be involved, especially when located in should be delivered 24 hours after surgery under constant direct supervi- the interdigital webbing or affecting the pads. Surgery is the mainstay of sion. If the animal can handle meatballs with aspirating, ice cube and then therapy and positively impacts survival and quality of life. Other factors water can be delivered. The animal should be closely watched for the next such as patient age, tumour type, site and stage have not been shown 2 weeks. The animal is at risk for aspiration pneumonia for its entire life to be as important as a curative-intent surgical procedure and so that is after surgery. where attention should be focused. Concern exists in surgery of the foot regarding appropriate margins to take, how high to amputate the digit, whether to amputate mid phalanx or intra-articular, and how the resulting amputation is likely reconstructed. A number of options exist for surgery ranging from removal of P3 through to partial foot amputation. Staging is recommended prior to surgery and consists of foot radiographs, local lymph node palpation and aspiration, and thoracic radiographs. Techniques which will be covered in the lecture include; BIER block Named after August Bier, this is an intravenous regional anaesthesia technique in which the foot is anaesthetised for digit surgery. A distal vein is catheterized, the foot ex-sanguinated by use of an Esmarch tourniquet secured just proximal to the carpus or the hock, and then local anaesthet- ic solution instilled intravenously to infuse the tissues of the foot. The tourniquet ensures the local anaesthetic does not leave the foot, as well as ensuring a bloodless field to work in, making for faster more precise surgery. The added benefit is that patients do not need full general anaesthesia, but heavy sedation can often be sufficient. In an elderly patient, this can offer some real advantages and allows the surgery to performed as an out-patient basis. It is a useful, versatile, easily learnt technique. Immediately after surgery a primary layer should be placed on the foot and secondary layer added PRIOR to releasing the tourniquet to allow for mild pressure to be placed on the wound. The dressing can then be completed as per normal. Given the dressing is placed over an exsanguinated foot it must be replaced at 24 hours to avoid any ischaemic bandage injury. At 24 hours if the foot is not bleeding then it can be redressed and left for 3-4 days before redressing. If bleeding is seen, repeating the dressing change at another 24 hours is advisable. Partial foot amputation It is widely believed that only lateral toes can be removed, and amputation of even one central toe will result in lameness and decreased function. 185

13–15 NOVEMBER, 2021 Partial foot amputation is used in reference to removal of typically two or 0119 more toes, including, at times, the two central toes. When this is per- formed, the remaining lateral and medial toes are partially filleted and the HOW I MANAGE END STAGE CARDIOPULMONARY remaining skin dorsally and palmar/plantarly sutured together, including DISEASES the pads, creating a modified fusion podoplasty. The alternative would be to leave the remaining toes separated and the skin closed around each P. Fox toe, a so-called separation podoplasty. New York/United States of America Phalangeal fillet Qualifications: A technique to preserve the skin and soft-tissue within the digit, when it is not necessary to be excised in terms of achieving margins. It can be Philip R. Fox preserved by closely following the digit and dissecting the bones out with minimal to no attached soft tissues. The aim is to leave as wide a base as Dipl.ACVIM (Cardiology), Dipl. ECVIM-SA Cardiology), Dipl. ACVECC possible and use the skin to rotate into defects dorsally or on the palmar/ plantar aspect. [email protected] HOW I MANAGE END-STAGE CARDIOPULMONARY DISEASE Pad resection General outlook: Mast cell tumours, fibrosarcomas and melanomas and other malignancies are seen within pad tissue. The dense fibrous nature of pad tissue means End-stage heart failure (or Stage D in dogs with chronic myxomatous mi- that achieving margins can be simpler than expected even with limited tral valve disease), is associated with disease progression, resistance to pad ‘space’. Reconstruction techniques for pads include partial excision diuretics, and or inability of owners to administer medications. Recurrent and fusion, undermining, and simple resection/repair. or resistant congestive heart failure will become a major debilitation, signals poor outcome, and often, imminent death.1-5 In the dog, the Separation podoplasty most common cause of resistant congestive heart failure is myxomatous valve disease and less commonly, dilated cardiomyopathy. In the cat, Typically when the central toes are removed, this is an alternative to the the most common cause of end-stage heart disease is cardiomyopathy, fusion podoplasty described above, and places less axial stress on the particularly, hypertrophic cardiomyopathy. In cases of resilient pulmonary metacarpo/metatarso-phalangeal joints than the fusion. Concerns exist hypertension, recurrent pulmonary infiltrates, tachypnea, exercise inability, re function given the subsequent ‘splaying’ of the foot, but walking and and right sided heart failure can develop. Arrhythmias and other comor- running are still possible and largely normal. bidities require specific management strategies. With close attention and planning, certain steps can help maintain quality of life for short periods Fusion Podoplasty of time. Often involving the entire foot, the goal is to fuse the digits together vis Key steps to manage end-stage cardiopulmonary disease: skin dorsally, and pad tissue on the palmar/plantar aspect to create a single large pad to walk on. This technique is often used for interdigi- 1. Confirm your diagnosis, reevaluate contributing tal skin disease which has not successfully been managed medically. comorbidities, seek referral to a specialist. All interdigital and palmar skin is resected leaving only the pad tissue. Dorsally a bridge of skin is left in the midline of each digit. Sutures are Make sure your diagnosis is correct and that the disease process has then pre-placed deep into the central pad and to all the digital pads prior not changed. Have you missed something? Has it been a while since you to tying, to ensure accurate placement. The subcutaneous tissue and then performed key tests and diagnostics? skin is closed routinely. Many clinical signs can be associated with both cardiac and respiratory The foot is dressed and supported with moderate coaptation but a splint diseases as well as systemic or metabolic disorders. Do not take for should not be required. Sutures are removed at 2 weeks and the foot granted that your diagnosis is correct or that the condition that you diag- should continue to be supported for at least an additional two weeks nosed many months ago has not fundamentally changed. longer. Also, other diseases may have progressed or developed anew. Further, more than one condition may be present and contribute to signs. For example, severe pulmonary hypertension and severe mitral and tricuspid regurgitation, or renal failure, electrolyte imbalance, and heart failure. Get a current and accurate diet history to rule out possible nutritional cardiomyopathy. Show your radiographs to a radiologist. Call in a mobile echocardiographer that has suitable training credentials. If you are over your head, please consider referring this pet to a specialist right away. 2. Obtain a new, detailed medical history. Repeat key tests. Consider repeating or adding chest radiographs, biochemical profile, CBC, heartworm/lungworm test; T4 (cat); SBP; Echocardiogram. Perform and ECG recording if you detect rapid or slow heart rate or irregu- 186 WSAVA GLOBAL COMMUNITY CONGRESS

larities in heart rhythm. 3. Long-term incidence and risk of noncardiovascular and all-cause mortality in apparently healthy cats and cats with preclinical hypertrophic Consider other tests such as abdominal ultrasound examinations which cardiomyopathy. Fox PR, Keene BW, Lamb K, Schober KE, Chetboul V, Luis can help identify some causes of arrhythmia (hemangiosarcoma seen in Fuentes V, Payne JR, Wess G, Hogan DF, Abbott JA, Häggström J, Culshaw liver/spleen; lymphadenopathy in cats with lymphoma, etc). G, Fine-Ferreira D, Cote E, Trehiou-Sechi E, Motsinger-Reif AA, Nakamu- ra RK, Singh M, Ware WA, Riesen SC, Borgarelli M, Rush JE, Vollmar A, 3. Optimize drug doses. Lesser MB, Van Israel N, Lee PM, Bulmer B, Santilli R, Bossbaly MJ, Quick N, Bussadori C, Bright J, Estrada AH, Ohad DG, Del Palacio MJF, Brayley Firstly, verify the intended doses of each cardiac medication. Just be- JL, Schwartz DS, Gordon SG, Jung S, Bove CM, Brambilla PG, Moïse NS, cause your records indicate a certain dose and administration rate does Stauthammer C, Quintavalla C, Manczur F, Stepien RL, Mooney C, Hung not mean that the pet owner is in compliance. Ask the owner to bring in YW, Lobetti R, Tamborini A, Oyama MA, Komolov A, Fujii Y, Pariaut R, Uechi the medications and show you exactly what they are giving. M, Yukie Tachika Ohara V. J Vet Intern Med. 2019 Nov;33(6):2572-2586. doi: 10.1111/jvim.15609 Verify whether the owner can successfully pill the animal or instead, whether they put the drug in the food or water (which of course reduces or 4. International collaborative study to assess cardiovascular risk and limits drug efficacy). evaluate long-term health in cats with preclinical hypertrophic cardiomy- opathy and apparently healthy cats: The REVEAL Study. Fox PR, Keene BW, Recalculate dose based upon current body weight. Calculate based upon Lamb K, Schober KA, Chetboul V, Luis Fuentes V, Wess G, Payne JR, Hogan lean body weight. Reduce dose in cases of cachexia or large volume DF, Motsinger-Reif A, Häggström J, Trehiou-Sechi E, Fine-Ferreira DM, ascites. Nakamura RK, Lee PM, Singh MK, Ware WA, Abbott JA, Culshaw G, Riesen S, Borgarelli M, Lesser MB, Van Israël N, Côté E, Rush JE, Bulmer B, Santilli Consult label doses as well as published cardiac drug tables. RA, Vollmar AC, Bossbaly MJ, Quick N, Bussadori C, Bright JM, Estrada AH, Ohad DG, Fernández-Del Palacio MJ, Lunney Brayley J, Schwartz DS, Increase furosemide from q 12 hr to q 8 hr administration (coordinate with Bové CM, Gordon SG, Jung SW, Brambilla P, Moïse NS, Stauthammer CD, renal values and electrolyte levels); consider switching to torsemide. Stepien RL, Quintavalla C, Amberger C, Manczur F, Hung YW, Lobetti R, De Swarte M, Tamborini A, Mooney CT, Oyama MA, Komolov A, Fujii Y, Pariaut 4. Add polypharmacy and verify client understanding of the R, Uechi M, Tachika Ohara VY. J Vet Intern Med. 2018 May;32(3):930-943. disease process. doi: 10.1111/jvim.15122. Review and reeducate clients with regard to disease process, clinical 5. Longitudinal Analysis of Quality of Life, Clinical, Radiographic, Echocar- signs, and teach how to assess breathing rate and effort at rest or while diographic, and Laboratory Variables in Dogs with Preclinical Myxomatous sleeping. Separate concern for coughing with steady and consistent Mitral Valve Disease Receiving Pimobendan or Placebo: The EPIC Study. assessment of breathing rate and effort. Boswood A, Gordon SG, Häggström J, Wess G, Stepien RL, Oyama MA, Keene BW, Bonagura J, MacDonald KA, Patteson M, Smith S, Fox PR, Switch to torsemide if you have maximized furosemide dosage. Take care Sanderson K, Woolley R, Szatmári V, Menaut P, Church WM, O’Sullivan to follow renal and electrolyte values. ML, Jaudon JP, Kresken JG, Rush J, Barrett KA, Rosenthal SL, Saunders AB, Ljungvall I, Deinert M, Bomassi E, Estrada AH, Fernandez Del Palacio Add ACEI and spironolactone, especially to dogs. MJ, Moise NS, Abbott JA, Fujii Y, Spier A, Luethy MW, Santilli RA, Uechi M, Tidholm A, Schummer C, Watson P. J Vet Intern Med. 2018 Jan;32(1):72- Consider vetmedin in cats or off-label dose increase of vetmedin in dogs. 85. doi: 10.1111/jvim.14885 Administer clopidogrel to cats with cardiomyopathy. Manage tachycardia (sotalol for ventricular tachycardia; diltiazem for hart rate control with atrial fibrillation) Consider sildenafil for severe pulmonary hypertension that accompanies myxomatous valve disease. Manage electrolytes, especially hypokalemia, with electrolyte supple- ments. Obtain a nutritional consultation from a board-certified veterinary nutri- tionist to try to mitigate cardiac cachexia. 5. Set realistic expectations Perform regular thoraco- or abdominocentesis as needed. Set short term goals that include appetite, mobility, and quality of life. Discuss end of life preparations. References 1. ACVIM consensus statement guidelines for the classification, diagno- sis, and management of cardiomyopathies in cats. Luis Fuentes V, Abbott J, Chetboul V, Côté E, Fox PR, Häggström J, Kittleson MD, Schober K, Stern JA.J Vet Intern Med. 2020 May;34(3):1062-1077. doi: 10.1111/jvim.15745 2. ACVIM consensus guidelines for the diagnosis and treatment of myxo- matous mitral valve disease in dogs. Keene BW, Atkins CE, Bonagura JD, Fox PR, Häggström J, Fuentes VL, Oyama MA, Rush JE, Stepien R, Uechi M.J Vet Intern Med. 2019 May;33(3):1127-1140. doi: 10.1111/jvim.15488 187

13–15 NOVEMBER, 2021 0120 were not identified, etc… HOW I TREAT BREAKTHROUGH PAIN T. Grubb Uniontown/United States of America Qualifications: Tamara Grubb DVM, PhD, Diplomate ACVAA President Elect IVAPM, Fear Free Level 3 Certified [email protected] Breakthrough pain, or severe pain that occurs in a patient who is receiving analgesic therapy, can be very difficult to treat and can be a component of either acute or chronic pain. Break through pain is often associated with inadequate pain relief but, because pain is a very individual sensa- tion, breakthrough pain can also occur in patients receiving analgesic protocols that are adequate for other patients. This emphasizes that pain assessment is critical in patients with painful conditions, whether the pain is acute (eg, surgery, trauma) or chronic (eg, arthritis, cancer, pancreatitis, otitis, cystitis, etc.). Do NOT let the patient suffer in pain! Pain causes a myriad of negative health, behavior and welfare/quality of life conse- quences. Treating breakthrough pain in patients with acute pain (eg, postoperative- ly, post-trauma): Determine that the patient is painful and not just dysphoric (see accompa- nying notes for this meeting). Utilize palpation of painful areas to differen- tiate the two conditions – but this doesn’t always work. Also consider the current analgesic therapy: when was last dose of analgesic administered, what drug, what dose, expected duration of action. This may uncover the need for a repeat dose of the analgesic drug or the administration of a different drug (as in multimodal analgesia). If unsure whether the patient is painful or dysphoric, treat for pain since pain will have a greater impact on the patient’s health and well-being. In addition, pain can cause dysphoria. Consider administering an alpha-2 agonist (medetomidine, dexmedetomi- dine) because the alpha-2s provide both sedation and analgesia and thus treat both dysphoria and pain. Administer opioids instead of or along with the alpha-2 agonist. Choose the opioid based on the level of expected pain. Full mu- and kappa-re- ceptor agonists (morphine, methadone, hydromorphone, fentanyl) are the most potent opioids and generally preferred for break-through pain. Butorphanol is not a potent opioid but could be used in absence of other opioids or if pain is low. Butorphanol is generally more sedating than the other opioids so could also play a role in decreasing dysphoria. Buprenor- phine has a slow onset (10 minutes for initial onset, up to 30 minutes for full onset) and thus must be paired with a faster acting drug (eg, an alpha-2 agonist) if used for break-through pain. If break-through pain recurs even after a bolus of an opioid and/or an alpha-2 agonist, an additional bolus can be administered. An analgesic infusion should be considered if the pain is expected to be long-duration and/or if break-through pain continues to recur when the effects of the drug bolus dissipate. Utilize opioids, lidocaine, ketamine and/or medeto- midine or dexmedetomidine in the infusion. Another option for recurrent break-through pain is to consider adminis- tering an alpha-2 agonist or other sedative and administering a local/ regional block. The local anesthetic drugs provide profound analgesia and decrease the need for systemic drug administration. If these tactics fail to relieve the pain, reassess the patient for other com- plications, like internal fixators impinging on a nerve, trauma lesions that 188 WSAVA GLOBAL COMMUNITY CONGRESS

0121 vomiting or diarrhoea) (Little S. 2011, Little S. 2013). INFECTIOUS DISEASE IN KITTENS: PREVENTION Nutrition AND CURE Kittens with vomiting, diarrhoea, sepsis, hypothermia or inadequate K. Rolph nutritional intake are at risk of developing hypoglycaemia. This can occur rapidly as hepatic function is not mature, and therefore, they can rapidly Basseterre/Saint Kitts and Nevis deplete their glycogen stores (Macintire D.K. 1999). Hypoglycaemic kittens will become weak, lethargic, anorectic and hypothermic. If a kitten Qualifications: has developed hypothermia, this should be addressed prior to providing nutrition per os as ileus or delayed GI motility are frequently encountered Dr Kerry Rolph in hypothermic kittens, predisposing to regurgitation and with this aspira- tion pneumonia. BVM&S CertVC PhD FANZCVS (Feline Chapter) DipECVIM-CA FRCVS, RCVS Specialist in Feline Medicine, European Recognised Specialist in Pre-weaning Small Animal Internal Medicine In a young kitten that is hypoglycaemic a stomach tube can easily be [email protected] placed (as the gag reflex is not present in kittens under 10 days). This can then be used to periodically administer 5% to 10% dextrose orally at 0.25 Infectious Disease in Kittens to 0.50 mL/100 g body weight (Macintire D.K. 1999). The tube should be occluded prior to withdrawal to ensure the stomach content isn’t aspirat- Neonatal kittens have immature immune systems, receiving only about ed. 5% of their required maternally derived antibody (MDA) transplacentally. In order to gain protection from infectious disease there must be transfer In critically ill neonates a bolus infusion of 12.5% dextrose IV or IO (0.1 of MDA from the colostrum (Greco D.S. 2014). At the time of birthing, the to 0.2 mL/100 g or more) may be required. This can be followed by a queen begins to secrete colostrum and the kittens must ingest this in the constant-rate infusion of 1.25% to 5% dextrose in a balanced electrolyte immediate perinatal period. The ability of neonates to absorb MDA begins solution to prevent rebound hypoglycemia (Little S. 2011, Little S. 2013). to decline from 6h after birth, and it is no longer possible after about 48h. The protective effect of systemically absorbed MDA usually begins to If oral feeding can be tolerated meal size should be limited to about 4–5 wane from 3-4 weeks of age (but may wane as early as 2 weeks in some ml/100 g body weight, as this is the maximum stomach capacity for a instances). However, the kittens’ natural immunity is still developing at kitten (Macintire D.K. 1999). this time leaving kittens particularly at risk from infectious diseases. Food should be introduced gradually to avoid re-feeding syndrome. Viral Disease Post Weaning Viral disease is particularly prevalent within the kitten population, with Kittens who cannot smell, due to upper respiratory tract disease tend to 71% of deaths being attributed to viral infection (Cave T.A. 2002). Com- decrease their food intake. Cleaning any nasal discharge, and moistening mon viruses isolated include Feline Herpes virus (FHV), Feline Calicivirus the airway by nebulization or steam inhalation can increase food intake. (FCV), Feline Coronavirus (FCoV), Feline panleukopenia virus (FPV), Feline Providing warmed, strongly scented foods can also encourage food intake Leukaemia Virus (FeLV) and Feline Immunodeficiency Virus (FIV). in kittens with URT congestion. Treatment of Viral Disease in Kittens If cats cannot be encouraged to take adequate nutrition orally, a feeding tube can be placed. The majority of viruses have no specific treatment and is often very difficult to manage. If the kitten has an infection in which recovery is a Antiviral Medications possibility, then the mainstay of treatment is good nursing care. If sys- temic medications are indicated the age of the kitten should be taken into Both recombinant feline interferon-⍵ and human recombinant interferon-⍺ account prior to administration. have been shown to inhibit FHV-1 replication in vitro. However, controlled clinical trials are lacking (Sykes J.E. 2014). Fluid Therapy Specific viral infections may have specific treatments ie: Famciclovir Kittens do not develop the ability to concentrate their urine until around 10 (40–90 mg/kg PO every 8 hours) is the most potent and safe antiviral drug weeks of age (Little S. 2011). Therefore, if they are losing fluid (vomit- for FHV. It has been reported to be well tolerated when administered orally ing or diarrhoea) or have a decreased fluid intake, they are prone to the to kittens (Sykes J.E. 2014). development of hypovolaemia. Unfortunately, this can be hard to assess as the skin contains more water and therefore skin tent does not develop Antibiotics until the kitten is markedly dehydrated (Macintire D.K. 1999). Furthermore, the sympathetic nervous system is not fully mature until approximately 8 Secondary bacterial infections are common in kittens and therefore anti- weeks of age and therefore young kittens cannot respond to hypovolae- biotics may be indicated. If secondary infection is suspected broad-spec- mia in the same way as an adult (Little S. 2011). trum antibiotic cover with good penetration of the affected tissue is recommended (see below). The volume of fluid required to rehydrate is higher than that required for an adult. Kittens’ bodies contain a larger percentage of water; they have Bacterial Infection less body fat and a higher metabolic rate and so they require more water. However, the skin is more permeable to fluid and they have a high surface Whilst bacterial infections may be secondary to viral infection, some will area to volume ratio; all-in-all increasing the maintenance requirement for occur as a primary complaint. Clinical signs will vary depending on the a neonate. It is advised that the daily fluid requirement for a young kitten site and type of infection, but can include diarrhoea, coughing, dyspnoea, is 80-100ml/kg/day with further adjustments added for ongoing losses (ie polyarthritis, omphalophlebitis, or dermatitis, as well as the less specific signs more typical of fading kittens. Many of these infections may result 189

13–15 NOVEMBER, 2021 in septicaemia and death. Neonates have a propensity to develop hypo- Little S. (2013). “Playing Mum: Successful management of orphaned glycaemia and hypothermia, which predispose to the onset of intestinal kittens.” Journal of Feline Medicine and Surgery 15: 201-210. ileus. If ileus develops there is significant risk that bacteria will translo- cate from the GI tract and enter the blood stream. Clinical signs can occur Macintire D.K. (1999). “Pediatric Intensive Care.” Veterinary Clinics of very rapidly or the disease may run a more protracted course. Severe North America Small Animal Practice 29(4): 971-989. cases will present with bradycardia, dyspnoea, dehydration, weakness, crying, seizures, coma or death. The most common cause of sepsis are Sykes J.E. (2014). “Pediatric Feline Upper Respiratory Disease.” Veterinary gram-negative bacteria, but can include; Streptococcus, E. coli, Staphylo- Clinics of North America Small Animal Practice 44: 331-342. coccus, Klebsiella, Enterobacter, Enterococcus, Pseudomonas, Clostridi- um, Bacteroides, Fusobacterium, Pasteurella and Salmonella. Treatment of Bacterial Infections Kittens in septic shock will present with a bradycardia, hypotension and hypothermia. It is important that volume depletion is addressed prior to warming, as warming a volume deplete, hypotensive animal will increase peripheral circulation and result in a decrease in central blood pressure, which is highly correlated with survival. Therefore, intravenous or intraos- seous fluids should be provided and the circulating volume normalised prior to warming. Hydration and nutrition should be managed as detailed above. Antibiotics Antibiotics would ideally be selected according to culture and sensitivity testing. However, often it isn’t possible to wait for laboratory results as neonates can decompensate rapidly. Therefore, in the majority of situations antibiotics are selected empirically. The penicillins are often the first choice, as they are generally less toxic than most other antibiotics (Little S. 2011, Sykes J.E. 2014). In general, the parenteral administration of antibiotics is preferred because oral medications may not be absorbed efficiently. Cephalosporins are often used as a second choice. Parasitic Infections Kittens may succumb to substantial parasitic infestations. This can result in a poor body condition, soft or bloody stools, lack of appetite, a pot-bel- lied appearance, weight loss, and occasionally death. A severe flea, tick or hookworm infestation can result in significant anaemia. Gut parasites, such as Giardia, Tritrichomonas foetus, Isospora or Cryptosporidia may cause diarrhoea and a failure to thrive. Toxoplasma infection may result in abortion, stillbirths and fading kittens. Treatment of parasitic infections Toxocara species can be transmitted transplacentally. Infected kittens can be treated with either pyrantel pamoate or fenbendazole as early as 2 to 3 weeks of age, and this can be repeated every 2 to 3 weeks until at least 12 weeks of age (Macintire D.K. 1999). Giardiasis can be treated with either metronidazole or fenbendazole. T. foetus may be treated with ronidazole; whilst Coccidal infections may be treated with toltrazuril or trimethoprim/ sulphonamide, and improved sanitation. Toxoplasma infections may be treated with clindamycin or azithromycin. Some flea and tick products should not be used in nursing animals. How- ever, fipronil can be used to treat fleas and lice in neonates from 2 days of age. Bedding should be washed or discarded and a flea comb can be used to remove dead and dying fleas. Cave T.A., T. H., Reid S.W.J., Hodgson D.R, Addie, D.D. (2002). “Kitten mor- tality in the United Kingdom: a retrospective analysis of 274 histopatho- logical examinations (1986 to 2000).” Veterinary Record 151: 497-501. Greco D.S. (2014). “Pediatric Nutrition.” Veterinary Clinics of North Ameri- ca Small Animal Practice 44: 265-273. Little S. (2011). “Feline Pediatrics: How to Treat the Small and the Sick.” Compendium: Continuing Education for Veterinarians Sept: E1-E6. 190 WSAVA GLOBAL COMMUNITY CONGRESS

0122 resources for example and guarding of food by other cats, or noisy homes and unpredictable feeding times, all may affect a cats appetite. MANAGEMENT OF INAPPETANT CATS Consequences of inadequaten nutrition S. Taylor For cats, consuming less than RER and entering a negative energy balance Tisbury/United Kingdom can reduce wound healing, tissue repair and recovery from illness or surgery. It may alter drug metabolism and result in muscle loss. There is Qualifications: a risk of hepatic lipidosis, sepsis and reduced immune function. Malnutri- tion is poorly defined in cats but a lack of adequate nutrition is associated Samantha Taylor with a negative outcome in many species including humans. BVetMed(Hons) CertSAM DipECVIM-CA MANZCVS FRCVS Why is the cat not eating in hospital? [email protected] The main reasons will be, the underlying disease, pain, nausea, ileus, Can’t eat, won’t eat: management of inappetant cats constipation, drug adverse effects and importantly stress (novel envi- ronment, noise, dogs, inadequate places to hide etc). Of course some Introduction cats cannot eat (due to jaw fractures etc). Food aversions can be easily formed for cats with nausea or those that have been syringe or force fed. Inappetence (also called hyporexia, anorexia) is a common present- Other causes include electrolyte abnormalities, hypocobalaminaemia and ing sign in cats and can be the first sign of illness noticed by owners, hypotension. Polypharmacy should be avoided and bitter drugs swapped considering how subtly cats may show they are unwell. Feeding cats is for palatable or injectable alternatives. Simple changes to hospital cages an important part of ownership and owners can feel distressed by their and care regimes can result in improved food intake. All cats should have cat’s lack of appetite. Often there are multiple reasons a cat is not eating, somewhere to hide, even if it is only a cardboard box, as this will reduce particularly when hospitalised. Periods of inappetence can have serious stress. Seperate cat wards make an enormous difference to anxiety and consequence for feline patients. Managing inappetence requires the fear. Handling should be gentle and predictable and always kind. Nausea clinician to pay attention to small details and often requires a mtulimodal and pain must be managed - including regular pain scoring using a validat- approach. A lack of appetite in a cat should never be ignored. ed scheme such as the feline grimace scale (https://www.felinegrimaces- cale.com/). Nutritional assessment When to intervene Assessment of nutrition should be considered the fifth vital sign (as well as TPR and pain assessment). Every patient should be weighed and have Hyporexia and intake less than RER for more than 3 days was associated a body condition score (BCS) measured in every consultation - this does with reduced immune function and hence the advice to intervene after this not take long! Owners can even be taught to do a BCS at home. Addition- time. Early intervention can result in shorter hospitalisation. So interven- ally, it is important to ask about diet, to check it is suitable, and to identify tion should be considered for cats eating less than RER for >3 days or the cat’s preferences. The latter is important in hospitalised patients as predicted for > 3 days eg post surgery. if offered an unfamiliar diet (flavour or texture) they may refuse. A cat’s preferences for certain textures and types of food my be led by their Appetite stimulants mother and can last lifelong. Questionnaires can be provided for owner’s to save time. Muscle condition score is also now recommended. This is a Can be very useful but will not be effective until the nausea/pain/stress way of grading muscle quality independent of BCS and weight. See WSA- etc have been managed. Consider use in recovering patients, to encourage VA nutritionl assessment guidelines for more information: https://wsava. a cat to eat an appropriate diet, to facilitate medication in food and whilst org/wp-content/uploads/2020/01/WSAVA-Nutrition-Assessment-Guide- pending results of tests to support the cat’s clinical condition. Mirtazap- lines-2011-JSAP.pdf and https://wsava.org/wp-content/uploads/2020/01/ ine has been studied in cats with CKD and other comorbidities orally and Muscle-Condition-Score-Chart-for-Cats.pdf. transdermally - the latter being licensed in some countries. Not appro- priate to use diazepam or prednisolone (unless prednisolone used in the Monitoring nutrition in hospitalised patients management of the underlying disease). We cannot know when nutrition is a concern if we are not monitoring Feeding tubes what our hospitalised patients are eating. All cats in hospital should their resting energy requirements calculated in terms of calories and then Underutilised in first opinion practice. Naso-oesophageal (NO) and grams of food and everything they eat should be recorded so deficiencies oesophageal (O) tubes used most frequently and can be easily removed in nutrient intake are noted and acted on. Patients should also be weighed if the patient is eating. They are simple to place and adverse effects are at least daily and food adjusted accordingly. unusual (cellulitis/insertion site infection for O tubes). Shoudl be placed preemptively for example after surgery on the GI tract, to provide food, Inappetence at home water and medications (O tubes). NO tubes are narrower bore and shorter duration but useful for short periods of inappetence or to stabilise the A chronic reduction in food intake due for example to age, pain, disease patient prior to procedures or placing an O tube. Gastrostomy tubes are can result in reduced body condition and lifespan. Owners should be used less commonly, but useful in some cases with gastric or oesoph- encouraged to attend the clinic for check ups including weight recording ageal disease. Start feeding 1/3 RER on day 1, 2/3 on day 2 etc (further so small losses (or gains in overweight cats) can be identified. Becoming discussion in talk). Slower increase in feeding volumes in cats with ileus an ISFM Cat Friendly Clinic can help encourage clients to visit the clinic. or at risk of re-feeding syndrome. Be aware that some clients will have their owen ideas on suitable diets so you may need to check and be diplomatic! Conversely, some owners NEVER SYRINGE FEED will try and feed a prescription diet at a cost of calories, for example if they have been told the cat should be on a renal diet. Stress in the home Syringe feeding rarely meets RER, risks aspiration, food aversion and environment can reduce food intake, multicat homes with inadequate 191

13–15 NOVEMBER, 2021 causes stress in the vast majority of cats. 0123 In conclusion, inappetence is common, is a sign of illness or stress, and A BETTA SOLUTION - EXPLORING SIAMESE should be managed appropriately and promptly looking at causes of FIGHTING FISH MEDICINE stress/illness/pain/nausea for example. N. Saint-Erne Glendale/United States of America Qualifications: Nicholas Saint-Erne, DVM Certified Aquatic Veterinarian [email protected] #188 A Betta Solution - Exploring Siamese Fighting Fish Medicine Nick Saint-Erne, DVM, CertAqV The Siamese Fighting Fish (Betta splendens), or more appropriately called today the Betta, is one of the most commonly kept tropical fishes. It is a beautiful fish available in many color varieties, and the males can have long flowing fins as a result of selective breeding. In its native swampy waters of Thailand and close-by countries in southeast Asia, the fish are tan to greenish with the males having blue and red on the fins. The females are less colorful than the males, and typically have several brownish bars running along the sides of their bodies. Now, with selective breeding for over a hundred years, the Bettas are elaborately colored, and even the females can have beautiful color variations. The name Siamese Fighting fish comes from the aggressive nature of the males, which will fight with each other if kept together. For this reason, the males are housed in separate containers, although one male can be maintained with other community aquarium fishes if they do not resemble another Betta. Do not keep them with fin-nipping fish species, though, as Bettas are slow swimmers and can be picked on by other aggressive fish species. Female Bettas can usually be kept together or with other fish species, although occasionally there may be a female that can get a bit aggressive towards the others. The Bettas belong to a group of fish known as Anabantoids, which have an accessory air breathing organ called the Labyrinth, due to its maze-like shape. It is in the pharynx above the gills and the fish can take in a bubble of air from the surface and hold in in the labyrinth and absorb oxygen from it. Because of this, the Betta can live in stagnant water with zero dissolved oxygen content. That is why a Betta can live comfortably in a bowl of water with no aeration, although the water must be changed regularly to prevent ammonia, nitrate or nitrate from accumulating. Bettas are sedentary fish and tend not to swim too much in the aquarium; The Betta will often sit on the bottom of the tank or hide wedged in among plants. If the water flow from filtration is too strong, it can blow the male Betta around due to its flowing fins. They have a normal life expectancy of 2-3 years. One study showed that making a Betta swim actively each day by stimulating it to move with touches from a glass rod would increase its life expectancy considerably. Problems with Bettas are often associated with buoyancy issues and the physoclistous gas bladder will enlarge and make it float at the water surface. Using a tuberculin or insulin syringe to transdermally remove some of the gas from the bladder can help it return to neutral buoyancy. As with any aquarium fish, maintaining proper water quality by filtration or frequent water changes is necessary. Because of their air breathing abil- ity, keeping Bettas in one liter to a gallon or more sized bowl or aquarium can be suitable for housing them individually. Two male Bettas if placed together will fight and injure themselves, and can even lead to death. It is best to house Bettas where they cannot see other male Bettas to prevent them from constantly trying to fight with each other. They will even try to 192 WSAVA GLOBAL COMMUNITY CONGRESS

fight their own reflection in a mirror. 0124 WINTER WOES - COLD WEATHER KOI POND PROBLEMS J. Questen Conifer/United States of America Qualifications: Jena Questen Doctor of Veterinary Medicine Certified Veterinary Acupuncturist CertAqV (Certified Aquatic Vet) Professional Animal Trainer [email protected] In this presentation we discuss the care and survival of Koi fish in outdoor ponds overwintering in cold climates. We discuss the most important elements of Koi being able to survive over winter, including being in optimal health before the ambient temperatures begin to fall, as well the importance of temperature to the immune system, and the importance of optimal water quality. One of the most important things we discuss is not disturbing the fish, or the water column excessively, as this alone is likely the biggest stress and threat to fish not being able to overwinter well. We discuss the shapes and depths of different ponds and how that af- fects water circulation and the fish health in freezing temperatures. We also discuss at length the ways to ensure there is adequate flow in the pond over winter so it does not freeze solid, but yet is not too much as to be disruptive to the water column and actually cause stress to the fish. We discuss the different ways to prevent freezing over of the pond, the use and risk of venturi’s, Ph crash concerns, pond de-icer placement, and some parasites of Koi fish that can survive and even thrive in a cold water environment. We discuss the risks and complications of attempting to treat diseases in animals who have virtually no immune response in cold water. Clients must be willing to move the fish to an indoor quarantine area, or bring the fish to a hospital for quarantine. The use of a chiller may even be needed to temperature match the pond water before the water temperature that the fish are in can be slowly raised in order to maximize the animal’s own immune system. In conclusion, to maximize the probability Koi fish can survive winter weather temperature extremes outdoors, they must first be in excellent health going in the fall (no wounds, or parasites), the water quality should be ideal, and the water flow should be slow enough to prevent freezing over of the pond but not so fast as to be disruptive and cause the dormant fish stress. Special thanks to Dr. Julie Tepper CertAqV for his invaluable assistance in the preparation of this presentation. 193

13–15 NOVEMBER, 2021 0125 0126 A QUICK GLOBAL REVIEW OF THE MYRIAD OF THE FILARIOID PARASITES, OTHER THAN TREMATODES FOUND IN DOMESTIC CATS DIROFILARIA IMMITIS, OCCURRING IN THE D. Bowman DOMESTIC CAT D. Bowman Ithaca/United States of America Ithaca/United States of America Qualifications: Qualifications: Dwight D. Bowman, MS, PhD Dwight D. Bowman MS, PhD Professor of Parasitology Professor of Parsitology [email protected] [email protected] Introduction In the United States, we focus almost exclusively on the canine heart- Introduction worm, Dirofilaria immitis, relative to parasitic Filarioidea, but in the rest of the world there are many additional such parasitic worms to consider. There are many, many flukes found in cats around the world. This is due to the fact that cats eat many of the intermediate and paratenic hosts that Objectives serve as agents of the transmission of these trematodes. These parasites This talk will present the life cycle and biology of these many different are found in the buccal cavity, the intestine, the pancreatic ducts, the fall helminths and the different diseases they cause in their feline hosts and bladder and bile ducts, the nasal fossae, the lungs, and the blood vessels. how they might be diagnosed and treated. Objectives Methods The discussion will focus on the different biology of the different species Discussing the major agents found within the hosts in these areas and and means of their prevention and control. how the final host becomes infected. Results Methods The goal is to convince the attendees that it is important to consider these agents as being a danger to cats when living in areas where these The presentation will begin with the digestive tract and then will then parasites are present. move to the pancreatic and bile ducts moving onto the nasal fossae and lungs. It will end with a discussion of the different Schistosomatidae Conclusions found in various blood vessels. When known, diagnosis and treatment will be considered and discussed. Results The goal is to show that there are many more trematodes than are expect- ed by most to be present in the cats – and although the same genus may be present in many areas, there are often different species in different parts of the world. Conclusions When known, diagnosis and treatment will all be considered and dis- cussed. 194 WSAVA GLOBAL COMMUNITY CONGRESS

0127 ceptor binding affinity and concentration, and insulin receptor antibodies. Insulin resistance is usually attributable to obesity or disorders causing NUTRITIONAL APPROACH TO THE DIABETIC excessive secretion of insulin - antagonist hormone, such as cortisol, glu- PATIENT cagon, epinephrine, growth hormone, progesterone, or thyroid hormone. E. Carlson, Cvt, Vts (Nutrition) Bacterial infections are common in diabetic dogs and cats. The in- creased susceptibility to infections in diabetics is thought to be caused Woburn/United States of America by decreased blood supply, resulting in decreased delivery of oxygen, phagocytes, and antibodies to the site of infection, impaired humoral Qualifications: immunity, resulting in decreased antibody production; abnormal chemo- taxis of neutrophils; defects in phagocytosos and intracellular killing of Ed Carlson, CVT, VTS (Nutrition) organisms; and impaired cell-mediated immunity. Correction of concur- rent severe bacterial infection (for example of the urinary tract, skin, and [email protected] oral cavity) has been shown to improve glycemic control. Identifying any bacterial infections in our diabetic dog patients, determining the cause, NUTRITIONAL APPROACH TO THE DIABETIC PATIENT and treating/eliminating the infection is extremely important to improve glycemic control. Once the infection has resolved, the amount of insulin Canine diabetes mellitus is characterized by a deficiency of insulin secre- administered may be reduced, with the possibility of a significant reduc- tion due to the destruction of pancreatic beta cells. tion in administered insulin. Obesity causes insulin resistance in dogs however may not increase the The goal of treatment of diabetic cats has changed from simply con- risk of developing diabetes. Insulin resistance leads to hyperinsulinemia trolling the disease to achieving non-insulin dependence (remission). which in turn leads to impaired glucose tolerance. Diets high in saturated fat may cause more severe glucose intolerance in obese dogs. One nutritional approach for diabetic cats is a diet with increased fiber that is high in carbohydrates. The increased dietary fiber is beneficial to Twice daily insulin administration, at the time of feeding, is the recom- slowing gastric emptying which slows gastrointestinal glucose absorp- mended protocol for the management of diabetes mellitus in dogs. There tion, increasing insulin sensitivity, and improving the control of nutrient is an increased chance of hypoglycemia in dogs when insulin is only metabolism. administered once daily. Dogs treated once daily also generally require higher doses of insulin than those treated twice a day. For these reasons, Another nutritional approach for diabetic cats is a high protein/low car- once-a-day insulin administration is not recommended for dogs. bohydrate diet. The theory behind this type of formulation is based on the concept that cats, being obligate carnivores, have a digestive system that The key nutritional factors for diabetic dogs as increased-fiber/high-carbo- is better designed to process protein than carbohydrates and starch. hydrate diets; foods with no more than 55% digestible carbohydrate, 7 to 18% fiber, <25% fat and, 15 to 35% protein[1]. The increasing fiber content “In general, it is much easier to maintain near-normal glycemia in insu- is thought to minimize postprandial glycemic response and can also pro- lin-treated, diabetic cats when they are fed a high protein, low carbohy- mote weight loss in obese dogs. Despite multiple studies, however, none drate diet. Postprandial hyperglycemia is almost absent, and the average have shown a consistent benefit to high or low fiber diets for diabetic blood glucose level is reduced.”[2] One study of the use of a high-fiber diet dogs. Increased fiber diets may improve glycemic control in some diabetic showed improved glycemic control in cats compared with low-fiber diets. dogs however others show little or no improvement with this approach. [3] However, many of the high-fiber diets formulated for cats also contain High fiber, moderate starch diets and adult maintenance diets with moder- high levels of carbohydrates. It is therefore important to select a high fiber ate fiber and low starch content appear to provide similar glycemic control diet with moderate carbohydrates when using this method. for many stable diabetic dogs. Increased insoluble fiber is recommended for diabetic dogs fed high fiber diets; a blend of soluble and insoluble fiber Research shows cats newly diagnosed with diabetes mellitus, when man- is recommended for diabetic dogs fed a diet of moderate fiber content. aged with a combination of appropriate insulin therapy and appropriate dietary management, can achieve remission, no longer requiring insulin The carbohydrate source of diets has been shown to directly influence therapy. Remission is most likely to occur in the first year after diagnosis, postprandial glucose and insulin responses in diabetic dogs. Barley has however, diabetic cats already receiving exogenous insulin therapy may been shown to produce the lowest insulin response and sorghum the benefit from and may achieve remission with nutritional intervention. lowest postprandial glucose response while rice produces the highest. Therefore rice-based diets are generally not recommended for diabetic Diabetic cats already receiving insulin therapy often require a reduction in dogs. the amount of insulin they require when switched to a low carbohydrate/ high protein diet. Cats already receiving insulin therapy, when changing There is no evidence of any benefit to restricting dietary fat in the diets fed from a high carbohydrate to a low carbohydrate diet, should have the to diabetic dogs, with the exception of those with or prone to pancreatitis. initial insulin dose reduced by 30% to 50% to avoid hypoglycemia. It is therefore important to monitor these patients to ensure their blood glu- The recommended amount of protein is the same for diabetic and non-di- cose does not drop to a dangerous level. abetic dogs. Semi-moist foods and other diets containing simple sugars should not be fed to diabetic dogs. Studies have shown approximately 25% of diabetic cats that achieved remission reverted to overt diabetes again requiring exogenous insulin Uncontrolled and poorly controlled diabetic dogs often have poor body to control the disease. It is important to continue feeding cats that are in condition, are prone to weight loss, have an altered fat metabolism, hepat- remission a low carbohydrate/high protein diet to increase their chances ic changes, and ketogenesis. L-Carnitine supplementation, which has been of remaining in remission.[4] shown to suppress acidosis and ketogenesis in dogs during starvation, may also benefit diabetic dogs. Obese cats are four times more likely to develop diabetes than cats of normal body weight and about 60% of obese cats will become diabetic.[5] Insulin resistance in dogs may result from problems occurring before It is therefore important to begin educating owners of kittens and cats on the interaction of insulin with its receptors. Possible problems include the health risks linked to obesity, including the predisposition to devel- increased insulin degradation and insulin binding, alterations in insulin-re- oping diabetes mellitus, from their very first visit to the veterinary clinic. 195

13–15 NOVEMBER, 2021 Bodyweight needs to be monitored at each visit. Developing a nutritional 0128 recommendation for every feline patient and remembering to educate owners to reduce the caloric intake at the time of neutering is important to NUTRITION FOR THE HOSPITALIZED VETERINARY reducing the risk of the animal developing DM. PATIENT Once a cat is diagnosed with diabetes mellitus, weight loss is more im- E. Carlson, Cvt, Vts (Nutrition) portant than ever. Insulin resistance induced by obesity can be reversible once the animal returns to normal body weight. A low carbohydrate/high Woburn/United States of America protein diet is the best option for many obese cats, not only to facilitate weight loss and maintain muscle mass but to also provide them the best Qualifications: chance of achieving remission. Gradual weight loss in obese cats is cru- cial; loss of 0.5 to 1% of initial body weight per week is considered safe Ed Carlson, CVT, VTS (Nutrition) to avoid hepatic lipidosis.[6] Many diabetic cats have poor body condition scores; high protein diets may assist in the prevention of hepatic lipidosis [email protected] during weight loss, aid in the replacement of muscle loss, and help to increase metabolism. NUTRITION FOR THE HOSPITALIZED VETERINARY PATIENT While a low carbohydrate/high protein diet may work very well with many Medical intervention to stabilize the critically ill patient before initiating diabetic cats, there are times when this type of diet is contraindicated. nutritional support, including dehydration and acid-base and electrolyte One common example of this is a diabetic cat with advanced renal dys- imbalances, is important to reduce the risk for possible additional com- function which may require protein and phosphorus restriction. plications. Patients in a state of shock, for example, may have reduced perfusion to the gastrointestinal tract, leading to reduced gastrointestinal Many diabetic cats do well fed twice a day with insulin administered just motility, nutrient absorption, and digestion.1 after meals. However, many cats fed on an adlib basis prior to diagnosis may resist changing to being fed twice daily. WHY IS NUTRITION SO IMPORTANT FOR THE HOSPITALIZED PATIENT? Postprandial glucose levels in cats fed a high protein diet appear to increase only slightly as compared to cats fed a high carbohydrate diet. Daily nutrients in controlled amounts are crucial to maintaining optimal One unpublished study indicates that the timing of insulin injection had immune function and normal cellular structure and assist with drug me- little effect on metabolic control leading some to believe the composition tabolism.2 Patients not consuming adequate nutrition are prone to lean of the diet to be more important than the timing of meals. However, food body mass loss, delayed wound healing, weakness, and organ dysfunc- must be available once insulin is administered to prevent life-threatening tion.3 These patients may also have an increase in acquired infections hypoglycemia. and bacterial translocation.4 Bacterial translocation is defined as the passage of viable bacteria from the intestines to extraintestinal sites, References such as the mesenteric lymph node complex, liver, spleen, kidney, and bloodstream.5 [1] Hand MS, Thatcher CD, Remillard RL, Roudebush P, Novotny BJ. Small Animal Clinical Nutrition, 5th ed.Topeka, KS: Mark Morris Institute; 2010. Research has shown that the addition of glutamine, arginine, and omega-3 fatty acids can augment intestinal barrier function and prevent bacterial [2] Pibot, Biourge, Elliott, Encyclopedia of Feline Clinical Nutrition, France, translocation.6 Multiple studies have shown that providing early enteral Royal Canin, 2006 nutritional support can shorten hospital stays.3,7,8 [3] Nelson RW, Scott-Moncrieff C, Feldman EC, et al. Effect of dietary insol- DIETARY CONSIDERATIONS uble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. JAVMA 2000;216(7):1082-1088. Healthy dogs and cats use and store energy derived from protein, fat, and carbohydrates very effectively. However, in an unhealthy state, reduced [4] Feline Diabetes Mellitus: Diagnosis, Treatment, and Monitoring, Com- gastrointestinal absorptive and digestive enzyme production, as well as pendium 12/2008, Lori Rios, DVM, PhD, DACVIM, Cynthia Ward, VMD, PhD, insulin resistance, may affect dietary carbohydrate tolerance. This may DACVIM result in altered glucose control and/or diarrhea. Diets formulated for recovery are more often calorically dense and have lower carbohydrate [5] Pibot, Biourge, Elliott, Encyclopedia of Feline Clinical Nutrition, France, content.2 Royal Canin, 2006 It is important to provide critical patients with adequate dietary protein [6] Hand MS, Thatcher CD, Remillard RL, Roudebush P, Novotny BJ. Small that supplies essential amino acids. High dietary protein may be used in Animal Clinical Nutrition, 5th ed.Topeka, KS: Mark Morris Institute; 2010. place of carbohydrates in critical feline and canine patients who are not able to handle carbohydrates well. High protein may be contraindicated in patients with renal disease and those with comorbidities, such as hepatic disease and encephalopathy with pancreatitis. Calories provided from fat are equally important in the critical patient. Fat is more calorically dense than protein or carbohydrates; therefore, patients may ingest a smaller volume of food while still consuming more calories. High-fat content is contraindicated in patients with pancreatitis.9 Arginine, an amino acid, is essential to protein synthesis and has an im- munopreserving effect on protein malnutrition.2 Glutamine, also an amino acid, plays a role in protein metabolism, nutrient absorption, and intestinal immune function.2 Folic acid, thiamin, riboflavin, niacin, pantothenic acid, 196 WSAVA GLOBAL COMMUNITY CONGRESS

pyridoxine, and vitamin B12 are required for the metabolism of protein, PARENTERAL NUTRITION fat, carbohydrates, and glucose. Patients consuming their resting energy requirement (RER) of a commercial diet should be receiving an adequate Parenteral nutrition (PN) is a nutritionally balanced solution that provides amount of these vitamins. However, patients that are not eating should be calories and nutrients to patients that cannot tolerate enteral nutrition or supplemented with vitamin B complex in crystalloid intravenous fluids or should not be fed by mouth PN provides caloric, protein, and micronutri- with parenteral nutrition containing vitamin B complex.2 ent requirements and should be administered only via a central venous catheter because of its high osmolality. Partial PN provides only part of FEEDING RECOMMENDATIONS a patient’s caloric, protein, and nutrient requirements. However, it has a lower osmolality and therefore may be administered via peripheral intrave- Enteral feeding is preferred in patients who can tolerate it. Feeding tubes nous catheters. Complications associated with PN include hyperglycemia, should be considered in patients that are unwilling or unable to eat. Naso- hyperlipidemia, the potential risk for infection, intestinal atrophy (with gastric feeding tubes are easily placed without anesthesia and are often subsequent risk for bacterial translocation), increased rate of sepsis, a good option in critical patients; they allow for trickle feeding or bolus and azotemia. Aseptic technique is required, and extreme care should be feedings of a liquid diet. Esophagostomy tubes and percutaneous-guided taken with the handling and administration of PN. If contaminated, PN gastrostomy tubes should be considered for patients requiring long-term can become an excellent growth medium for bacteria. A study by Jensen assisted nutritional support once stable enough for general anesthesia. and Chan showed that patients receiving PN that were also trickle-fed had Force-feeding patients by mouth may cause food aversion and should be a higher survival rate than those receiving PN only.10 If PN is used, the avoided.10 general recommendation is to begin trickle feeding as soon as the patient will tolerate it and gradually increase enteral feeding.10 Obtaining a nutritional history, including how long the patient has been an- orexic at home before being admitted to the veterinary hospital, is crucial NURSING CARE in critical patients. Feeding tube placement to provide nutritional support for feline and canine patients that have been anorexic for 3 or more days An important role of the veterinary nurse is to closely monitor hospital- should be considered. Parenteral nutrition should be considered in pa- ized patients. Identifying potential problems and alerting the veterinarian tients that are unable to tolerate feeding by mouth, such as patients with allows for the patient treatment plan to be adjusted, potentially improving uncontrolled vomiting. patient outcomes. In addition to the standard monitoring of vital signs, vomiting, and diarrhea, hospitalized patients should be monitored for ENERGY REQUIREMENTS signs of refeeding syndrome, food aversions, fluid overload, electrolyte imbalances, feeding tube malfunction, and infection of feeding tube The RER is the energy requirement for a normal animal, which has not insertion sites. fasted and is at rest under thermo-neutral conditions, such as hospitalized patients. Two equations are used to calculate RER: Experienced veterinary nurses generally use a variety of coaxing tech- niques to encourage their patients to eat. Warming canned food, for exam- RER = 70 × (body weight in kg)¾ or ple, may work for some patients, while chilled canned food may be better accepted by nauseous patients. Hand feeding, petting, and talking to the RER = √√ × (weight in kg × weight in kg × weight in kg) = × 70 patient in a soothing manner during feeding time may work with some patients, while others may prefer to eat when left alone and undisturbed. Alternatively, for animals weighing between 3 kg and 25 kg, the following calculation should be used:1 Good record-keeping is essential to determine whether the patient is con- suming adequate calories or whether assisted feeding should be initiated, RER = (30 × current body weight in kg) + 70 continued, or discontinued. The general recommendation to begin enteral feeding of anorexic patients References is one-third of the patient’s total RER for the first 12 to 24 hours and, if well-tolerated, to gradually increase this amount every 12 hours until full 1. Chan DL, Freeman LM. Nutrition in critical illness. Vet Clin Small Anim RER is reached.2 If at any time the patient vomits, discontinue feeding 2006;36(6):1225-1241. until vomiting has resolved, reduce the volume when feeding is resumed, and increase the volume more slowly. In the past, an illness factor was 2. Hand MS, Thatcher CD, Remillard RL, Roudebush P, Novotny BJ. Small often added to the RER when feeding hospitalized patients. However, this Animal Clinical Nutrition, 5th ed.Topeka, KS: Mark Morris Institute; 2010. practice is no longer recommended because excessive nutrition during times of illness may increase the risk for hyperglycemia and other meta- 3. Brunetto MA, Gomes MO, Andre MR, et al. Effects of nutritional bolic complications.1 support on hospital outcome in dogs and cats. J Vet Emerg Crit Care 2010;20(2):224-231. NASOGASTRIC AND NASOESOPHAGEAL TUBE FEEDING 4. Krentz T, Allen S. Bacterial translocation in critical illness. J Small Anim Only liquid veterinary diets should be used for feeding through nasogastric Pract 2017;58(4):191-198. and nasoesophageal tubes because of the small diameter of these tubes. Trickle feeding via constant rate infusion is most often used for hospital- 5. Berg RD. Bacterial translocation from the gastrointestinal tract. J Med ized patients, although these tubes may also be used for bolus feedings 1992;23(3-4):217-244. and to administer oral liquid medications. 6. Campbell JA, Jutkowitz LA, Santoro KA. Continuous versus intermittent Many liquid diets designed for humans are also available; these diets are delivery of nutrition via nasoenteric feeding tubes in hospitalized canine typically less expensive than veterinary liquid diets. However, they are nu- and feline patients. J Vet Emerg Crit Care (San Antonio) 2010;20(2):232- tritionally inadequate for long-term use. These human diets are especially 236. inappropriate for cats because they are too low in protein, taurine, and arginine. 7. Liu DT, Brown DC, Silverstein DC. Early nutritional support is associated with decreased length of hospitalization in dogs with septic peritonitis: a retrospective study of 45 cases. J Vet Emerg Crit Care (San Antonio) 2012;22(4):453-459. 197

13–15 NOVEMBER, 2021 8. Mohr AJ, Leisewitz AL, Jacobson LS, et al. Effect of early enteral 0129 nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis. J Vet Intern Med 2003;17(6):791- CANINE PANCREATITIS - DO WE FINALLY HAVE A 798. TREATMENT? 9. Case LP, Daristotle L, Hayek MG, Foess M. Canine and Feline Nutrition: J. Steiner A Resource for Companion Animal Professionals. Maryland Heights, MO: Mosby-Elsevier; 2011. College Station/United States of America 10. Jensen KB, Chan DL. Nutritional management of acute pancreatitis in Qualifications: dogs and cats. J Vet Emerg Crit Care (San Antonio) 2014;24(3):240-250. Joerg M. Steiner, Dr.med.vet., PhD, DACVIM-SAIM, DECVIM-CA, AGAF University Distinguished Professor Dr. Mark Morris Chair for Small Animal Gastroenterology and Nutrition Director, Gastrointestinal Laboratory [email protected] Introduction Pancreatitis is very common in dogs, but the clinical presentation is highly variable, reaching from subclinical disease to an acute presentation with systemic clinical signs and a significant mortality. Advances in the diagnosis with advanced imaging and assays for the measurement of pancreatic lipase concentration in serum have improved our diagnostic accuracy for this condition, but treatment remains largely symptomatic and supportive. More recently, a new medication has been developed and has now been licensed for use in dogs with pancreatitis in Japan. Licens- ing in other countries is under way. Current Treatment Strategies for Pancreatitis in Dogs Treatment of Inciting Cause Whenever possible the inciting cause of the disease should be removed or treated. However, this may be difficult to accomplish as most cases of canine and feline pancreatitis are considered idiopathic. Several diseases and risk factors have been associated with pancreati- tis. Dietary indiscretion is considered to be an important risk factor for pancreatitis in dogs. Also, severe hypertriglyceridemia (statistically sig- nificant increase in risk for serum triglyceride concentrations > 850 mg/ dL) is considered a risk factor for pancreatitis. Pancreatitis is especially common in the Miniature Schnauzer and recently 3 different mutations have been identified in the SPINK-1 gene of affected dogs. This gene has also been associated with hereditary pancreatitis in humans. Traumatic pancreatitis (due to road traffic accidents in both dogs and cats or falling from heights in cats) has been reported. Surgical trauma can cause pancreatitis, but many human patients that undergo surgery of organs distant from the pancreas have also been shown to be at an increased risk for pancreatitis suggesting that hypoperfusion of the exocrine pancreas during anesthesia may be of bigger concern than surgical handling of the organ itself. Babesia canis has been reported to be associated with pan- creatitis in dogs. Many pharmaceutical compounds have been implicated in causing pancreatitis in humans and dogs. Hypercalcemia or calcium infusions can also be associated with pancreatitis. Chronic hepatitis may coexist in patients with pancreatitis, but there is no evidence that they play a causative role. A serum chemistry profile should be performed to rule out hypertriglyeri- demia or hypercalcemia. Exposure to unnecessary drugs, especially those implicated in causing pancreatitis in dogs or other species, should be avoided. Thus, a careful, drug history should be taken and the clinician should carefully determine whether treatment is still needed. For example, a patient that is treated with an anticonvulsant medication may need to 198 WSAVA GLOBAL COMMUNITY CONGRESS

be maintained on some anticonvulsant therapy, but, if being treated with 5HT3 antagonists work through different mechanisms both drugs can be potassium bromide and/or phenobarbital, the patient should be switched combined. to another anticonvulsant medication. Antiinflammatory Agents Supportive Care Glucocorticoids have not shown any benefit in human patients with acute Aggressive fluid therapy is the mainstay of supportive therapy for dogs pancreatitis that do not have autoimmune pancreatitis. One recent study with severe forms of pancreatitis. Fluid, electrolyte, and acid-base suggested beneficial effects of glucocorticoid treatment in dogs with imbalances need to be assessed, and corrected as early as possible. severe pancreatitis, but further studies are needed before glucocorticoids This is especially important since systemic complications are associated can be recommended for routine use. with a worse outcome and many of the systemic complications, once established, are difficult to treat. Recent studies in humans have shown Other Therapeutic Strategies that minimal differences in blood urea nitrogen concentrations at time of admission to the hospital and also minimal changes of BUN during the Many other therapeutic strategies, such as the administration of fresh first 24 to 48 hours after admission to the hospital can have a dramatic frozen plasma, antibiotics, trypsin-inhibitors (e.g. trasylol), platelet activat- impact on the outcome in humans with acute pancreatitis. ing factor inhibitors (PAFANTs), dopamine, antacids, antisecretory agents (i.e., anticholinergics, calcitonin, glucagon, somatostatin), or selenium, Traditionally, dogs with pancreatitis have been held off food, but over the and peritoneal lavage all have been evaluated in human patients with last 10 years this practice has been questioned based on experiences in pancreatitis. With the exception of PAFANTs and selenium, none of these human patients with pancreatitis. There is good evidence in humans with have shown any beneficial effect at this point. The efficacy of selenium, severe forms of pancreatitis that alimentation is crucial to counterbalance which has also been shown to decrease mortality in dogs in a single the catabolic effects of pancreatitis. Also, it has been shown in several uncontrolled study, needs to be further evaluated before its use can be studies that enteral nutrition is superior for the nutritional management recommended. of human pancreatitis patients. A recent study has made similar observa- tions in dogs. While there was no difference in mortality between dogs fed Fuzapladib by esophagostomy tube or total parenteral nutrition, dogs fed by esopha- gostomy tube improved significantly faster than dogs fed parenterally. Many patients with severe acute pancreatitis ultimately succumb to a sys- Also, studies in humans have shown that alimentation that enters the temic inflammatory response syndrome and it has long been recognized digestive tract before the duodenal papilla is not associated with a worse in humans that addressing this systemic inflammation has the biggest outcome when compared to patients fed by a jejunostomy tube. In fact, hope for treating these patients successfully. One such approach is the feeding patients through nasogastric tubes has been shown to be quite treatment with fuzapladib. effective in humans with pancreatitis. Thus, in general dogs and cats with pancreatitis should be fed whenever possible. An ultra low-fat diet should Fuzapladib sodium monohydrate (fuzapladib) is a leucocyte function-as- be chosen in dogs and a moderately fat-restricted diet in cats. If patients sociate activation (LFA-1) inhibitor that has been shown to effectively are not interested in food feeding by gastrostomy, esophagostomy, or block neutrophil extravasation in experimental animals. In a proof of nasogastric tube should be attempted. If the patient vomits relentlessly a concept study in Japan, the mortality in dogs with experimentally induced jejunostomy tube should be placed or the patient should be fed by partial pancreatitis was decreased from 50% to 0% after treatment with fuzap- or total parenteral nutrition. ladib. Furthermore, in two controlled clinical trials (one performed in Japan and another one performed in the USA), treatment with fuzapladib Analgesia was associated with faster clinical recovery and a more rapid decrease in serum C-reactive protein or Spec cPL concentrations. Abdominal pain is the key clinical sign in human patients with pancreatitis and is recognized in excess of 90% of all pancreatitis patients, but ab- Fuzapladib has recently been licensed for use in dogs with pancreatitis dominal pain is much less commonly recognized in dogs with pancreatitis in Japan under the brand name Brenda Z. However, fuzapladib is not yet (58% of dogs with severe pancreatitis). It is unlikely that abdominal pain licensed for use in dogs in other countries. However, data collected so far occurs less frequently in dogs than in humans and it is much more likely would suggest that this drug should be highly effective in treating dogs that abdominal pain remains unidentified in dogs. Thus, the presence of with acute pancreatitis. abdominal pain should be assumed and analgesic drugs are indicated in all dogs with pancreatitis. Meperidine, butorphanol tartrate, morphine, fentanyl, or combinations of multiple analgesic drugs can be used in hospitalized patients. Antiemetics Until recently, the choices for antiemetic agents for use in dogs with pancreatitis was limited. Metoclopramide, a dopamine inhibitor, was most widely used. However, its effect on splanchnic perfusion remains in question and the author does not like to use metoclopramide in dogs with pancreatitis. Fortunately, several other antiemetic agents have become available over the last few years. Maropitant, an NK1 antagonist has become widely available for use in dogs. Maropitant is a highly efficacious antiemetic agent through both peripherally and centrally-medicated mechanisms and can be used both parenterally in patients that are actively vomiting and orally in patients that appear mostly nauseous. Ondansetron is a 5HT3 antagonist and is also a very effective antiemetic agent in dogs. Since maropitant and 199

13–15 NOVEMBER, 2021 0130 patient-side test assay, SNAP fPL®, is also available. A negative SNAP test suggests that pancreatitis is very unlikely and that other differen- FELINE PANCREATITIS - ACVIM CONSENSUS tial diagnoses should be pursued. A positive SNAP test suggests that STATEMENT SUMMARY pancreatitis is possible and should prompt the clinician to submit a serum sample for the quantitative Spec fPL test as a positive test can be J. Steiner obtained if the sample is in the gray range or in the range diagnostic for feline pancreatitis. College Station/United States of America Traditionally, a pancreatic biopsy has been viewed as the most definitive Qualifications: diagnostic tool for feline pancreatitis. The presence of pancreatitis can be easily diagnosed by the gross appearance of the pancreas in many Joerg M. Steiner, Dr.med.vet., PhD, DACVIM-SAIM, DECVIM-CA, AGAF cases, which can then be confirmed by histopathological evaluation of a pancreatic biopsy. However, the absence of pancreatitis can be difficult University Distinguished Professor to prove as pancreatic inflammation is often highly localized. Pancreatic cytology may be a better choice to verify pancreatitis in cats. Similar to Dr. Mark Morris Chair for Small Animal Gastroenterology and Nutrition histopathology, cytologic evaluation of a fine-needle aspirate of the pan- creas is a great diagnostic modality to confirm a diagnosis of pancreatitis. Director, Gastrointestinal Laboratory Various studies have shown that if care is taken there is little risk with a fine needle aspiration of the pancreas. The presence of pancreatic acinar [email protected] cells confirms the successful aspiration of the pancreas and presence of inflammatory cells in the same aspirate confirms the presence of pancre- Introduction atic inflammation. However, in patients with severe pancreatic necrosis only cellular debris may be aspirated and the cytological evaluation may Traditionally, exocrine pancreatic disease has been considered to be rare be inconclusive. Also, lack of inflammatory cells in the infiltrate does not in cats, but over the last decade it has been recognized that exocrine rule out pancreatitis as the inflammatory lesions maybe highly localized. pancreatic disease, and especially pancreatitis is an important entity in cats. In one study, 115 cats were evaluated at necropsy. At least 3 biop- Management sies were collected from each pancreas and each biopsy was assessed separately for evidence of pancreatitis. The results were very surprising in Treatment of the cause, supportive care, and alimentation that only 33% of cats had no evidence of pancreatitis, 15.7% had lesions suggestive of acute pancreatitis and 60% had evidence suggestive of Whenever possible the inciting cause should be removed. However, this chronic pancreatitis. Late in 2019, a panel of 8 experts in the field (5 may be difficult to accomplish as most cases of feline pancreatitis are internists, 1 radiologist, 1 clinical pathologist, and 1 anatomic patholo- idiopathic. A serum chemistry profile should be performed to rule out gist), with support from a librarian, was formed to assess and summarize hypertriglyceridemia and/or hypercalcemia. Exposure to unnecessary evidence in the peer reviewed literature and complement it with con- drugs, especially those implicated in causing pancreatitis in cats or other sensus clinical recommendations. The current literature as it relates to species, should be avoided. In general any unnecessary drugs should be etiology, pathogenesis, diagnosis, and management of pancreatitis in cats discontinued and those that are deemed necessary should be replaced was evaluated and summarized and clinically relevant suggestions for with alternative drugs if possible. veterinary clinicians that are based on evidence, and where such evidence is lacking, based on consensus of experts in the field was prepared. The In cats with severe pancreatitis aggressive fluid therapy is the mainstay of following is a summary of some of the panel’s findings. The consensus supportive therapy. Fluid, electrolyte, and acid-base imbalances need to statement is available through open access at: https://onlinelibrary.wiley. be assessed, and corrected as early as possible. This is especially import- com/doi/10.1111/jvim.16053 ant since systemic complications are associated with a worse outcome and many of the systemic complications are difficult to treat once they are Diagnosis established. Complete blood count and serum chemistry profile often show mild and The traditional recommendation for any patient with pancreatitis is to give nonspecific changes. More severe changes can be observed in patients nothing per os for three to four days. However, there is little evidence to with severe forms of pancreatitis. Serum amylase and lipase activities justify this strategy. The issue is complicated further in cats by the fact are of no clinical value for the diagnosis of feline pancreatitis. Abdominal that cats with pancreatitis often develop hepatic lipidosis. Thus, aggres- ultrasound is useful for the diagnosis of pancreatitis in cats if stringent sive antiemetic therapy is crucial and, if possible, the cat should be fed criteria are applied. The sensitivity is largely operator-dependant. Changes through the gastrointestinal tract. In cats that eat voluntarily they can be identified include pancreatic swelling, changes in echogenicity of the fed a moderately fat-restricted diet. Cats that do not eat voluntarily can be pancreas (hypoechogenicity in case of pancreatic necrosis and, less fed with a gastrostomy tube, and esophagostomy tube, or a nasogastric frequently, hyperechogenicity in case of pancreatic fibrosis) and of peri- tube. If the patient vomits relentlessly the preferred routes of alimentation pancreatic fat (hyperechogenicity in case of peripancreatic fat necrosis), are a jejunostomy tube or total parenteral nutrition. Regardless of the fluid accumulation around the pancreas, and a mass effect in the area of mode of alimentation, a diet that is relatively low in fat should be chosen. the pancreas. Abdominal computed tomography is a routine diagnostic procedure in humans suspected of having pancreatitis, but has not been Analgesia sufficiently studied in cats for routine use. Abdominal pain is the key clinical sign in human patients with pancreatitis Many different cell types of the body synthesize and secrete lipases. In and is recognized in excess of 90% of all human pancreatitis patients. contrast to catalytic assays for the measurement of serum lipase activity, Abdominal pain is only recognized in approximately ¼ of all cats with use of an immunoassay allows for the specific measurement of lipase pancreatitis. However, it is unlikely that abdominal pain occurs less fre- originated from the exocrine pancreas. In one study, a wide variety of cats quently in cats than in humans and it is much more likely that abdominal were clinically evaluated by a panel of internists as to their pancreatitis pain remains unidentified in many cats. Thus, the presence of abdominal status. This study confirmed that serum fPLI concentration is the most pain should be assumed and analgesic drugs are indicated in all cats with sensitive diagnostic test for pancreatitis currently available for cats. A pancreatitis. 200 WSAVA GLOBAL COMMUNITY CONGRESS