WSAVA Nov 2021 Proceedings

communities. By designing the REC course in such a way that both rabies claring of freedom by 2030 fast-approaching. While considerable effort prevention and responsible pet ownership is discussed in detail, the needs to be made towards vaccinating a significant proportion of at-risk course content ensures that participants obtain a high level of knowledge dogs within these countries, ongoing efforts to maintain an adequate level and understanding upon completing the course. Since the launch of the of knowledge of rabies and its prevention also needs to be maintained REC course in February 2015, almost 10,000 individuals, originating from towards reaching the elimination target. It is envisaged that a significant 128 countries, have become certified rabies educators in one of the four cohort of qualified graduates from the free GEP courses would be exceed- languages, viz. English, French, Spanish, and Simplified Chinese. While ingly constructive as widespread disseminators of accurate, life-saving the number of graduates might seem insignificant compared to the global information to members of the public in the many dog-rabies endemic human population living in at-risk countries, a survey of the global commu- countries of the world. nity of REC graduates found the reach of the certified rabies educators to be significant. In fact, an estimated 8,58 million people have been reached References with information on rabies and responsible dog ownership through the information provided in the REC coursework between 2015 and 2020. 1. Banyard AC, Horton DL, Freuling C, Müller T, Fooks AR. Control and pre- vention of canine rabies: The need for building laboratory-based surveil- The second course available on the GEP is the Community Coordinator lance capacity. Antiviral Res. 2013;98(3):357–64. for Rabies Certificate (CCC). The CCC course an informative course that 2. Nilsson M. Effect of rabies education programs on rabies awareness, provides an additional layer of proficiency to certified rabies educators. attitudes towards dogs and animal welfare among children in Lilongwe, The course enables REC graduates to become rabies champions in their Malawi [Internet]. Swedish University of Agricultural Sciences; 2014. Avail- community and focuses on the following: i) building relationships with able from: https://stud.epsilon.slu.se/6516/7/nilsson_m_140320.pdf community’s authority figures (e.g., community leaders and tradition- 3. World Health Organization. WHO Expert Consultation on Rabies, third al healers) so that rabies activities can be effective and impactful, ii) report. WHO Technical Report Series. Geneva; 2018. assisting with the planning and implementation of dog vaccination events 4. Katongo M, Sumbi V, Pereko D, Wambugu M. The Effectiveness of Ther- so that all of the dogs, and community members, can be protected, iii) apeutics Committees ( TCs ) in Addressing Key Public Health Problems. In giving accurate advice to community members that have been exposed 2007. p. 2002. to suspect animals so that they receive the correct treatment, and iv) 5. Sanchez-Soriano C, Gibson AD, Gamble L, Jordana L, Bailey B, Mayer advocating for proper waste management to reduce free-roaming dogs D, et al. Implementation of a mass canine rabies vaccination campaign and prevent unnecessary bite cases. Since the official launch of the CCC in both rural and urban regions in southern Malawi. PLoS Negl Trop Dis. course in September 2016, more than 1,200 people (from 82 countries) 2020;14(1):e0008004. have graduated from the course in either English or French. 6. Spargo RM, Coetzer A, Makuvadze FT, Chikerema SM, Chiwerere V, Bha- ra E, et al. Knowledge, attitudes and practices towards rabies: A survey The third course available on the GEP is the Animal Handling and of the general population residing in the Harare Metropolitan Province of Vaccination Certificate (AVC) course. The AVC is a profession-specific Zimbabwe. PLoS One. 2021;16(1 January). course that empowers animal health professionals by providing them the 7. Rinchen S, Tenzin T, Hall D, van der Meer F, Sharma B, Dukpa K, et al. latest knowledge on the safe and humane vaccination of dogs and cats. A community-based knowledge, attitude, and practice survey on rabies To this end, the AVC coursework covers the following topics in detail: i) among cattle owners in selected areas of Bhutan. PLoS Negl Trop Dis. understanding animal behavior and how to use the knowledge to safely 2019;13(4):e0007305. approach and handle dogs and cats, ii) how to safely and effectively use 8. GARC. The GARC Education Platform (GEP) [Internet]. 2020 [cited 2021 the various types of animal handling equipment, iii) how to safely and Sep 20]. Available from: https://rabiesalliance.org/capacity-building/gep correctly administer and record rabies vaccinations, and iv) the different types of vaccination campaigns and special considerations that you might encounter or plan for. Since the launch of the AVC course in December 2015, more than 2,200 people, originating from 94 countries, have gradu- ated from the course in either English or French. The fourth course available on the GEP is the Rabies Healthcare Certifi- cate (RHC) course. The RHC is a profession-specific course that has been developed to provide human health professionals with the latest World Health Organization (WHO) guidelines pertaining to all aspects related to rabies vaccination protocols, treatment, and diagnosis in human patients. By incorporating the latest recommendations made by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) into the coursework, the RHC course provides graduates with the latest and most up-to-date information pertaining to: i) the correct administration of rabies biologics for either pre- or post-exposure prophylaxis (PrEP and PEP), ii) special considerations for providing human PEP, iii) the management of potential rabies exposure cases, and iv) the clinical diagnosis of suspect human rabies cases and the importance of subsequent laboratory confirmation. Since the launch of the RHC course in December 2018, more than 400 individuals have graduated from the course in either English or French (representing 54 countries). Canine-mediated rabies still poses a considerable public health threat in more than 120 countries around the world, with the target for self-de- 51

13–15 NOVEMBER, 2021 0024 of palliative care when human rabies cases are encountered. Healthcare workers in rabies-endemic countries routinely face difficult ONE HEALTH IN ACTION: RABIES IN THE SHOES OF decisions when facilities lack the equipment and biologics required to pro- A HUMAN HEALTH PROFESSIONAL 20 vide optimal treatment (including limited or highly centralized stocks). The most pertinent knowledge and skills in support of the assistance that can A. Coetzer1, T. Scott2, L. Nel1 be provided therefore becomes all the more critical. It is envisaged that the free RHC coursework on the online GARC Education Platform (GEP) 1Pretoria/South Africa, 2Luxembourg/Luxembourg will assist healthcare providers to provide their communities with the most appropriate rabies-specific healthcare and, in so doing, contribute to Qualifications: the fight to eliminate canine-mediated human rabies by 20305. Andre Coetzer References 1. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, PhD, Microbiology Attlan M, et al. Estimating the Global Burden of Endemic Canine Rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709. [email protected] Available from: http://dx.plos.org/10.1371/journal. Rabies is a neglected disease that kills an estimated 59,000 people every pntd.0003709 year, with one human dying from rabies every 9 minutes1. Rabies is a 2. World Health Organization. WHO Expert Consultation on preventable disease – firstly by avoidance of exposure (99% of cases Rabies, third report. WHO Technical Report Series. Geneva; result from exposure to rabid dogs) and secondly pre-exposure vacci- 2018. nation where appropriate. In addition, should an exposure nevertheless 3. World Health Organization. Rabies vaccines: WHO have occurred, the timely administration of post-exposure prophylaxis position paper – April 2018. Wkly Epidemiol Rec / Elev (PEP) will prevent the onset of the disease. There should therefore be épidémiologique Hebd. 2018;16:201–20. no human fatalities attributed to this disease. In modern times however, 4. GARC. The GARC Education Platform (GEP) [Internet]. 2020 human rabies still persist in more than 120 countries and there are several [cited 2021 Sep 20]. Available from: https://rabiesalliance. common factors that contribute to this atrocity, viz. a lack of community org/capacity-building/gep awareness/education, a lack of accessible biologics (vaccine and immune 5. Minghui R, Stone M, Semedo MH, Nel L. New global globulin) and the incorrect administration of biologics2. strategic plan to eliminate dog-mediated rabies by 2030. Lancet Glob Heal. 2018;(18):4–5. In an effort to address the shortcomings associated with the limited avail- ability of biologics and the incorrect provision of PEP by human health- care providers, the World Health Organization (WHO) issued an updated position paper on the use of rabies vaccines and biologics3. The position paper presented new evidence on the use of rabies vaccines, focusing on programmatic feasibility, simplification of vaccination schedules and the improved cost-effectiveness of certain routes of administration. This information, however, needs to be presented in an easy to digest format to ensure that healthcare professionals gain the most benefit from it. To disseminate the information provided in the updated guidelines, the Global Alliance for Rabies Control (GARC) developed an e-learning course that acts as a teaching aid to human health professionals that want to update their knowledge on the latest WHO guidelines on human rabies and its prevention4. The Rabies Healthcare Certificate (RHC) include all aspects related to rabies vaccination protocols, treatment, and diagnosis in humans. By incorporating the latest recommendations made by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) into the coursework3, the RHC course provides graduates with the latest and most up-to-date information pertaining to the following critical healthcare paths: I. the correct administration of rabies biologics for pre-exposure prophy- laxis (PrEP) using either intradermal or intramuscular routes, II. the correct administration of rabies biologics for PEP using either intradermal or intramuscular routes, and III. special considerations for providing human PrEP and PEP. In addition to the learning content focusing on the routine treatment of patients exposed to suspect rabid animals, the coursework also provides an additional layer of proficiency by offering content on situations that are often encountered by healthcare professionals in rabies-endemic countries. These include i) liaising with the community’s animal health professional to assess whether the biting animal could be rabid, ii) priori- tizing treatment when multiple bite victims seek treatment at a healthcare facility with a limited amount of rabies biologics, iii) the clinical and laboratory diagnosis of suspect human rabies cases, and iv) the provision 52 WSAVA GLOBAL COMMUNITY CONGRESS

0025 signs of immune-mediated destruction. UPDATES ON IMHA DIAGNOSIS AND TREATMENT; Evidence of hemolysis INCORPORATING NEW GUIDELINES The next step of the IMHA diagnostic algorithm is to assess for signs of C. Sharp hemolysis. This can either be extravascular hemolysis or intravascular hemolysis. Extravascular hemolysis is evidenced by hyperbilirubinemia, Murdoch/Australia significant hyperbilirubinuria, or icterus without functional hepatic disease, post-hepatic cholestasis or sepsis. In Snowflake’s case a mild Qualifications: hyperbilirubinemia (TBili 21 umol/L [2-17] was present, and so she was considered to fulfil this criterion. Evidence of intravascular hemolysis Dr Claire R. Sharp includes hemoglobinemia, hemoglobinuria, or the presence of erythrocyte ghosts on a blood smear. BSc, BVMS(Hons), MS, DACVECC In Snowflake’s case she fulfilled two criteria for immune-mediated eryth- [email protected] rocyte destruction, and one criteria for hemolysis and thus this was con- In 2019, two American College of Veterinary Internal Medicine (ACVIM) sidered “Diagnostic for IMHA”. Cases that fulfil fewer diagnostic criteria consensus statements were published regarding the diagnosis and treat- may be considered either “Supportive of IMHA” or “Suspicious for IMHA, ment of immune mediated hemolytic anemia (IMHA)(1, 2). This lecture provided another cause of anemia cannot be identified”.(1) reviews some of the highlights of these guidelines in the context of a clinical case scenario. Other diagnostic considerations for IMHA The case – Snowflake The ACVIM consensus statement classifies IMHA as non-associative if no other disease processes are identified in the patient, or associative if oth- The case presented is a 6 year old, female spayed, Maltese cross with a er disease(s) are present. Dogs with associative IMHA are classified as two day history of lethargy, anorexia, and orange stools. A complete blood having secondary IMHA if their concurrent disease is suspected to have count (CBC) revealed a moderate normocytic, normochromic anemia (Hct triggered IMHA, or to have an incidental comorbidity when causation is 17% [37-55]), with 1+ spherocytes, but a saline agglutination test (SAT) not suspected. Of putative trigger factors for IMHA in dogs, there is most was negative. She was mildly hyperproteinemic (TS = 78 g/L [60-75]). evidence for infectious triggers followed by drugs and vaccines. There is Based on a severe anemia without hypoproteinemia we were concerned less evidence for the potential of neoplastic or inflammatory disorders to that Snowflake may have IMHA. trigger IMHA. Diagnostic algorithm for IMHA Minimum diagnostics include a complete history, physical examination, blood tests prior to transfusion (as above), urinalysis, and abdominal ra- The ACVIM consensus statement on the diagnosis of IMHA has an excel- diographs (to rule out a zinc foreign body). Other diagnostics that may be lent algorithm (Figure 2 of that document),(1) that informs the diagnosis considered in individual cases include a urine culture, faecal diagnostics, of IMHA and can easily be applied in cases such as Snowflake. The FIV/FeLV testing in cats, screening diagnostic imaging (thoracic radio- algorithm dictates that in order to reach a definitive diagnosis of IMHA graphs, abdominal ultrasound), and infectious disease testing. Of interest, in a patient with anemia you need both strong proof of immune-mediated a recent study showed limited utility of screening diagnostic tests in iden- erythrocyte destruction and hemolysis. tifying associative IMHA in dogs.(3) Infectious disease testing should be based on patient signalment, lifestyle and an understanding of endemic Evidence of immune-mediated erythrocyte destruction diseases in the area. Babesia gibsoni in dogs (testing by serology and PCR), and B.felis and hemotropic mycoplasmas in cats (PCR testing) are Strong proof of immune-mediated destruction includes two or more of the the infections most strongly associated with IMHA. Identification of these following: spherocytes (in dogs only), a positive SAT without washing, a infections is important since treatment with antimicrobials may be all that positive direct antiglobulin test (DAT; or Coombs’ test) or flow cytometry. is required (ie. immunosuppression is not necessary in most cases). Alternatively a positive SAT that persists with washing alone is considered strong proof of immune-mediated destruction as a single criterion. Each IMHA Treatment of these criteria are described briefly in more detail. The mainstays of IMHA treatment are immune suppression, blood product Spherocytes are small, round, intensely stained erythrocytes that lack transfusion, and antithrombotic therapies. Figure 3 in the ACVIM consen- central pallor. These cells are created by phagocytosis of a portion of sus statement is an algorithm that outlines the initial treatment of IMHA antibody coated erythrocytes and thus prominent spherocytosis in dogs treatment in dogs.(2) suggests immune mediated erythrocyte destruction. Differential diagno- ses for spherocytosis include oxidative erythrocyte damage, envenom- Immunosuppression ation, hypersplenism, pyruvate kinase deficiency and diseases associated with erythrocyte fragility. Glucocorticoids are recommended as the first line immunosuppressive drug for dogs and cats with IMHA. Initial dosing should be in the range The SAT is a way to differentiate autoagglutination from rouleaux. When of 2-3mg/kg/day (50-60mg/m2) of oral prednisone / prednisolone as four drops of saline is added to one drop of blood, persistent gross a single daily dose or divided. IV dexamethasone can also be used granularity is consistent with a positive SAT and suggests the presence of temporarily in patients that are too sick for oral dosing. The addition of a anti-erythrocyte antibodies. In contrast, if gross granularity resolves with second immunosuppressive drug is indicated either a. from the outset of the SAT (ie. a negative SAT), rouleaux formation was the likely cause. The treatment to decrease the dose of glucocorticoid required, or if the patient DAT involves the addition of anti-dog immunoglobulin to a patient sample. has signs of a poor prognosis (more detail in the guidelines). Options If agglutination occurs the DAT is considered positive, and suggests the for second immunosuppressives include cyclosporine (5mg/kg PO q12h, presence of anti-erythrocyte antibodies coating the erythrocytes. In our adjusted based on therapeutic drug monitoring), azathioprine (2mg/kg case of Snowflake, she had spherocytosis but was SAT negative. As such or 50mg/m2 PO q24, and then reduced to every other day dosing after we added on a Coombs test (DAT), and the positive result then fulfilled 2 53

13–15 NOVEMBER, 2021 2-3 weeks), or mycophenolate mofetil (8-12mg/kg PO q12h). The use of Care (ACVECC) Consensus on the Rational Use of Antithrombotics in three or more immunosuppressive drugs concurrently should be avoided Veterinary Critical Care (CURATIVE) guidelines: Small animal. J Vet Emerg and rather adjunctive therapies such as human IVIG, or splenectomy, can Crit Care. 2019;29(1):12-36. be considered. The guidelines also contain extensive information about monitoring and tapering immunosuppressive therapies. Blood product transfusion Blood transfusion is recommended when dogs with IMHA have clini- cal signs attributable to decreased oxygen delivery as a result of their anemia. This may include mental obtundation, tachycardia, weakness, and hyperlactatemia. Packed red blood cells (pRBCs) are the product of choice, but whole blood is considered a reasonable alternative if pRBCs are not available.(2) Transfusion of fresh pRBCs, less than 7-10 days old is recommended, given one study that suggests older units may be associated with a higher risk of complications and mortality.(4) The most accurate formula to guide transfusion dosing is that 1.5mL/kg of pRBCs will increase the recipient PCV by 1%,(5) and we usually aim to transfuse a dog with IMHA to a PCV of 20-26%. Additionally, the guidelines contain information about considerations for blood typing and crossmatching patients with IMHA prior to transfusion.(2) Antithrombotic therapies Both the ACVIM consensus statement(2) and the ACVECC Consensus on the Rational use of Antithrombotics in Veterinary Critical Care (CURATIVE) (6) provide guidance on the use of antithrombotic therapies in dogs with IMHA. The CURATIVE guidelines state that IMHA is strongly associated with the development of thrombosis, and as such antithrombotic therapy is recommended. Since IMHA is most commonly associated with venous thrombosis, anticoagulant therapy may be considered first. But, since both venous and arterial thrombosis has been reported in dogs with IMHA, the concurrent use of an antiplatelet agent may be indicated when the risk of thrombosis outweighs the risk of bleeding. That being said, there is insufficient evidence of make strong recommendations regarding which anticoagulant and which antiplatelet agent is most appropriate. Options for anticoagulants include individually adjusted unfractionated heparin (with anti-Xa activity), low molecular weight heparin (LMWH), or a direct Xa inhibitor, such as rivaroxaban. Use of clopidogrel is suggested over aspirin as an antiplatelet drug. The appropriate duration of antithrombotic therapy for dogs with IMHA is not known. My suggestion is a minimum of 2 weeks, but longer if owner finances allow; ideally until the prednisolone has been tapered below 1mg/kg/day. References 1. Garden OA, et al. ACVIM consensus statement on the diagnosis of immune-mediated hemolytic anemia in dogs and cats. J Vet Intern Med. 2019;33(2):313-34. 2. Swann JW, et al. ACVIM consensus statement on the treatment of immune-mediated hemolytic anemia in dogs. J Vet Intern Med. 2019;33(3):1141-72. 3. Woodward GM, White JD. The utility of screening diagnostic tests in identifying associative immune-mediated haemolytic anaemia in dogs. Aust Vet J. 2020;98(12):586-90. 4. Hann L, et al. Effect of duration of packed red blood cell storage on morbidity and mortality in dogs after transfusion: 3,095 cases (2001- 2010). J Vet Intern Med. 2014;28(6):1830-7. 5. Short JL, et al. Accuracy of formulas used to predict post-transfu- sion packed cell volume rise in anemic dogs. J Vet Emerg Crit Care. 2012;22(4):428-34. 6. Goggs R, et al. American College of Veterinary Emergency and Critical 54 WSAVA GLOBAL COMMUNITY CONGRESS

0026 the bags were negative.(2) Based on this study some hospitals started to stock never frozen refrigerated plasma in their blood banks, with a 14 day NOVEL TRANSFUSION PRODUCTS; REFRIGERATED expiry date. PLASMA, PLATELET TRANSFUSIONS AND MORE A more recent study from my research group evaluated the stability of ex C. Sharp vivo coagulation factor activity in never-frozen and thawed refrigerated canine plasma stored for 42 days.(5) We collected whole blood from 10 Murdoch/Australia dogs, and separated the plasma, storing half as never frozen refrigerated plasma, and half as thawed refrigerated plasma. The thawed refrigerated Qualifications: plasma was frozen at -20C for six months, after which it was transferred to the refrigerator. In the never frozen plasma we found that activity of Claire R. Sharp FV, VII, IX and X decreased slowly over time but stayed within reference intervals for 42 days. The 95% confidence intervals around the estimated BSc, BVMS(Hons), MS, DACVECC marginal means for FVIII, von Willebrand factor (vWF) and fibrinogen concentration dropped below the reference interval by day 35-39, such [email protected] that we recommended an expiry date for never-frozen refrigerated plasma of 32 days. Indications for transfusion Thawed refrigerated plasma Blood product transfusions are indicated for a variety of situations including whole blood loss, anemia, and coagulopathy. Whole blood loss The findings were similar for thawed refrigerated plasma, in that activity may be external (eg. bleeding from a large wound), but is more commonly of FV, VII, IX and X decreased slowly over time but stayed within reference internal, secondary to trauma, or a bleeding neoplasm. Anemia may be intervals for 42 days. The 95% confidence intervals around the estimated due to red cell destruction, such as in immune mediated hemolytic anemia marginal means for FVIII, vWF, and fibrinogen concentration dropped (IMHA), or lack of production associated with kidney failure or anemia below the reference interval by day 32-35, such that we recommended of chronic / inflammatory disease. Plasma transfusion for patients with an expiry date for thawed refrigerated plasma of 28 days.(5) We are now coagulopathy is indicated when they have clinical signs of bleeding, or stocking two bags of thawed refrigerated plasma in our blood bank at prior to an invasive or surgical procedure. any one time, such that it is available for patients that require immediate transfusion. Novel transfusion products Lyophilized plasma Veterinary blood banking is constantly evolving, and this led to evidence supporting the use of novel transfusion products, as well as data to chal- Desiccated, freeze-dried plasma has been produced by the company lenge our understanding of the benefits of existing blood products. Three BodeVet in the United States (https://www.bodevet.com/) but is not novel transfusion products that I believe are practice changing include in- currently commercially available. This product is able to be reconstituted fusion ready plasma, lyophilized platelets, and stored whole blood (SWB). within 5 minutes, and following reconstitution is stable for 14 days. A Each will be discussed below. study has shown equivalent hemostatic capacity to fresh frozen plasma. (6) Hopefully, if the cost of production is able to be reduced, this product 1. Infusion ready plasma will reach the market and be another source of infusion ready plasma, particularly for hospitals with a lower case load that can’t justify stocking As outlined above, plasma transfusion is indicated for the treatment of co- frozen plasma products. agulopathy. Frozen plasma storage is considered the best way to preserve clotting factors and prevent bacterial contamination, however the need for 2. Lyophilized platelets thawing leads to a delay in having the product ready for transfusion. Thaw times for canine plasma are reported to be between 15.5 minutes in a run- Platelet transfusions are not commonly performed in veterinary medicine ning water bath,(1) and 34.7 minutes in a warm water bath(2). While this but are indicated in patients with marked thrombocytopenia that have may not be a problem in a stable patient, this time delay could contribute active and life-threatening hemorrhage, as well as part of massive trans- to a poor patient outcome in very unstable patients. One possible solution fusions. In human medicine fresh platelet products (platelet rich plasma to this problem is the use of microwave plasma defrosters or modified or platelet concentrate) are used but have special storage requirements commercial microwave warmers, however data has shown that clotting (room temperature, with constant gentle agitation) and a short life (3-5 factor activity is decreased when dog plasma is thawed with these prod- days). In veterinary medicine, cryopreserved platelets in DMSO have been ucts.(3, 4) As such, investigators have explored three options for infusion used but are also associated with their own drawbacks. ready plasma; never frozen refrigerated plasma, thawed refrigerated plasma, and lyophilized plasma. BodeVet produces a lyophilized platelet product that is revolutionising our approach to platelet transfusions. This product can be stored at room Never frozen refrigerated plasma temperature for 2 years, and can be reconstituted and ready for transfu- sion in 5 minutes. The efficacy of StablePlate Rx, their trehalose-stabilized Never frozen refrigerated plasma is that which is separated from packed lyophilized platelet product was recently evaluated in a multicenter ran- red blood cells immediately after collection, and stored refrigerated domized clinical trial.(7) Enrolment criteria included dogs with a platelet without ever having been frozen. One study has evaluated the ex vivo count of < 50,000/uL, and evidence of bleeding based on a DOGiBAT score coagulation factor stability in this product in dogs.(2) Whole blood was of ³2. Dogs were randomized to receive a dose of 3 x 109 platelets/kg as collected from 9 dogs and half kept as never frozen refrigerated plasma, either lyophilized platelets (n=50 dogs) or DMSO-stabilized cryopreserved while the other half was frozen for comparison. Samples were collected platelets (n=38 dogs). The enrolled dogs had a variety of diagnoses, from the never frozen refrigerated plasma at baseline, day 1, 5, 7 and 14 but primary and secondary ITP accounted for the majority of the cases. for measurement of coagulation factor activity. The authors found that Lyophilized platelets were superior to cryopreserved platelets with regard although the activity of all clotting factors decreased over time, no values to the change in DOGiBAT score and hematocrit at 1 hour post-transfusion were outside the reference intervals. Additionally, bacterial cultures from relative to baseline, and non-inferior compared to cryopreserved platelets 55

13–15 NOVEMBER, 2021 in these parameters at 24 hours. Overall, lyophilized platelets were non-in- 0027 ferior with regard to change in platelet count (at 1 and 24 hours), the need for additional pRBC transfusions, and survival to discharge.(7) These were INTRAVENOUS LIPID EMULSION FOR TOXICITIES IN encouraging results given that lyophilized platelets are logistically supe- DOGS. rior. As such, if you practice in the United States and occasionally have patients for which a platelet transfusion would be beneficial, this product C. Sharp may be good to have on your shelf. Murdoch/Australia 3. Stored whole blood Qualifications: Stored whole blood is that collected from a donor into anticoagulant solu- tion and stored refrigerated for up to 28-30 days before transfusion. Tradi- Claire R. Sharp tionally, this product has been used mostly as a way to provide red blood cells, since it was thought that the platelets rapidly lost their activity and BSc, BVMS(Hons), MS, DACVECC clotting factor activity was also short-lived. However, new data challenges this paradigm, and suggests that SWB may have more hemostatic capac- [email protected] ity than previously thought. A recent veterinary study assessed canine SWB with platelet aggregation, thromboelastography, and measurement What is ILE? of prothrombin time, activated partial thromboplastin time, and fibrinogen assays.(8) They found that SWB maintains significant clotting strength up Intravenous lipid emulsion (ILE) is a great tool to have in your toolbox for to 21 days, despite decreases in platelet aggregation, and reduced speed treating toxicities. ILE is produced commercially because it is a compo- of clot formation.(8) Further studies are warranted to explore the utility of nent of parenteral nutrition. A common brand is IntralipidÒ. this product as part of our transfusion armamentarium for dogs. History of ILE in the treatment of toxicity References: The therapeutic benefit of ILE was somewhat of an accidental discovery, 1. Torkildsen L, et al. Comparison of multiple thawing techniques on thaw by a physician named Dr Guy Weinberg, when he was investigating local time and stability of hemostatic proteins in canine plasma products. J anesthetic toxicity in animal models, including rats and dogs.(1, 2) It was Small Anim Pract. 2018. identified that rats pre-treated with ILE had a significant increase in the lethal dose (LD)50 of bupivacaine.(1) Similarly, when cardiopulmonary 2. Grochowsky AR, et al. An ex vivo evaluation of efficacy of refrigerated arrest (CPA) was induced with a 10mg/kg IV bolus of bupivacaine in dogs, canine plasma. J Vet Emerg Crit Care. 2014;24(4):388-97. those treated with ILE (n=6) and internal cardiac massage achieved return of spontaneous circulation, whereas those in the placebo group (saline, 3. Turner MA, Rahilly LJ, Katheryn O’Marra S. Ex vivo evaluation of the n=6) did not survive.(2) efficacy of canine fresh-frozen plasma thawed using a microwave plasma defroster. J Vet Emerg Crit Care. 2018;28(6):603-7. Mechanisms of action of ILE 4. Pashmakova MB, Barr JW, Bishop MA. Stability of hemostatic proteins Three potential mechanisms of action of ILE are hypothesised, and it is in canine fresh-frozen plasma thawed with a modified commercial micro- likely that different mechanisms are at play either alone, or in combina- wave warmer or warm water bath. Am J Vet Res. 2015;76(5):420-5. tion, in different toxicoses(3-5): 5. Chee W, Sharp CR, Boyd CJ, Claus MA, Smart L. Stability of ex vivo The first hypothesis, and that which is most relevant to LAST, is of coagulation factor activity in never-frozen and thawed refrigerated canine mitochondrial recovery. The fatty acids in ILE are thought to provide a po- plasma stored for 42 days. J Vet Emerg Crit Care. 2021;In Press. tential alternative (and preferential) energy substrate to the myocardium, restoring ATP levels, improving myocardial performance, and reversing 6. Mays EL, Hale A, Montgomery J, Fitzpatrick GM. Lyophilized plasma cardiovascular dysfunction. (Stableplas) is safe and noninferior to fresh frozen plasma during plasma exchange in the dog. J Vet Emerg Crit Care. 2019;29:S49-50. The second proposed mechanism is that by increasing intracellular cal- cium concentrations in cardiomyocytes, ILE may result in direct inotropy. 7. Goggs R, Brainard BM, LeVine DN, Calabro J, Harrell K, Mills T, et al. This hypothesis is thought to contribute to the beneficial effects of ILE in Lyophilized platelets versus cryopreserved platelets for management of calcium channel blocker toxicity. bleeding in thrombocytopenic dogs: A multicenter randomized clinical trial. J Vet Intern Med. 2020;34(6):2384-97. The third hypothesis is the lipid sink theory; this is used to explain poten- tial therapeutic benefits of ILE in treating a wide range of lipophilic drug 8. Edwards TH, Darlington DN, Pusateri AE, Keesee JD, Ruiz DD, Little JS, toxicities. The lipid sink theory postulates that administering high doses et al. Hemostatic capacity of canine chilled whole blood over time. J Vet of lipid creates a lipid compartment within the intravascular space that Emerg Crit Care. 2021;31(2):239-46. can then sequester lipophilic drugs, making them unavailable to bind to the receptors through which they have their toxic mechanisms. Based on the partition coefficient (P) and log P, and distribution coefficient (D) and log D, of various drugs, the potential therapeutic effect of ILE has been postulated for overdose situations. So what is the evidence for the use of ILE in dogs? Most of the evidence for the use of ILE in dogs is either experimental models, or case series, and case reports. These are considered relatively low levels of evidence and caution must be exercised with their interpreta- tion. Some key evidence is summarised below. 56 WSAVA GLOBAL COMMUNITY CONGRESS

Local anesthetic toxicity: Weinberg et al. first described that “Lipid Emul- including Heinz body anaemia and spherocyte formation.(12) Another sion Infusion Rescues Dogs From Bupivacaine-Induced Cardiac Toxicity”. study documented that ILE added to dog blood ex vivo caused hemolysis, (2) In this study CPA was induced in 12 dogs with bupivacaine; after 10 and that the severity of hemolysis was proportional to ILE concentration in minutes of conventional CPR, 6 dogs were treated with a 4mL/kg bolus the blood.(13) ILE has been associated with corneal lipidosis in two cats of ILE followed by a CRI, while the remainder did not receive ILE. In this (but not yet in dogs), and in both cases this abnormality resolved within a study, all 6 dogs receiving ILE survived, while those that did not died. week. Calcium channel blocker toxicity: An early experimental study in dogs also Conclusions investigated the “Hemodynamic Effects of Intravenous Fat Emulsion in an Animal Model of Severe Verapamil Toxicity Resuscitated with Atro- There are currently no consensus veterinary recommendations to guide pine, Calcium, and Saline”.(6) In this study only 1/7 placebo treated dogs the use of ILE. Nonetheless, it is generally well accepted that ILE is used survived, whereas 7/7 ILE treated dogs survived. A clinical case report of for local anesthetic overdose, and severe / life-threatening lipophilic drug the use of ILE in combination with high-dose insulin therapy for diltiazem toxicosis in the absence of other specific therapy. Similarly, ILE is general- overdose has also been reported.(7) ly avoided when other effective and specific therapies are available, or in cases that are likely to survive. In every case, risk to benefit ratio should Macrocyclic lactone toxicity: Numerous case reports and small case se- be assessed. ries have documented the use of ILE in patients experiencing an overdose of macrocyclic lactones such as ivermectin and moxidectin.(8-10) Results References: are somewhat variable, and it seems that dogs with the ABCB-1 (MDR-1) mutation have a less complete response to ILE therapy, than those with- 1. Weinberg GL, et al.. Pretreatment or resuscitation with a lipid infusion out the mutation; nonetheless, in the absence of other effective therapies shifts the dose-response to bupivacaine-induced asystole in rats. Anesthe- for this toxicity, and the potentially high rates of mortality, the benefit of siology. 1998;88(4):1071-5. ILE is thought to outweigh the risk by most ECC specialists. Additionally, a recent two dog case series suggest a role for lipid dialysis in the treat- 2. Weinberg G, et al. Lipid emulsion infusion rescues dogs from bupiva- ment of ivermectin toxicosis.(10) caine-induced cardiac toxicity. Reg Anesth Pain Med. 2003;28(3):198-202. Other case reports in dogs document the use of ILE for toxicosis associat- 3. Robben JH, Dijkman MA. Lipid Therapy for Intoxications. Vet Clin North ed with baclofen, organophosphates, NSAIDs, severe marijuana intoxi- Am Small Anim Pract. 2017;47(2):435-50. cation, synthetic cannabinoids, and others. Most of these case reports suggest benefit, although one case report of monensin toxicity suggested 4. Fernandez AL, et al. The use of intravenous lipid emulsion as an anti- that ILE did not result in benefit in ventilatory status in that case. dote in veterinary toxicology. J Vet Emerg Crit Care. 2011;21(4):309-20. Treatment recommendations 5. Kaplan A, Whelan M. The use of IV lipid emulsion for lipophilic drug toxicities. J Am Anim Hosp Assoc. 2012;48(4):221-7. In dogs, an ILE dose of 1.5-4mL/kg is usually given as a bolus, followed by a CRI of 0.25mL/kg/min for 30-60 minutes. The bolus is most vital for 6. Bania TC, et al. Hemodynamic effects of intravenous fat emulsion in those with cardiotoxicity (particularly CPA), but may not be necessary for an animal model of severe verapamil toxicity resuscitated with atropine, other toxidromes. If clinical signs continue after the first 30-60 minutes calcium, and saline. Acad Emerg Med. 2007;14(2):105-11. of therapy, further therapy may be based on whether or not the patient has gross lipemia. The serum is checked q 4-6 hours, and if not lipemic, 7. Maton BL, et al. The use of high-dose insulin therapy and intravenous a repeat dose of ILE is given. If lipemia persists at 4-6 hours, most would lipid emulsion to treat severe, refractory diltiazem toxicosis in a dog. J Vet avoid giving another ILE treatment, given the perception of an increased Emerg Crit Care. 2013;23(3):321-7. risk of complications. Guideline recommendations in human medicine limit dosing to <10% of total blood volume to reduce the risks of compli- 8. Crandell DE, Weinberg GL. Moxidectin toxicosis in a puppy successfully cations.(11) treated with intravenous lipids. J Vet Emerg Crit Care. 2009;19(2):181-6. Potential side effects of ILE 9. Wright HM, et al. Intravenous fat emulsion as treatment for ivermectin toxicosis in three dogs homozygous for the ABCB1-1Delta gene mutation. Like all drugs, the administration of ILE is not without the potential for J Vet Emerg Crit Care. 2011;21(6):666-72. adverse drug reactions. Most reports of side effects of ILE are in humans, but adverse effects are increasingly reported in the veterinary literature. 10. Londono LA, et al. Clearance of plasma ivermectin with single pass Particularly when it is used as part of parenteral nutrition, ILE has been lipid dialysis in 2 dogs. J Vet Emerg Crit Care. 2017;27(2):232-7. associated with bacterial contamination and hence septic complications in the recipient. As such, proper handling with aseptic technique is vital to 11. Gosselin S, et al. Evidence-based recommendations on the use reduce this risk. Gloves should be worn, the solution should be drawn up of intravenous lipid emulsion therapy in poisoning. Clin Toxicol. aseptically, and the bottle / bag discarded after use (or at least within 24 2016;54(10):899-923. hours of opening). 12. Romans CW, Day TK, Smith JJ. Oxidative red blood cell damage asso- Hyperlipidemia will interfere with laboratory testing, and some suggest ciated with propofol and intravenous lipid emulsion therapy in a dog treat- that it may increase the risk of pancreatitis. Additionally, lipid emboli, ed for 5-fluorouracil toxicosis. J Vet Emerg Crit Care. 2020;30(4):481-6. alterations in pulmonary function (including ARDS), and trapping of other lipid soluble medications have been reported. Fat overload syndrome 13. Behling-Kelly EL, Wakshlag J. A commercial soy-based phospholipid (FOS) is a recognised complication of ILE in humans associated with emulsion accelerates clot formation in normal canine whole blood and hyperlipidemia, hepatosplenomegaly, icterus, thrombocytopenia, thrombo- induces hemolysis in whole blood from normal and dogs with inflammato- cytopathia, and hemolysis. Although FOS has not been reported in dogs, ry leukograms. J Vet Emerg Crit Care. 2018;28(3):252-60. hemolysis has been associated with ILE. In one case report, a dog that received both propofol and ILE experienced oxidative erythrocyte damage, 57

13–15 NOVEMBER, 2021 0028 DISEASE CONDITIONS IN DOGS CONDITIONS IN CATS MECHANISMS N/A TIGHT JAW L. Garosi Vascular N/A IPER/United Kingdom Inflammatory/ Masticatory Muscle Myositis Infectious (MMM) Qualifications: Inflammatory processes of the Inflammatory processes of the TMJ, middle ear or retrobulbar TMJ, middle ear or retrobulbar Dr Laurent Garosi DVM, Dip ECVN, FRCVS area area RCVS & EBVS® European Specialist in Veterinary Neurology Meningoencephalitis (rare) Meningoencephalitis (rare) [email protected] Generalised inflammatory myop- Trismus describes a limited ability to open the mouth and is also called athies: “lock-jaw”. By definition, trismus is due to spasm of the jaw muscles as typically seen with tetanus or more rarely with other central nervous immune-mediated polymyositis, Generalised inflammatory myop- system diseases. However, “mechanical” abnormalities of the temporo- infectious aetiology (Toxoplasma, athies: mandibular joint (TMJ) (ankylosis due to fracture, luxation, dysplasia, Neospora, Borrelia, Rickettsial, osteoarthritis) or fibrosis of masticatory muscles secondary to chronic Hepatozoon), para-neoplastic immune-mediated polymyositis, masticatory muscle myositis (MMM)0 may also lead to trismus. Acute syndrome, breed-associated infectious aetiology (Toxoplas- onset MMM, craniomandibular osteopathy, osteomyelitis or tumours (Newfoudland, Boxer and Hungari-ma), para-neoplastic syndrome affecting the bones of the jaw or in the vicinity of the TMJ can also lead to an Vizsla) severe pain and reluctance to open the mouth. Extraocular myositis (rare) NEUROANATOMICAL BASIS Trauma Ankylosis due to fracture or luxa- Ankylosis due to fracture or luxa- Masticatory muscles contain a unique muscle fiber (type 2M) that differs tion of the TMJ, foreign bodies tion of the TMJ, foreign bodies both histochemically and biochemically from fiber types present in limb muscles (types 1A and 2A). Toxic Tetanus Tetanus The presence of “lock jaw” can be due to “genuine” trismus caused by Strychnine Strychnine spasm of the jaw muscle or arise from disease affecting the muscles of mastication or the TMJ itself. Spasms of the jaw muscles reflect an Anomalous TMJ dysplasia Myotonia congenita (rare) “upper motor neuron” defect, where upper motor neurons or interneurons Myotonia congenita (rare) lose their inhibitory effect on the lower motor neuron, which results in increased muscle tone. Idiopathic Craniomandibular osteopathy With diseases affecting the TMJ or mandible, “lock jaw” is either due to a Neoplastic Tumours of the mandible or TMJ, mechanical restriction or is pain associated. Moreover, any painful condi- Tumours of the mandible or TMJ, tions of the skull that cause referred jaw pain can make animals reluctant to open the mouth. Paraneoplastic polymyositis Brain tumours (rare) NEUROLOGICAL EVALUATION Brain tumours (rare) Complete physical and neurological examination is important to try distinguishing neurological from non-neurological causes of trismus. Pa- TMJ osteoarthritis TMJ osteoarthritis tients should be closely examined for evidence of trauma that could have Degenerative Muscular dystrophy (rare) resulted in temporomandibular joint luxation/subluxation. Thorough oral and ophthalmic examinations should be performed. Retrobulbar masses Muscular dystrophy (rare) often cause visible swelling or drainage behind the carnassial teeth. Animals with trismus caused by tetanus often show a characteristic facial COMMON CAUSES OF TRISMUS expression (‘risus sardonicus’) resulting from an increase in facial muscle tone. With disease affecting the TMJ or mandible itself, the neurological Masticatory Muscle Myositis (MMM) examination will not reveal any deficits, even though masticatory muscles can become severely atrophied over several weeks (disuse atrophy). On MMM is an auto-immune inflammatory myopathy of the masticatory an acute basis there will be no evidence of muscle atrophy. Limb muscle muscles in dogs mass, tone and segmental spinal reflexes should be evaluated to investi- gate the possibility of a more generalized myopathy. Circulating auto-antibodies against masticatory muscle type 2M fibers (fiber type-specific auto-antibodies) can be detected in more than 80% of DIFFERENTIAL DIAGNOSIS dogs with MMM and are the basis of serology testing for this condition. The list of differential diagnoses for trismus is dependent on the overall MMM can be seen in any breed of dog with no apparent gender predilec- clinical and neurological evaluation, as well as on signalment, history and tion. The average age of onset is 3 years; the condition has been reported course of the disease. The following table lists the differentials for dogs in dogs as young as 3 months of age (Cavalier King Charles Spaniels) and cats with trismus. Two types of clinical presentation are seen: the acute painful form and the chronic atrophic form The acute form presents with bilateral masticatory muscle swelling, oc- casional ocular signs (exophthalmus, conjunctivitis), pyrexia, mandibular lymphadenopathy and inability to open the mouth, primarily due to pain. The signs may initially be unilateral without concurrent trismus. 58 WSAVA GLOBAL COMMUNITY CONGRESS

The chronic form is a progression of the acute phase, and results in dog more comfortable; appropriate nutrition needs to be assured marked bilateral masticatory muscle atrophy; fibrosis of masticatory muscles can lead to an inability to open the mouth; forceful opening of the The abnormal bone growth usually ceases by 1 year of age, and lesions jaw must be avoided, even under sedation or anaesthesia may then regress (partially or completely); if the TMJ is severely affected, a permanent inability to move the jaw may result; surgery may partially Diagnosis is made based on the presence of antibodies against mastica- correct the problem tory muscle type 2M fibers; this serum antibody titer is 100% specific with a sensitivity of 85-90%; previous corticosteroid medication can result in SPECIFIC DIAGNOSTIC TESTS FOR TRISMUS false-negative results; some cases of end-stage MMM may also be asso- ciated with negative serum results; CK may be elevated in acute stages of If trismus is the only presenting sign the disease - Type 2M antibody titres in dogs to investigate for MMM EMG can help to confirm the selective involvement of masticatory muscles and differentiate MMM from polymyositis. However, EMG may - CK serum measurement to investigate for a myopathy be normal in dogs with end-stage disease because of severe fibrosis and myofiber depletion. - Electromyography (EMG) to exclude a generalised myopathy Evaluation of muscle biopsy taken from the masticatory muscles can - Muscle biopsy in case of an abnormal electromyography also provide diagnostic confirmation of the disease as well as prognostic information by determining the stage of the disease - Radiographs to assess the TMJ; mandible and bullae Masticatory muscle biopsies of dogs with MMM are characterised by - Otoscopic examination to assess for middle ear disease causing referred intense multifocal lymphocytic and plasmacytic perivascular infiltration, pain and reluctance to open the jaw occasional eosinophils, necrosis and phagocytosis of type 2M myofibers. - Advanced diagnostic imaging of the head (CT or MRI) to aid in selection MRI and CT are mainly helpful to exclude other causes of trismus, but may of sites for muscle biopsy be an aid in the selection of sites for muscle biopsy; MRI is not routinely performed to diagnose MMM. If additional neurological deficits are present and there is suspicion of structural brain disease Therapy for acute cases consists of immunosuppression with prednis- olone (starting at 1 to 2 mg/kg PO bid until serum CK and jaw function - Advanced brain imaging (CT or MRI) return to normal, gradually tapering off to the lowest alternate day dose, which should be maintained for 4-6 months). Serum antibody titres can be - Cerebrospinal fluid (CSF) analysis; infectious disease titres and PCRs as used as a treatment guide. appropriate. Other immuno-suppressive agents such as azathioprine (1 to 2 mg/kg If additional signs of a generalised myopathy are present every 24 hours orally) are indicated in dogs that fail to respond to cortico- steroid treatment or that relapse when the dose is tapered. - CK serum measurement In chronic cases, prednisolone should be administered at an anti-inflam- - EMG matory dose for 1 month and physical therapy is recommended; the latter can be performed by encouraging the dog to play with tennis balls or chew - Infectious titres rawhide; adequate nutrition is essential at all times - Muscle biopsy of the masticatory muscles as well as limb muscles Prognosis is good if MMM is identified and treated aggressively during the early phase, but persistent muscle atrophy is a common manifestation If myotonic signs are present (additional muscle stiffness without cramp- ing; muscle dimpling, percussion myotonia, after being struck with a reflex Tetanus hammer) Tetanus should be considered when evaluating any animal with acute - EMG – myotonia is characterized by trains of repetitive discharges which onset of head and face abnormalities, especially when trismus is present. wax and wane in frequency, producing an audible “dive-bomber” or motor- cycle sound. These myotonic discharges are independent of neural control Craniomandibular osteopathy (CMOP) and persist even under general anaesthesia. CMOP is a non-neoplastic, developmental bone disease affecting the - Genetic tests for myotonia congenita in certain breeds (Miniature mandible, tympanic bullae and temporal region of young, growing dogs Schnauzer, Australian Cattle dog) (4-8 months of age) - Exclude hyperadrenocorticism Lesions are mostly bilateral and consist of irregular enlargement of the affected bones due to cyclical resorption of normal bone and replacement by immature bone It is inherited in West Highland White terriers. Typical clinical signs include firm swelling of the jaw, difficulty eating, pain on opening the mouth, sometimes inability to open the mouth, cyclic fever, atrophy of masticatory muscles and lymphadenopathy Diagnosis is usually made via radiographs, which reveal irregular bone thickening; rarely, a biopsy is necessary for confirmation Pain relief and anti-inflammatory medication (prednisolone) can make the 59

13–15 NOVEMBER, 2021 0029 9) and/ or Horner’s syndrome without any postural reaction deficits, a middle/ inner ear neurolocalisation must be suspected based on the DROOPY FACE close proximity of the 8th cranial nerve and the cranial cervical ganglion/ post-ganglionic sympathetic neurons. L. Garosi 2.2) Polyneuropathy IPER/United Kingdom If spinal reflexes are reduced, the facial paresis / paralysis may be part of Qualifications: a more generalised peripheral neuropathy. Facial weakness, in particular a decrementing blink reflex, may be seen with junctionopathies such as Dr Laurent Garosi DVM, Dip ECVN, FRCVS myasthenia gravis, or more rarely botulism and tick paralysis in Australia RCVS & EBVS® European Specialist in Veterinary Neurology 2.3) Idiopathic facial nerve dysfunction [email protected] If facial paresis / paralysis occurs as the sole sign, idiopathic facial Facial paresis or paralysis is often featured as a sole sign, as seen with paresis is the most likely diagnosis. However, even though hypothyroid- idiopathic facial paresis/ paralysis. However, it can also occur with more ism commonly causes polyneuropathies, facial paresis may be the only complex diseases of the middle/ inner ear or central nervous system, and clinical sign. occasionally reflect part of a generalised peripheral neuropathy. Muscles that regulate facial expression and maintain a physiological appearance DIFFERENTIAL DIAGNOSIS of the mouth, ear position and palpebral fissure are innervated by the facial nerve (CN VII). A thorough neurological examination will help to lo- DISEASE CONDITIONS IN DOGS CONDITIONS IN CATS calise the problem, establish an appropriate list of differential diagnoses, MECHANISMS and determine the choice of diagnostic tests. Vascular Brain haemorrhage/ infarct (rare Brain haemorrhage/ infarct (rare NEUROANATOMICAL BASIS cause) cause) The facial nerve (CN VII) is motor to the muscles of facial expression and sensory (providing the sense of taste) to the rostral two thirds of the Inflammatory/ Otitis media/ interna Otitis media/ interna tongue and hard palate. Its parasympathetic component innervates the Infectious Middle ear polyps lacrimal gland, the mandibular and sublingual salivary glands. Neurons innervating the muscles of facial expression are located in the facial Meningoencephalitis of unknown Meningoencephalitis of unknown nucleus in the rostral medulla oblongata. The axons pass in the internal aetiology (eg GME); Infectious aetiology (presumed immune-me- acoustic meatus of the petrosal bone on the dorsal surface of the vestib- encephalitis (Distemper, Rabies diated) (rare) ulocochlear nerve and leave the skull through the stylomastoid foramen. The facial nerve courses through the middle ear before branches are Toxoplasma, Neospora, Fungal, Infectious encephalitis (Toxoplas- distributed to the muscles of facial expression (ear, eyelids, nose, cheeks, Bacterial, Rickettsial) and lips) as well as caudal portion of the digastricus muscle. ma, FIP, Rabies, Bacterial, Fungal) Motor dysfunction of CN VII produces the following signs: drooping and Acute canine polyradiculoneuritis inability to move the ear and lip, drooling, widened palpebral fissure, ab- sent spontaneous and provoked blinking, absent abduction of the nostril (Chronic demyelinating polyradic- during inspiration, deviation of the nose toward the normal side due to the uloneuritis) unopposed muscle tone on the unaffected side. With chronic denervation, the lips are retracted further than normal and the nostril is deviated to Trauma Head trauma / peripheral facial Head trauma / peripheral facial the affected side as a result of muscle fibrosis. Lesions of the individual branches of the facial nerve produce paresis or paralysis to the specific trauma trauma muscle they innervate. Involvement of the parasympathetic supply of the lacrimal and nasal glands produces keratoconjonctivitis sicca and a dry Iatrogenic following bulla oste- Iatrogenic following bulla oste- nose respectively. otomy otomy NEUROLOGICAL EVALUATION Hypersensitivity associated with The neurological evaluation should help to localise the problem as a peripheral cranial nerve disease or central cranial nerve disease. Toxic potentiated sulphonamides (Tick paralysis) 1) Central cranial nerve disease/ brainstem disorder causing facial paral- Tick paralysis ysis Anomalous Chiari like malformation (mild If the brainstem is affected, hemiparesis and/or postural reaction deficits facial paresis, possible bilateral)* are usually present, which occur on the same side of the facial paresis/ paralysis, Moreover, brainstem signs can include. the involvement of Metabolic Hypothyroidism further cranial nerves, altered mentation or presence of vestibulocerebel- lar signs; Idiopathic facial nerve paresis/ Idiopathic facial nerve paresis/ 2) Peripheral nerve disease causing facial paralysis Idiopathic paralysis paralysis 2.1) Middle/ inner ear disease Acquired myasthenia gravis Acquired myasthenia gravis If there is evidence of ipsilateral vestibular signs (section 3 chapter Neoplastic Primary or metastatic brain Primary or metastatic brain tumour tumour Middle ear tumour Middle ear tumour *If Chiari like malformation is associated with syringomyelia, neck/ flank 60 WSAVA GLOBAL COMMUNITY CONGRESS

scratching, neck pain and postural reaction deficits due to the latter are (CT) or magnetic resonance imaging (MRI) to assess for otitis media/ the most common signs interna. Facial muscle weakness can be seen in conjunction with myasthenia C) If CNS involvement is suspected (postural reaction deficits, altered gravis, botulism or tick paralysis; facial paresis/ paralysis (often bilateral mental status, other cranial nerve deficits, cerebellar or forebrain signs) but may be asymmetrical) may theoretically occur as part of any acute onset peripheral neuropathy: however more generalised neuropathic signs - Advanced brain imaging (CT or MRI) should also be present - Cerebrospinal fluid analysis (nucleated cell count and cytology, total COMMON CAUSES OF FACIAL PARESIS/PARALYSIS protein concentration) Idiopathic facial nerve paresis / paralysis - Serum and CSF infectious disease titers and/or PCR for various infec- tious organisms and CSF culture if indicated Most common cause of facial nerve paresis / paralysis in dogs and cats D) If a polyneuropathy or more generalised neuromuscular disease is sus- Cocker Spaniels and Boxers are predisposed pected (reduced spinal reflexes, postural reaction deficits, other cranial nerve involvement) Aetiology is unknown - Electromyography (EMG) and motor nerve conduction studies indicated Occurs mostly as unilateral dysfunction, but may occur bilaterally; other in patients suspected of a more diffuse polyneuropathy or multiple cranial neurological deficits are usually absent although some animals might nerve neuropathy develop concurrent idiopathic vestibular syndrome - Search for an attached tick Diagnosis is attained by exclusion of other possible causes. Even in the absence of other neurological deficits, thorough investigation for ear - Consider botulism intoxication disease as well as blood tests for hypothyroidism (dog) are recommended - Thyroid function testing (dog) CSF evaluation can help exclude CNS inflammatory causes of facial paresis - If electrodiagnostic testing is abnormal: chest radiographs and abdom- inal ultrasound to exclude paraneoplastic polyneuropathy; muscle and MRI evaluation revealing lack of contrast enhancement of the intratem- nerve biopsy may aid in definitive diagnosis poral part of the facial nerve may be associated with a better outcome in dogs with idiopathic facial paralysis - Anti-acetylcholine receptor antibody titre to rule-out focal myasthenia gravis in cases showing facial paresis No specific treatment exists. Even though tear production is expected to be normal with idiopathic facial paresis / paralysis, corneal lesions may - Cerebrospinal fluid analysis (nucleated cell count and cytology, total occur because of exposure due to reduced eyelid closure and this should protein concentration) be addressed. - Serum and CSF infectious disease titers and/or PCR for various infec- Prognosis for complete recovery is guarded; recovery can take weeks to tious organisms and CSF culture if indicated months, but may not occur at all. Occasionally, this disorder progresses to affect both facial nerves. - Thoracic radiographs and abdominal ultrasound to evaluate for paraneo- plastic causes Chronicity may result in muscle contracture and deform the facial expres- sion permanently SPECIFIC DIAGNOSTIC TESTS FOR FACIAL PARESIS A) If facial paresis/ paralysis is the only presenting sign - Thyroid function testing (dog): total T4 and TSH determinations as mini- mum screening; if inconclusive, free T4, T3 and antithyroid antibody levels should be analysed - Otoscopic and pharyngeal examination (particularly to check for possible inflammatory polyps in cats), should be performed under general anaes- thesia if necessary - If otitis media/interna is suspected from the history, see (b) below. B) If otitis media/ interna is suspected (history, concurrent vestibular signs and / or Horner’s syndrome) - Otoscopic and pharyngeal examination should be performed, if neces- sary under general anaesthesia - Swabs for cytology and culture (aerobic, fungal and yeast) from the middle ear cavity if the tympanic membrane is ruptured - Myringotomy with a 20-gauge spinal needle to obtain samples from the middle ear cavity for cytology and culture if the tympanic membrane is intact but bulging or of an abnormal colour - Imaging of the tympanic bullae with radiographs, computed tomography 61

13–15 NOVEMBER, 2021 0030 that the affected animal maintains a normal mental state (normal con- sciousness) during the episode and that there is no loss of bladder/bowel PAROXYSMAL DYSKINESIA function or excessive salivation.When possible, owners should be asked to provide a video recording of an episode to assist the clinician with the L. Garosi evaluation of the affected animal. IPER/United Kingdom The most important differential diagnosis for paroxysmal movement disorders is simple, partial (focal) seizures. Such disorders are recognized Qualifications: in animals with stereotypic (i.e. repeatedly similar), episodic muscle movements. As such, they can be easily misconstrued as a paroxysmal Dr Laurent Garosi DVM, Dip ECVN, FRCVS movement disorder. Given the difficulty in the clinical differentiation from simple partial (focal) seizures, along with a lack of a defined diagnostic RCVS & EBVS® European Specialist in Veterinary Neurology algorithm for PD, strong consideration should be placed on pursuing diagnostic testing aimed at eliminating structural disease of the CNS. [email protected] Consequently, performing an MRI scan of the brain, with cerebrospinal flu- Paroxysmal dyskinesias (PDs) are episodic movement disorders in which id (CSF) analysis, is usually recommended. Complete blood count, serum abnormal movements are present only during attacks. Although increas- biochemical evaluation and urinalysis to exclude underlying metabolic or ingly being recognised they are often poorly characterised in the veteri- endocrine disorders may also be considered prior to evaluation of possi- nary literature and are commonly mistaken for an epileptic seizure, both ble structural brain disease. by owners and by vets. SELECTED BREED-SPECIFIC PAROXYSMAL DYSKINESIA The term paroxysmal indicates that the signs occur suddenly against a background of normality. The term dyskinesia broadly refers to a Episodic falling syndrome (EFS) is a canine paroxysmal hypertonicity movement of the body that is involuntary, which means that your dog has disorder found in Cavalier King Charles Spaniels. Episodes are triggered no control the movement and remains fully aware of its surroundings. by exercise, stress or excitement and characterized by a gradually Between attacks, dogs are neurologically normal and there is no loss of worsening muscle spasm in the fore and hind limbs during an attack, consciousness during the attacks, though some dogs find the episodes with the trunk also affected; this results in a characteristic ‘deer-stalking’ disconcerting and do not respond normally. The attacks can last anything or ‘praying’ position. Episodes begin between fourteen weeks and four from a few minutes to a couple of hours and can sometime occur in years of age and dogs are normal between episodes. The condition gets clusters. its name from the fact that all four limbs will often cramp during exercise can cause falling. Other conditions, including heart problems, can also Most neurologists consider that PD results from dysfunction an area of cause collapse during exercise but EFS causes no loss of consciousness the brain called the basal nuclei (often call the basal ganglia). Nerve cells or colour change in the gums. Other clinical signs that sometimes occur in this area play an important role in initiating and controlling movement include facial muscle stiffness, stumbling, a ‘bunny-hopping’ gait, arching and any abnormal activity here can result in spontaneous and uncontrolled of the back or vocalization; again, other conditions can sometimes cause muscle activity. The underlying cause of many PDs is unknown, with the similar behaviour. A genetic test is available, so that suspected cases majority being described as idiopathic (meaning of unknown cause). In can have a blood sample taken and submitted via Laboklin (http://www. humans, some are recognised to be caused by genetic abnormalities and laboklin.co.uk/) or the Animal Health Trust (http://www.aht.org.uk/) for can be familial in origin. Some patients develop paroxysmal movement analysis. Treatment is possible, with most dogs responding to the use disorders as a result of a structural disease (eg. tumour, inflammation, of a drug called acetazolamide. A ten-year breeder-led investigation into infection, stroke…) affecting the basal nuclei. the inheritance of EFS has suggested an autosomal recessive mode of inheritance (http://cavalierepisodicfalling.com); this means that dogs can In veterinary medicine, PD have been described in a number of breeds carry the disease and pass is on to their offspring, without necessarily (Cavalier King Charles spaniel, Border terrier, Cairn terrier, Scottish terrier, being affected themselves. Clonazepam can be used as add-on treatment Dalmatian and Norwich terrier, Boxer, Bichon Frise, Pugs, Chinook, in to acetazolamide in difficult to control cases, though its beneficial effects which they have been ‘labelled’ as breed-specific entities (see below). sometimes diminish with time; other drugs can also be considered. Although not reported in the literature, similar paroxysmal movement dis- orders are increasingly seen in other breeds, particularly Jack Russell ter- Scottie cramp is a syndrome observed in young adult Scottish or Cairn riers (JRT) or Labrador retrievers in the UK. The most common appearance terriers. In this condition, there is again sustained muscle contractions, of affected dogs is ‘cramping’/’spasm’ involving the hind limbs, which is primarily affecting the hind limbs. With excitement, the hind limbs typical- seen as an increase in the muscle tone of the limbs. While all four limbs ly assume a stiff, extended position, though affected dogs occasionally may be affected, the hind limbs are often affected to a greater degree display exaggerated flexion of the limbs; the forelimbs can also cramp. than the fore limbs. During attack, animals can be severely incapacitated, During an attack, affected dogs develop a stiff, stilted gait over a few min- since the spasm overcomes any attempts at voluntary movement; howev- utes. Severely affected dogs assume an arched posture over their back er, many dogs will still attempt to walk. In some cases, episodes can be and may fall onto their side, with their head and tail flexed. The disease triggered by excitement or exercise. has a presumed autosomal recessive inheritance pattern with variable expression of the clinical signs. Diagnosis is based on a dog having HOW IS PAROXYSMAL DYSKINESIA DIAGNOSED? typical episodes and no evidence of other conditions that might appear similar. Treatment is aimed at using drugs to improve muscle relaxation or Dogs and people with PD are often misdiagnosed as having unusual epi- to increase serotonin levels. leptic seizures (in some types of seizure, the patient remains conscious – as in an attack of PD). Correct identification of the exact nature of the Another breed associated syndrome, which has been well documented in paroxysmal event is therefore fundamental. Many involuntary muscle Border terriers, is often known as canine epileptoid cramping syndrome movement disorders are episodic in nature. Consequently, when examined (CECS also known as ‘Spike’s disease’). Episodes in this condition are very between attacks, neurological evaluation is often completely normal. A variable, ranging from ataxia (a wobbly gait) to an inability to stand, con- thorough history is crucial in the evaluation of affected animals, since tractions of abdominal, neck and back muscles; which results in abnormal many unrelated conditions can appear superficially similar. Paramount to posturing and contractions/cramping of the leg muscles (extensor rigidity establishing the existence of an involuntary muscle movement is ensuring 62 WSAVA GLOBAL COMMUNITY CONGRESS

or flexion of the limbs). The duration of the episode is also very variable, 0031 ranging from a few seconds to half an hour or longer during; throughout this time, the dog remains aware of their surroundings, though they might IS THERE MORE TO THE BRACHYCEPHALIC HEAD be more subdued than normal. In many affected dogs, there is increased STORY APART FROM BOAS? - THE EVIDENCE intestinal motility during an episode, which manifests as borborygmus (stomach rumbling). A genetic basis for the syndrome is suspected but D. O’Neill no specific genetic abnormality has been found. A recent study performed at DVS has revealed a link between CECS and gluten sensitivity and we Hatfield/United Kingdom are in the process of validating a serological test for gluten sensitivity in this breed. Currently, the most effective way to manage CECS in Border Qualifications: terriers is to use a gluten-free diet, though it can take several weeks for an improvement to be noted and not all dogs will respond. Dan O’Neill MVB BSc(hons) GPCert(SAP) GPCert(FelP) GPCert(Derm) GPCert(B&PS) CAN WE TREAT PAROXYSMAL DYSKINESIA PGCertVetEd FHEA MSc(VetEpi) PhDFRCVS [email protected] Paroxysmal dyskinesia can be extremely frustrating to treat. Aside for Veterinary concerns for the health and welfare of brachycephalic dogs CKCSs who respond to acetazolamide and Border terriers who generally have become increasingly discussed over the past decade. Marked rises respond to exclusive gluten free diets, most cases of PD do not respond in the popularity of breeds such as the French Bulldog, Pug and English to medication. In particular, the large majority of PD do not respond to an- Bulldog are set against a backdrop of increasing evidence of the health ti-epileptic medication. We recently followed group of affected Labradors compromises associated with their exaggerated body morphology. Some and JRT with PD receiving no treatment. Our findings suggest that these veterinarians now even question whether some of these brachycephalic dogs with PD had a young onset, were often triggered by startle or sudden breeds are just too compromised to justify their continued breeding (1). movements, and had a male bias (75%) with the majority being entire. A Historically, much of the concern for brachycephalic breeds was related third of dog had at least one event comprising cluster episodes. Episode to breathing problems linked to the Brachycephalic Obstructive Airway duration and frequency varied dramatically, even within an individual. Syndrome (BOAS). However, the altered conformation of the skull may also affect the eyes and the skin on the head, thermoregulation, and even The natural history was self-limiting with a third entering remission and the ability of these breeds to give birth. But what is the evidence here? an improvement in three quarter of dogs. Episodes significantly reduced This presentation will follow an evidence-based approach to explore the in terms of frequency and duration in Labradors and JRTs respectively. wider perspective here. Remission was significantly lower in dogs with cluster episodes than those without. This exploration will rely on a new evidence resources developed over the past decade: the VetCompass Programme at the Royal Veterinary Based on these results and our experience trying various medication for College in the UK (2). VetCompass shares deidentified information on all PD, we usually only advise treatment if the frequency of these episodes of animals under veterinary care at a wide range of partner practices and PD is reaching one or more than one episode a week. Anecdotally, keppra practice groups. Currently, 1803 (>30% of all) UK veterinary clinics have (levetiracetam) has helped some affected Labradors. shared data on >20 million companion animals. VetCompass now holds >60 million measurements, >200 million clinical notes and >500 million treatments. VetCompass has published 91 peer-reviewed papers that include exploration of the impact of brachycephaly on dogs from several perspectives. For sure, VetCompass evidence supports upper respiratory issues, includ- ing BOAS, as being common and important welfare issues for brachyce- phalic dogs. An early VetCompass study assessed predispositions for up- per respiratory tract (URT) disorders in general between random samples from three extreme brachycephalic breed types (Bulldog, French Bulldog and Pug) compared to three other common small-to medium sized breed types (moderate brachycephalic: Yorkshire Terrier and non-brachycephal- ic: Border Terrier and West Highland White Terrier) (3). The prevalence of URT disorders among the study dogs overall was 15.8%, highlighting that URT disorders are a major contributor to the overall disorder burden of dogs regardless of skull shape. The prevalence of URT disorders was higher in extreme brachycephalic dogs (22.0%) than in the moderate and non-brachycephalic group (9.7%) (P < 0.001). Following multivariable mod- elling to account for confounding, the extreme brachycephalic breeds had 3.5 times the odds of having at least one URT disorder compared to the moderate and non-brachycephalic group. However, deeper analysis showed that breed also mattered. After mul- tivariable modelling, the Pug (OR 6.9), French Bulldog (OR 5.1), English Bulldog (OR 4.0), and Yorkshire Terrier (OR 2.2) had higher odds of having at least one URT disorder compared with the West Highland White Terrier. These results confirmed a substantial predisposition to URT disorders in brachycephalic breeds overall but also highlight the importance of more nuanced thinking than just brachycephalic versus non-brachycephalic. Large ‘adorable’ eyes are one of the features of brachycephalic animals 63

13–15 NOVEMBER, 2021 that owners find most appealing. The flattened brachycephalic skull through the birth canal without assistance and carries an estimated results in shallower eye sockets with eyeballs that are more exposed. mortality rate of over 20% for puppies and of 1% for dams. A VetCom- pass study identified 701 dystocia cases from 18,758 entire female dogs Keratoconjunctivitis sicca (KCS) results from a deficiency of the aqueous attending 50 emergency care clinics across the UK, resulting in an overall portion of the tear film and is associated with irritation of the ocular sur- dystocia prevalence of 3.7%. Multivariable modelling identified that the face that often leads to corneal ulcerative disease that can be perforating 4 breeds with the highest odds compared to crossbreds were all brachy- in some cases. A VetCompass study identified 1,456 KCS cases from cephalic: French Bulldog (OR: 15.9), Boston Terrier (OR: 12.9), Chihuahua 363,898 dogs, giving an overall prevalence of 0.40% across all dogs (4). (OR: 10.4) and Pug (OR: 11.3). Multivariable analyses showed that brachycephalic dogs had 3.63 times odds compared to mesocephalic dogs. Compared with crossbreds, the 4 It is clear from this breadth of VetCompass evidence that there are breeds with the highest odds for KCS were all brachycephalic: American serious welfare issues associated with the brachycephalic skull confor- Cocker Spaniel (OR 52.33), English Bulldog (OR 37.95), Pug (OR 22.09) mation. And while BOAS is certainly an important condition to consider and Lhasa apso (OR 21.58). in brachycephalic breeds, there is growing evidence that the welfare impacts from the shortened skull go well beyond simply leading to direct Corneal ulcerative disease (CUD) describes epithelial defects that expos- respiratory issues. Wider problems including ocular, skin, reproductive and es the corneal stroma, resulting in the development of pain, reflex uveitis, thermoregulation are also highly relevant to the overall brachycephalic temporarily or permanent blindness, and even perforation and loss of the welfare picture. eye. A VetCompass study identified 834 CUD cases from 104,233 dogs, giving a prevalence of 0.80% in dogs overall (5). Multivariable analyses References showed that brachycephalic dogs had 11.18 times the odds for CUD com- pared with crossbreds. The breeds with the highest odds compared with 1. Farrow T, Keown AJ, Farnworth MJ. An exploration of attitudes towards crossbred dogs were all brachycephalic, and included the Pug (OR: 19.05), pedigree dogs and their disorders as expressed by a sample of compan- Boxer (OR: 12.12) and Shih Tzu (OR: 10.04). ion animal veterinarians in New Zealand. New Zealand Veterinary Journal. 2014;62(5):267-73. Prolapse of the nictitating membrane gland (PNMG) (cherry eye) de- scribes protrusion of the nictitans gland from behind the nictitating mem- 2. VetCompass. VetCompass Programme London: RVC Electronic Media brane (third eyelid). If left untreated, PNMG often results in chronic con- Unit; 2021 [Available from: http://www.rvc.ac.uk/VetCOMPASS/. ditions such as keratoconjunctivitis sicca (KCS), inflammation, infection and trauma to the nictitans gland itself, and potential secondary corneal 3. O’Neill DG, Jackson C, Guy JH, Church DB, McGreevy PD, Thomson PC, trauma. In a VetCompass study that is in review, 1,802 PNMG cases were et al. Epidemiological associations between brachycephaly and upper re- identified from 905,543 dogs, yielding an annual overall prevalence of spiratory tract disorders in dogs attending veterinary practices in England. 0.20%. Brachycephalic breeds had 6.7 times the odds of PNMG compared Canine Genetics and Epidemiology. 2015;2(1):10. with mesocephalic breeds. The 5 breeds with the highest odds of PNMG compared with crossbred dogs were all brachycephalic, including the Ne- 4. O’Neill DG, Brodbelt DC, Keddy A, Church DB, Sanchez RF. Keratocon- apolitan Mastiff (OR 34.26), English Bulldog (OR 24.08), Cane Corso (OR junctivitis sicca in dogs under primary veterinary care in the UK: an epide- 14.66), Lhasa Apso (OR 12.37) and American Cocker Spaniel (OR 11.57). miological study. Journal of Small Animal Practice. 2021;62(8):636–45. This body of evidence shows strong evidence of substantial predisposi- 5. O’Neill D, Lee MM, Brodbelt DC, Church DB, Sanchez RF. Corneal tions to ocular disorders in brachycephalic breeds with a strong sugges- ulcerative disease in dogs under primary veterinary care in England: epi- tion that these disorder predispositions are linked to the brachycephalic demiology and clinical management. Canine Genetics and Epidemiology. conformation. 2017;4(1):5. Skin fold dermatitis is an inflammatory process of closely opposing 6. Hall EJ, Carter AJ, O’Neill DG. Incidence and risk factors for heat-relat- skin surfaces resulting from abrasion and is reported to elicit a burning ed illness (heatstroke) in UK dogs under primary veterinary care in 2016. pain sensation in human sufferers. In dogs, folded skin may result from Scientific Reports. 2020;10(1):9128. deliberate selection to meet breed standards or may be non-planned following obesity or skin disease. In a VetCompass study of 905,553 dogs that is still in preparation for publication, the one-year prevalence for skin fold dermatitis in dogs overall was 0.37%. Multivariable analyses showed that brachycephalic breeds had 4.5 times the odds of skin fold dermatitis compared with mesocephalic breeds. Compared with crossbred dogs, the 3 breeds with the highest odds of skin fold dermatitis were all brachyce- phalic: English Bulldog (OR 49.07), French Bulldog (OR 25.92) and Pug (OR 16.27). Heat-related illness (HRI) is a progressive disorder when core body temperatures rise above homeostatic limits, resulting in decreased cardiac output, fatigue of heat dissipation mechanisms, organ failure and ultimately death. A VetCompass study of 905,543 dogs under veterinary care during 2016 identified 1222 HRI cases giving an overall prevalence of 0.14% (6). Following multivariable analysis, 5 from 9 breeds with higher odds of HRI compared to Labrador Retrievers were brachycephalic: Chow Chow (OR 16.6), English Bulldog (OR 14.0), French Bulldog (OR 6.5), Dogue de Bordeaux (OR5.3), Greyhound (OR 4.3), Cavalier King Charles Spaniel (OR 3.5), Pug (OR 3.2), English Springer Spaniel (2.7) and Golden Retriever (2.7). Dystocia is defined as a difficult birth or the inability to expel the foetus 64 WSAVA GLOBAL COMMUNITY CONGRESS

0032 - Pain relieving positioning (including “prayer” posture) The main digestive diseases affecting the BDs are presented in table 1. MANAGEMENT OF DIGESTIVE DISEASES IN BRACHYCEPHALIC DOGS: A CRUCIAL STEP FOR A Redundant esophagus (deviation) Gastritis (potentially lymphofollicular) SUCCESSFUL APPROACH Esophagitis Pyloric mucosal folds hypertrophy V. Freiche Gastroesophageal reflux Pyloric stenosis Sliding hiatal hernia (type 1) Maisons Alfort/France Delayed gastric emptying Duodenitis Qualifications: Table 1: Main gastrointestinal diseases affecting identified in BDs3. Dr Valérie FREICHE, DVM, PhD, DESV-IM. According to recent studies, the incidence if hiatal hernia is probably high- er than previously suspected8. To diagnose gastro-esophageal abnormal- Internal Medicine Department ities, manipulations to increase the transdiaphragmatic pressure gradient could be of interest9. Hospital Practionner Finally, the respiratory and the digestive anomalies in BDs are suspected [email protected] to be correlated and respond to a common pathophysiologic pathway. Decades of genetic modifications in brachycephalic dogs (BDs) have led Chronic gastrointestinal clinical signs probably worsen the respiratory to hereditary and congenital disorders: both respiratory and gastroin- signs by stimulating inflammation and encumbering the pharyngeal testinal troubles are linked, and they define the “brachycephalic airway region. Moreover, chronic respiratory efforts and transdiaphragmatic obstruction syndrome” (BAOS)1,2. Over the two past decades, the increas- pressure promote gastrointestinal reflux and digestive discomfort in these ing popularity of these dogs resulted in breeding misconduct, leading to dogs2. deleterious consequences for their health, particularly in French bulldogs, English bulldogs and Pugs3. There is strong evidence that brachycephalic 2.Diagnostic approach in BDs. breeds are less healthy than their non-brachycephalic counterparts4. A global approach of BDs is mandatory, in order to both characterize the na- BAOS usually affects young BDs (range of presentation: a few months-to ture of the different problems and define the most appropriate treatment a few years). Therefore, it is unlikely to diagnose a BAOS after 5 y.o. in and follow-up in each dog. a dog. Various complementary examinations are needed in the global management of obstructive airway syndrome. A careful history of the 1.Bds anatomic and pathophysiologic changes leading to respiratory and disease is essential: in fact, the owners show an unreliable perception of digestive clinical signs. the clinical signs of their own dog. As a result, they may find “normal” to observe exercise intolerance, snoring, regurgitations or frequent vomiting. In addition to the aberrant shape of their skull, the soft tissue anomalies Even if the dog is presented for major respiratory disorders, digestive listed in BDs include disease is present in most of the cases. It is essential to specifically ques- tion owners even if they do not volunteer this information3. elongated soft palate, stenotic nares, aberrantly growing and malformed nasal conchae, undersized nasal chambers, macroglossia, tracheal hypo- Different subtypes of BDs can be presented in consultation: clinical signs plasia (particularly in English bulldogs) and acquired laryngeal complica- are often predominantly respiratory. However, the prevalence of gastroin- tions5, 6. testinal disorders can be the principal reason for consultation with upper airway obstruction. Severe vomiting and regurgitations episodes can even Clinical signs resulting from the upper anatomic anomalies are mainly1,7: mimic a digestive obstruction in those dogs. Heat intolerance The diagnostic approach includes: Exercise intolerance a.Extensive physical examination (it can be difficult to examine their oral cavity because they often struggle to breathe with their mouth wide Sleep disruption open3). Thoracic auscultation can be challenging due to by the presence of loud referred upper respiratory tract. Snoring b.Biochemical & hematological assessments. No specific changes are Syncope expected. In case of major respiratory difficulties, arterial blood analysis may be important. Cyanosis c.Diagnostic imaging investigations include Collapse - Thoracic radiographs (tracheal diameter evaluation, pulmonary lesions AND DIGESTIVE SIGNS assessment, esophageal anomalies or hiatal hernia identification). Alimentary tract signs reported in brachycephalic dogs are mainly3: - Video fluoroscopic swallow studies (hiatal hernia identification, esopha- geal - Vomiting motility evaluation). - Regurgitations (exacerbated by exercise) - Abdominal ultrasound is needed to document the differential diagnosis in any - Ptyalism vomiting dog. In Bds, gastric retention, thickened gastric mucosal folds - Retching - Dysphagia - Aerophagia - Gastroesophageal reflux - Pica 65

13–15 NOVEMBER, 2021 or an hypertrophic pylorus can be identified. d.Global endoscopic assessment: a combined upper airway and gastroin- testinal endoscopic evaluation is necessary. It provides a good overview of the lesions. Oral mucosal observation (tonsils, soft palate, tongue) Retrograde endoscopy of the pharynx Larynx and laryngeal ventricules visualisation, if present. Esophageal, gastric and duodenal assessment: gastrointestinal lesions are listed table 2. Esophagus Stomach Duodenum References -Non-specific • Poncet CM, Dupre GP, Freiche VG, et al. Prevalence of gastrointestinal gastritis tract lesions in 73 brachycephalic dogs with upper respiratory syndrome. J Small Anim Pract 2005; 46:273–9 Inflammato- Esophagitis (mainly (Localized or diffuse) Non-specific duo- ry lesions distal) denitis • Poncet C, Freiche V. Brachycephalic Airway Obstruction Syndrome. In: Bonagura JD, Twedt DC, editors. Kirk’s Current Veterinary Therapy XV -Lymphofollicular (2014). Section VII, Respiratory Diseases; 649-652. Elsevier Saunders, St gastritis Louis, Missouri. -Cardiac atony (rare) • Freiche V, German AJ. Digestive Diseases in Brachycephalic Dogs. Vet Clin North Am Small Anim Pract. 2021 Jan;51(1):61-78. Redundant esoph- -Delayed gastric agus emptying • Fawcett A, Barrs V, Awad M, et al. Consequences and Management of Canine Brachycephaly in Veterinary Practice: Perspectives from Austra- Anatomic or Gastroesophageal -Pyloric mucosal None lian Veterinarians and Veterinary Specialists. Animals (Basel). 2018 Dec functional reflux (frequent) hyperplasia 21;9(1):3. disorder • Kaye BM, Rutherford L, Perridge DJ, et al. Relationship between brachy- Hiatal hernia -Pyloric stenosis cephalic airway syndrome and gastrointestinal signs in three breeds of dog. J Small Anim Pract 2018;59:670–3. -Pyloric atony (very rare) • Roedler FS, Pohl S, Oechtering GU. How does severe brachycephaly af- fect dog’s lives? Results of a structured preoperative owner questionnaire. Table 2: gastrointestinal lesions most found in BDs3. Vet J 2013;198: 606–10. 3. Treatment of digestive diseases in BDs. • Fasanella FJ, Shivley JM, Wardlaw JL, et al. Brachycephalic airway ob- structive syndrome in dogs: 90 cases (1991-2008). J Am Vet Med Assoc After a global assessment, as previously described, most of the dog 2010;237: 1048–51. respond to: • Reeve, E. J., Sutton, D., Friend, E. J. & Warren-Smith, C. M. R. Docu- a.Surgical respiratory procedures including menting the prevalence of hiatal hernia and oesophageal abnormalities in brachycephalic dogs using fluoroscopy. J Small Anim Pract 2017; 58, - Palatoplasty 703–708. - Rhinoplasty • Broux O, Clercx C, Etienne AL, et al. Effects of manipulations to detect sliding hiatal hernia in dogs with brachycephalic airway obstructive syn- - Ventriculectomy if needed drome. Vet Surg 2017;47:243–51. In rare conditions, either a stenotic pylorus or a sliding hiatal hernia justify • Poncet CM, Dupre GP, Freiche VG, et al. Long-term results of upper respi- additional surgical procedures. ratory syndrome surgery and gastrointestinal tract medical treatment in 51 brachycephalic dogs. J Small Anim Pract 2006;47:137–42. b. Medical gastrointestinal treatment (see table 3). It has been highlighted that the surgical upper airway procedure if fol- lowed by a decrease of gastrointestinal clinical signs10. 66 WSAVA GLOBAL COMMUNITY CONGRESS

0033 Ectopic mites may cause pruritic, papular, crusting skin lesions on the neck, rump, or tail HOW TO RECOGNIZE PARASITIC SKIN DISEASES & TREAT IT PROPERLY Self-trauma result in secondary alopecia and excoriations on the ears and head M. Tunhikorn Diagnosis: presence of brown coffee-ground ear wax and mites from Bangkok/Thailand examining the ear canal with an otoscope, ear swabs for the parasite, or superficial skin scrapings. Qualifications: Treatment trial if the disease is suspected, but no mites were found. Maturawan Tunhikorn Treatment includes ear cleaning to remove accumulated debris, instilling DVM, DipACVD parasiticidal otic preparation, and treating the affected animal’s whole body for ectopic mites. [email protected] Systemic therapies include isoxazolines, selamectin or imidacloprid/mox- HOW TO RECOGNIZE PARASITIC SKIN DISEASES & TREAT IT idectin, and ivermectin and doramectin. PROPERLY Treat all in-contact animals as the parasites are highly contagious. External parasites are a frequent cause of skin disease in dogs and cats. Animals may acquire ectoparasites such as fleas or scabies from contact Sarcoptic mange: with other animals or the environment. Ectoparasites such as Demodex mite, a normal fauna of the skin, may increase abnormally under certain Sarcoptes scabiei var. canis in dogs circumstances, causing skin problems. Recognizing parasitic skin diseas- es can sometimes be challenging because the clinical manifestations can Sudden onset of severe pruritus, papulocrustous eruption, thick yellowish be similar among themselves and similar to those of other skin diseases. or hemorrhagic crusts, alopecia, and excoriation from self-trauma Clinical signs often seen may include pruritus, hair loss, crusting, and scaling. Ectoparasitic skin diseases commonly seen in general practic- Poor response to previous treatment with glucocorticoids es include fleas, ticks, pediculosis, sarcoptic mange, otodectic mange, demodicosis, and cheyletiellosis. Ear margins, face, elbows, ventrum, hocks, and generalized in chronic cases Obtaining a correct and detailed history is crucial. Knowing what to ask is very important and may need practice. Information from history taking can Definitive diagnosis is confirmed by finding the mite and their eggs and help raise the index of suspicion toward one or more diseases. Questions feces in superficial skin scrapings may include: False-negative skin scraping is not unusual and does not rule out scabies. Presence of parasites. Were any fleas or ticks seen on the animal lately? Trial treatment is indicated to confirm the diagnosis. Was there a history of fleas or other parasites causing a problem? Is the patient on any fleas or ticks prevention? Positive pinnal-pedal reflex and serology may assist in the diagnosis Pruritus. Was the patient itchy? Where did it start? What severe is the itch? Topical treatment with amitraz, selamectin, or moxidectin/imidacloprid Acute, intense pruritus would point to sarcoptic mange. However, parasitic skin diseases, such as cheyletiellosis, pediculosis, or demodicosis, might Systemic macrocyclic lactones (ivermectin, milbemycin oxime, doramec- not be pruritic in some animals. Thus, not being pruritic will not rule out tin) ectoparasitic skin diseases. Isoxazolines (afoxolaner, fluralaner, and sarolaner) History of possible contagion. Is any other animal in the household affected? Treat affected animal and all in-contacts Zoonosis. Does anyone in contact with the patient develop skin lesions? Mites can also transiently infect humans, but usually self-limiting, provid- ing that the animal is treated appropriately Environment. Does the patient spend time indoors or outdoors? Did the patient go to the dog park, pay a visit to the vet, or walk on the street? Notoedric mange: Seasonality. Did the patient start during late summer and fall? (chigger Notoedres cati mites) Highly pruritic skin disease involving the ears and head Thorough physical examination, both general and dermatological, is es- sential. Determine whether the lesions’ type, pattern, and distribution are Poor response to previous treatment with glucocorticoids compatible with the key clinical feature of any parasitic skin disease. Lesions include scaling leading to pruritus, thick yellow crusts, alopecia, Otodectic mange: and lichenification Otodectes cynotis Lesion starts initially on the medial edge of the ear pinnae, face, and neck, then spread generally Variable clinical signs; animals may be asymptomatic (especially in cats), and some might have intense pruritus of the ears. Mite hypersensitivity Mites are easier to find than the canine’s mite through superficial skin can cause severe pruritus bilaterally. scraping, tape strips, or fecal floatation. If in doubt, trial therapy should be carried out. Thick reddish-brown crusts or coffee-ground debris in the ear canal 2% lime sulfur, selamectin, moxidectin/imidacloprid, ivermectin, and doramectin Isoxazolines (fluralaner and sarolaner) Cheyletiellosis: 67

13–15 NOVEMBER, 2021 Cheyletiella yasguri (dog, cats, rabbit), C. blakei (cats), C. parasitivorax cats that cannot groom well (rabbit, cat, dog) Clinical presentation depends on the number of lice. Affected animals can Variable clinical signs and variable pruritus be asymptomatic carriers if the number of lice is low. Dorsally-oriented disease with excessive scaling Pruritus, dull, dry hair coat, alopecia, papules, crust, and excoriations are commonly seen dorsally (head and neck area). Cats may be presented Cats may develop miliary dermatitis or self-induced alopecia with miliary dermatitis and symmetrical alopecia Animal can be an asymptomatic carrier, especially cats Diagnosis: Finding lice or the nits on the skin or hair with a magnifying lens, acetate tape strips and trichogram Skin scrapings, acetate tape impressions, coat brushing, trichogram, and fecal flotation can be unrewarding. Response to treatment can confirm the 2% lime sulfur, pyrethrin, pyrethroid (dogs only), fipronil, selamectin, imida- diagnosis. cloprid/moxidectin, and ivermectin Fipronil spray/spot on, amitraz, lime sulfur, ivermectin, doramectin, and Clipped matted hairs selamectin Treat all in-contact same-species animals and clean the environment Highly contagious, and all in-contact animals should be treated Tick bite hypersensitivity Environmental insecticidal sprays are advised Rhipicephalus sanguineus (brown dog tick or kennel tick) is the most com- Demodicosis: mon tick causing clinical problems in dogs Demodex canis Dermatologic disorders from direct irritation of the bites and initiate hypersensitivity Two forms: localized and generalized Commonly found on the interdigital space and ears Localized demodicosis: erythema with alopecia, fine scaling, thinning of hair. Common sites are the face and forelimbs. Erythema and maculopapular eruption adjacent to the attached tick Generalized demodicosis: juvenile- and adult-onset Mild pruritus, crusts, and inflamed, small nodules may be present at the site where the tick was removed. Focal ulceration may be seen. Clinical appearances are variable Diagnosis made through the presence of ticks with lesions. Erythema, pustules, papules, crusts, ulcers with multifocal or diffuse alopecia is often observed with scaling and seborrhea. Manual removal Pododermatitis can occur, and maybe the only region affected: swollen Isoxazolines, fipronil, selamectin, ivermectin, selamectin, parasiticidal feet, interdigital pruritus, interdigital furunculosis, and draining tracts. collars Severe cases: enlarge lymph node, fever, and septicemia Environment treated with acaricides Adult-onset is typically associated with systemic disease or treatment of Flea allergy dermaitits immunosuppressive drug therapy Ctenocephalides felis and Ctenocephalides canis are the common ones Secondary pyoderma usually develops and initiates pruritus. Not all animals will show symptoms as they might not be sensitive to flea Diagnosis: finding various stages of mites on microscopic examination bites and will act as asymptomatic carriers or develop mild skin irritation from deep skin scrapings, trichogram, exudate microscopy, squeeze tape preparations. Dogs: Treatment for localized demodicosis: rarely required as it usually heals pruritic, erythematous papular eruptions, alopecia with excoriations, spontaneously. Recommended to wait and see. May treat topically with an hyperpigmentation, scaling, crusts, or lichenification antibacterial agent (e.g., chlorhexidine, benzoyl peroxide) if desired. caudodorsal lumbosacral area, the base of the tail, the caudomedial Isoxazolines are very effective thighs, the abdomen, or the flanks Commonly used therapies in the past include amitraz, ivermectin, mox- Cats: idectin, milbemycin oxime, doramectin. pruritic miliary dermatitis, symmetrical alopecia, and eosinophilic granulo- Avoid the use of steroids ma complex lesions Continue treatment one month beyond two negative consecutive skin Infested area inclues the head, neck, dorsal lumbosacral area, caudomedi- scrapings, one month apart. al thighs, or ventral abdomen Identify underlying conditions in adult-onset generalize demodicosis and Diagnosis: clinical signs, evidence of fleas/flea dirt, response to aggres- treat. sive flea control trial Intact dogs should be neutered Combination of adulticides, insect growth regulators, chitin synthesis inhibitors should be used on affected and all in-contact animals Pediculosis: Isoxazolines are very effective with good speed of kill and effective Biting lice (Trichodectes canis in dogs and Felicola subrostratus in cats); residue sucking lice (Linognathus setosus in dogs) Other products: fipronil, imidacloprid, selamectin, nitenpyram, pyriprole, Young, neglected, and underfed animals, crowded situations, old or sick spinosad, indoxacarb, dinotefuran, etc. 68 WSAVA GLOBAL COMMUNITY CONGRESS

Summary 0034 A detailed history and a thorough physical and dermatological exam are STRATEGIES TO SUCCESSFULLY TREAT STAPH essential to help recognize parasitic skin diseases. Some diseases have PYODERMA IN THE ERA OF MULTIDRUG specific characteristics, but others might not. Tests can be dissatisfying, RESISTANCE and treatment trials should be conducted to prove the existence of mites. Treating properly with the right drug, treating all affected animals, and M. Tunhikorn treating the environment will ensure successful control of the disease. Reference Bangkok/Thailand • Miller WH, Griffin CE, Campbell KL. Chapter 6: Parasitic skin disease. In: Qualifications: Muller and Kirk’s Small Animal Dermatology 7thedition. Philadelphia, PA: Maturawan Tunhikorn Elsevier 2013; 284-342. • Miller WH, Griffin CE, Campbell KL. Chapter 8: Hypersensitivity disor- DVM, DipACVD ders. In: Muller and Kirk’s Small Animal Dermatology 7thedition. Philadel- [email protected] phia, PA: Elsevier 2013; 343-431. • Curtis C. Current trends in the treatment of sarcoptes, cheyletiella and STRATEGIES TO SUCCESSFULLY TREAT STAPH PYODERMA IN otodectes mite infestations in dogs and cats. Vet Dermatol 2004; 15: THE ERA OF MULTIDRUG RESISTANCE 108-114. Staphylococcal pyoderma is a common skin diseases seen in general • Mueller RS, Rosenkrantz W, Bensignor E et al. Diagnosis and treatment practice, especially in dogs. Treatment regularly involves the use of of demodicosis in dogs and cats: Clinical consensus guidelines of the systemic antibiotics and/or topical antimicrobials. Many a time, systemic World Association for Veterinary Dermatology. Vet Dermatol2020; 31:5-27. antibiotics were given without much thought regarding drug-resistant. Not surprisingly, there has been an escalation in reports of multidrug-resistant staphylococcal strains in canine pyoderma over the years. In this time of emerging multidrug-resistant, treating staphylococcal pyoderma turns out to be challenging. The clinician is responsible for finding a way to treat the infection without creating drug-resistant bacteria and be prepared to treat one once it occurs. Thus, a strategic plan for treating Staph pyoderma can help save the day (and the patient!). Staphylococcus pseudintermedius is considered the most significant pathogen in staphylococcal pyoderma. Other less common bacteria caus- ing infections are the S. aureus and S. schleiferi. The infection is usually secondary to underlying causes, and the most common of all are allergies and ectoparasites. S. pseudintermedius is part of the normal resident on the dog’s skin and will not cause infection in the normal skin of a healthy dog. The infection is often due to an insult to the skin, possibly from self-trauma. The bacteria then starts to colonize and eventually results in pyoderma. Primary infection is rare. Canine pyoderma is classified according to the depth of infection: surface, superficial, and deep. Erythema with pruritus is often the clinical presen- tation for surface pyoderma. Superficial pyoderma is the most common kind, and lesions such as papules, pustules, epidermal collarettes, scaling, focal alopecia are seen with pruritus. While furuncles, draining tracts, ulcers, nodules, and pain can be recognized in deep pyoderma. Diagnosis for pyoderma is based upon the history, physical examination, and cytological result. Cytology is essential to determine the depth of the infection. The presence of coccoid bacteria engulfed by the inflammatory cells, typically neutrophils, indicates a bacterial infection. Macrophages, eosinophils, and multinucleated giant cells are seen in both deep and chronic pyoderma. Once the diagnosis of staphylococcal pyoderma was confirmed, the stra- tegic treatment plan is as follows: • Know the organism and depth of infection • Think topicals first • Systemics if necessary: right drug, correct dose, suitable duration • Determine & treat the underlying cause The strategic plan can be breakdown into: 69

13–15 NOVEMBER, 2021 • Know which organism is causing the infection. Large diploid cocci precede culture to confirm a bacterial infection and assist in determining bacteria on cytology is probably S. pseudintermedius. Smaller cocci that the most important bacteria to treat if culture comes back with multiple form chains or irregular groups might be streptococci, micrococci, and species being detected. enterococci. Rod shape bacteria is possibly Pseudomonas, Proteus, and coliforms. • Identify and control underlying causes. Staphylococcal pyoderma usual- ly is secondary to underlying disease. To prevent recurrent pyoderma and • Know the depth of the infection. The depth of the infection is one of repeated use of antibiotics, the clinician should try to identify and control the factors determining whether the patient needs topical or systemic the underlying problem. Common underlying causes in young animals treatment. It also defines the duration of treatment. Superficial and deep include allergic skin diseases and external parasites. Recurrent bacterial pyoderma might have the same clinical presentation. Performing cytology infections in older animals often are from metabolic diseases such as and reviewing the type of inflammatory cells can help separate the two. hypothyroidism. While topical treatments can help maintain control of the Surface pyoderma and superficial pyoderma (mild to moderate in severity underlying condition, the use of “pulse therapy” (antibiotics given to the and extension) can be treated solely with topical treatment successfully. patient on a selected day of the week) does not and may result in drug-re- However, adjunct topical therapy and systemic antibiotics should be pre- sistant pyoderma. scribed in widespread or severe superficial and deep pyoderma. • Avoid concurrent corticosteroid when possible. Corticosteroids can • Choose treatment route. Mild cases of superficial pyoderma may be delay the resolution of pyoderma. If needs to be given concurrently with treated and managed with topical therapy. Topical therapy needed to antibiotics, do not stop both medications altogether since corticosteroids be applied daily to effectively clear the infection. Chlorhexidine (+/-mi- can suppress visible lesions and mislead the clinician to think the infec- conazole), benzoyl peroxide, ethyl lactate, , silver, sodium hypochlorite, tion has resolved. magnesium sulfate, and mupirocin can be used to treat the infection topically. Clipping of the hair coat will facilitate contact between the skin Therapeutic failure could be from poor compliance, poor choice of antibi- and the medication. Not all cases are suited for topical treatment. Topical otics, lack of therapeutic dosage, failure to maintain therapy long enough, therapy can be time-consuming and labor-intensive. In addition, localized and failure to identify and control underlying disease. Failing to treat the adverse reactions and contact allergies may occur. The clinician may have pyoderma properly can result in the development of antimicrobial-resis- no choice but to use systemic antibiotics. tant bacteria. The common ones are methicillin-resistant staphylococci (MRS), which is resistant to nearly all penicillins and cephalosporins. • Right drug, right dose, and right duration. The resistant strain in the dog is methicillin-resistant Staphylococcus psuedintermedius (MRSP), and the human strain is Staphylococcus • Right drug: Systemic antibiotics may be used empirically or be based aureus (MRSA). MRSA can occur in the dog but is less common. Dogs can on bacterial culture and susceptibility (C&S) tests. The diagnosis and acquire resistant bacteria from other animals and owners, vet visits, and antimicrobial therapy guidelines devised by an expert panel have made the environment. recommendations on selecting antibiotics. The guideline divided anti- biotics into three tiers. The first tier is for empirical therapy of known or The strategies for treating methicillin-resistant pyoderma are the same suspected superficial bacterial folliculitis, and the suggested antimicrobial with methicillin-sensitive Staphylococcus psuedintermedius (MSSP). The drugs are clindamycin/lincomycin, first-generation cephalosporins (e.g., antibiotic choices for MRSP would be based on culture and susceptibility cephalexin), and amoxicillin-clavulanate. Trimethoprim-sulfa can be an tests. If the culture and susceptibility results showed resistance to oxacil- additional choice if local, regional susceptibility of S. pseudintermedius is lin, beta-lactam antibiotics should be avoided even if the test showed sus- known. The second tier antibiotics (doxycycline/minocycline, fluoroquino- ceptibility. Some MRSP can be multidrug-resistant (resistant to at least lones, and aminoglycosides) are used when empirical selection of the first three antimicrobial classes) and has left clinicians with topical treatment tier antibiotics and topical treatment is inappropriate. These antibiotics as their only choice. Commonly used topical antiseptics for MRSP are should be used only when the culture and susceptibility test indicates. chlorhexidine, mupirocin, and sodium hypochlorite. The clinician should Tier three antibiotics, linezolid and vancomycin, are reserved for treating encourage the owners to practice good hand hygiene and teach how to serious methicillin-resistant Staphylococcus aureus (MRSA) infection in clean and disinfect the environment. If the animal is infected with MRSA, humans. The use of these antibiotics is strongly discouraged. There is a the clinician should notify the owner since it is a potential human health tier 1/2 antibiotic, which includes third-generation cephalosporins such as hazard. Wear gloves when examining or handling the patient to prevent cefovecin and cefpodoxime. It is controversial whether these antibiotics colonization with MRSA. The patient should be separated from immuno- may have the effect of selecting resistant strains of pathogens such as E. compromised individuals. coli. Some believe that it should only be used when susceptibility testing indicates. References • Right dose: Once the process of choosing the right antibiotics for the in- 1. Hillier A, Lloyd DH, Weese JS et al, Guidelines for the diagnosis and fections is fulfilled, the next thing the clinician should consider is the dose antimicrobial therapy of canine superficial bacterial folliculitis (antimicro- of the antibiotics. Inadequate dose of antibiotics often fails the treatment bial Guidelines Working Group of the International Society for Companion and induces drug-resistant. Animal Infectious Diseases), Vet Dermatol. 2014; 25:163-e43 • Right duration: Do not change the antibiotic or stop the treatment too 2. Morris DO, Loeffler A, Davis MF, Guardabassi L and Weese JS, Rec- soon. It can take 1-3 weeks until the treatment with antibiotics begins ommendations for approaches to methicillin resistant staphylococcal to be effective. Discontinuing the treatment too early can cause relapse. infections of small animals: diagnosis, therapeutic considerations and Superficial pyoderma should be treated 1-2 weeks beyond visible and cyto- preventative measures, Vet Dermatol. 2017; 28:304-e69 logical cure. Deep pyoderma should be treated 2-3 weeks beyond visible, cytological, and palpable cure. 3. van Duijkeren E, Catry B, Greko C et al; Scientific Advisory Group on Antimicrobials (SAGAM). Review on methicillin-resistant Staphylococcus • Know when to perform C&S tests. C&S tests should be performed before pseudintermedius. J Antimicrob Chemother. 2011; 66:2705-2714. starting antibiotic treatment in patients with poor response to appropriate therapy (e.g., developing new lesions), patients that have received multi- 4. Bryan J, Frank LA, Rohrbach BW et al. Treatment outcome of dogs with ple courses and/or multiple antibiotics, and patients with deep pyoderma. meticillin-resistant and meticillin-susceptible Staphylococcus pseudinter- Do not try to guess which antibiotic will work. Cytology should always mediuspyoderma. Vet Dermatol. 2012; 23:361-8, e65. 70 WSAVA GLOBAL COMMUNITY CONGRESS

0035 From a distance, without moving, LOOK at the patient: FIRST IMPRESSIONS COUNT: ASSESSING AND Airway: Is the patient breathing? NO? obviously the primary survey is STABILIZING aborted and emergency treatment is initiated. If breathing, LISTEN (still from a distance) to the breathing: can you hear respiratory sounds associ- A. Steele ated with inspiration or expiration? Guelph/Canada Assess the quality of the respirations: what is the respiratory pattern like? Is it regular or irregular? Shallow or very deep? Is there increased effort Qualifications: (abdominal component)? Is the rate normal or abnormal? Andrea M. Steele Attitude: Is the patient bright, alert and responsive, quiet, alert and respon- sive, or are they non-responsive? Are they interacting with their owner? MSc, RVT, VTS(ECC) Breathing: what is the respiratory rate? RR is always best assessed before [email protected] approaching the patient and observing at rest while they are relaxed with Every Veterinary Practice should have a plan for emergencies. Technicians the owner. This same concept is important when observing a hospitalized who perform triage in either situation should have a clear understanding patient: always assess the RR before opening the cage door. of what the veterinarian in charge wants them to do once they have tri- aged the patient. Should the patient be brought right to the treatment area Bleeding: Is there visible bleeding? Is the bleeding arterial (pulsating, and the veterinarian notified as this is happening? Should the veterinarian copious)? Is it compressible? (again, a very good point to stop the primary be notified while the patient is at the front and allowed to make the final survey if bleeding is present) call on treatment themselves? Is the technician allowed to initiate emer- gency action in the veterinarian’s absence (such as oxygen supplementa- From a distance, very important information has been obtained, and our tion, CPR, placing a compression bandage)? All of these actions should be gut instincts may be working overtime. At this point the Triage Class of discussed in advance amongst the veterinary team. this patient may be obvious, or further information may be required. If fur- ther information is necessary, we must approach the patient. Approaching When an emergent patient arrives, assessing and triage are most often the patient should evoke some response in a healthy animal. For example, performed by a technician. Triage, is a process for sorting the ill or injured a healthy dog may wag it’s tail, sniff the air, stand up to greet you, or it into groups based on their need for or likely benefit from immediate may move into a protective position in front of its owner (even many very medical treatment. It is a method of “prioritizing” patients, and is used ill dogs may still do this). Cats in carriers can be difficult to observe, so try when a number of emergencies are waiting at once. It is one of the most to ask the owner to move the cage into a more visible position. Observe important aspects of emergency medicine. the cat’s ear positions, pupil size, and its general demeanor. It may exhibit fear, interest, disinterest, or may be non-responsive. Again, these cues or When we see an emergent patient, we all have our “gut feelings” and can responses are used in assessment of the triage scale. in most cases easily place them into triage classes with minimal effort. After approaching the patient, LOOK, LISTEN and FEEL can be used to To categorize patients, we can use one of many triage scales: finish the Primary Survey: Class I: catastrophic, must be treated within seconds LOOK: Note the response of the patient to your presence and touch. Look at the mucous membranes and note the colour (normal pink, cyanotic, Class II: critical, must be treated within minutes injected pink, muddy, brown) and while you are assessing, check the capil- lary refill time (2 seconds or less is generally considered normal). Class III: urgent, must be treated within one hour LISTEN: Quickly auscult the heart, lungs and trachea. Does the heart Class IV: less urgent, should be treated within 24 hours sound regular? Is there a murmur? Are there increased lung sounds? Aus- cult the trachea to assist in localizing where the sounds are coming from In many cases, a Triage Class can be difficult to assign to a patient. There (large airways vs small airways and parenchyma). may be many reasons for this, and this is where the “ART” of Triage comes into play. While ultimately, triage can rely on “gut instincts”, in reality, we FEEL: assess pulses: strong, weak, bounding, pulse deficits? Do the mu- are using several methods of observation to come to a conclusion about cous membranes and limbs feel warm, cool or hot to the touch? the patient. The initial task is to perform a Primary Survey, which will give brief information on the most important aspects of the patient’s condition. **Remember, at ANY point during the primary survey, we can discontinue There is an “ART” to how the survey is performed….the order or manner in and initiate emergency treatment as necessary. which we perform the survey may change based on how we perceive the patient’s status. It is important to note that there is no need in the primary survey for numbers. For example, heart rate, there is no need to know it is 22 or 289 The Primary Survey is based on the ABC’s, where: bpm in a large dog. ABNORMAL (bradycardic, or tachycardic) or NORMAL is sufficient information. Counting for 15 seconds and multiplying a HR/ A: Airway/Attitude min is a waste of time in this initial phase. B: Breathing, Bleeding Having completed the Primary Survey, what information has been deter- mined? C: Cardiovascular, Circulation Airway: The Primary Survey can be further broken down into three actions: LOOK, LISTEN and FEEL. All of the ABC’s can be assessed using these actions. The animal is in fact breathing, or NOT The primary survey begins as you LOOK at the patient from a distance, then approach, and finally touch the patient. Keep in mind that if a patient Audible respiratory sounds (which may indicate upper airway obstruc- “fails” any of the actions along the way, the Primary Survey must be abort- tions) if present ed and emergency treatment initiated. Attitude: 71

13–15 NOVEMBER, 2021 The animal is responsive or unresponsive 0036 The animal does or doesn’t react normally to its surroundings TECHNIQUES IN CRITICAL CARE Breathing: A. Steele An approximate respiratory rate has been noted as NORMAL or ABNOR- Guelph/Canada MAL (fast or slow) Qualifications: Respiratory pattern: normal, increased effort, shallow, irregular has been noted Andrea M. Steele The chest has been briefly auscultated assessing for abnormal respiratory MSc, RVT, VTS(ECC) noises [email protected] Mucous membranes have been assessed for signs of cyanosis or other Nasal oxygen Catheter: This is a tube that is placed into the nasal cavity, derangements nasopharynx or even the trachea of the patient. This is the most invasive means of oxygen supplementation, but works well for patients requiring The presence and degree of obvious hemorrhage has been noted, and longer term oxygen, or in facilities where large volumes of oxygen use is whether it is compressible (for example on a limb) not desired (for example a clinic that requires changing of oxygen tanks frequently). The oxygen catheter is a very efficient means of delivering ox- Cardiovascular: ygen, and typically gives a high FiO2 of 40-60%, with a relatively low flow rate. Flow rates of 50-100 ml/kg/min are generally well tolerated. Bilateral Heart rate has been assessed and determined if ABNORMAL or NORMAL catheters may be placed, with flow rates between the two catheters of up to 200 ml/kg/min possible. Oxygen should be humidified with sterile water Heart rhythm has been assessed for arrhythmias to protect the nasal mucosa. Heart sounds have been assessed for murmurs, dullness, or other abnor- Equipment: malities Appropriate size and type of tube for patient Mucous membrane colour and capillary refill time has been assessed Permanent marker Pulse strength, regularity Proparacaine ophthalmic drops Limbs and mucous membranes have been assessed for temperature (indication of vasoconstriction or vasodilation) Lidocaine jelly (2%) to use as lubricant (non-sterile) The entire process should take one or two minutes MAXIMUM. Suture (non-absorbable) +/- waterproof white tape +/- Instant Glue In other cases, it may be difficult to determine the Class based on several A traditional nasal oxygen catheter is placed by measuring from the nose, factors: to the medial or lateral canthus of the eye, where a mark is placed on the tube with permanent marker. For a nasopharyngeal catheter, measurement Patients may act differently in the clinic than at home, and just because should be made to the vertical ramus of the mandible. The patient should they perk up does not mean they are not seriously ill. What you are ob- be restrained with the nose pointed towards the ceiling, and the person serving may not be how the owner has seen the patient. Respect what the performing the procedure should instill local anesthetic drops (such as owner says and include that in your judgment…in many cases, the owner proparicaine ophthalmic drops) into the nares. With one hand around the is right! muzzle, the tube is inserted into the chosen nostril by directing the cath- eter ventromedially. The tube is advanced gently, but quickly, and there “Red Herrings”! A patient arrives and based on the owners decription, you should be little resistance. The tube is advanced to the mark made on assume that the dog has had a single seizure. This, on its own may not be the tube, then advanced one or two more centimeters, to ensure that the an emergency, however, in performing your Primary Survey, you note the catheter is not in the dorsal meatus. If it continues to advance easily, you dog has pale gums and is tachycardic. Perhaps there is more to this story! are assured the tube is entering the nasal cavity, and the tube can then be pulled back to the measured mark. If the tube will not advance beyond the In many cases, the owners will feel that the condition is a true emergency. mark on the tube, suspect that it has gone into the dorsal meatus, in which For example, many owners will see a tapeworm segment and feel it is an case it needs to be pulled out and redirected. There is an increased risk of emergency. It is important to explain to owners the triage system and that bleeding in the dorsal meatus, and the patient will not receive a very high patients are seen in a priority, rather than order of arrival system. Having FiO2. The catheter can be affixed using cyanoacrylate glue (instant glue), a nice sign in your waiting room explaining triage is always a good idea. a finger-trap suture pattern, or tape wings and suture. If using glue, please Remind owners that the same system applies at human hospitals…the ensure that only the tiniest of drops are used to minimize hair loss on the most critical patients are seen first. Always offer and provide emergency face. The catheter should be sutured or glued at the junction of the nose service to people that wish to wait, but keep them updated on how long and the skin, then may be affixed along the side of the face, below the eye, a wait it will be. It is perfectly normal for owners to be extremely anxious or curved upward and affixed between the eyes. An Elizabethan collar may about their pets, and their idea of a true emergency may be different from need to be placed to ensure that the catheter does not get removed by the ours. Use the “primary survey” as your guideline. patient. If in doubt, don’t make assumptions: reassess the patient in 5-15 minutes, Nasal Feeding Tubes or treat immediately. Some patients just do not fit into the Classification system well. Trust your gut, even when the numbers are normal. There Nasal feeding tubes are very quickly placed options to provide liquid may be a cue that you are reacting to that may be subtle, but you just can’t enteral nutrition. Generally, they are short-term use to get an animal “over put your finger on it. Trust your experience! the hump” and eating on their own, and to prevent them from going further 72 WSAVA GLOBAL COMMUNITY CONGRESS

into a negative energy balance. Cats with hepatic lipidosis, dogs that have order for the catheter to easily enter the vein, the entire catheter must be had GI surgery are prime candidates for a nasal feeding tube. advanced and well seated prior to pushing off the stylet. Tube placement can be either esophageal or gastric, and the choice can Hold the stylet steady, and push off the catheter… do not withdraw the be made for different reasons. For example, a nasoesophageal tube is stylet until the entire catheter is in place. often sufficient if the animal is not regurgitating or vomiting, and there is no need to aspirate stomach contents. A nasogastric tube can be a Taping is the most important part of placement: valuable tool in managing the regurgitating patient, or those with GI ileus causing stomach distension. This can make the patient much more com- Ensure that the catheter is taped securely to avoid movement… movement fortable. Some have expressed concern of long term use of a nasogastric causes trauma to the site, and encourages bacterial growth tube, as it may allow reflux into the lower esophagus and irritate the lower esophageal sphincter. Keep the catheter on the same angle as the vein. Avoid bending the cathe- ter in any way, and this will help to minimize kinks. The tube must be measured and marked with a permanent marker. For an NE tube the 7-8 intercostal space is the landmark, while for an NG tube Bandaging is an “art form”, and needs to be snug, but not too snug, and it is measured from tip of nose to past the last rib. Mark the tube or note also consider tissue swelling in a patient receiving IV fluids. the measurement if indicated on the tube. The tube is initially placed similarly to a nasal oxygen catheter, however once the tube has traversed MAINTENANCE OF IV CATHETERS: the length of the rostrum, the head and neck are flexed downward to encourage the tube to enter the esophagus. Swallowing is ideally noted, It is important to have clear policies in your hospital regarding mainte- however if heavy sedation is used, may be absent. If the patient is awake, nance of IV catheters. Timed remove and replace policies have largely using a syringe with water and giving by mouth may help to get the patient been “debunked” in both human and veterinary medicine. Instead, a to swallow and help the tube enter the esophagus. remove and replace as needed policy should be instituted, accounting for the individual nature of our patients. Once (hopefully) in the esophagus, continue to advance the catheter. With an NE tube, the tube should pass easily to the measured point. For an NG Bandages should be examined daily for wetness or damage, and replaced tube, likely some resistance will be felt as the tube enters the stomach. if necessary. The site should be visualized daily, and the limb palpated Caution should always be exercised whenever resistance is felt, especially for any pain. Bandages should be removed and replaced immediately if if resistance is several inches/cm away from the target measurement. The it is noted that the toes are swelling. We should always remember that a concern could be that the tube has gone into the trachea and is now in bandage offers some protection, but is not a substitute for good catheter a lower airway. Often, a cough, or discomfort will be noted in the patient care, and must be replaced any time it has become wet or soiled. if the tube has been placed in the trachea, but again, if heavy sedation is used, this may not occur. In general, a well placed catheter should last for several days. Learning to place catheters using best practices is important for every veterinary Once placed, stabilized simply with a suture and perform a confirmatory nurse and we will discuss these best practices further in the lecture. radiograph. This is recommended even if gastric contents are aspirated, to visualize the placement and make any adjustments prior to affixing. Vascular Access in Veterinary Patients Intravenous catheters are the most common invasive device placed in veterinary patients. Every veterinary nurse should be skilled in the performance of this task. IV catheters allow us to have emergency venous access for anesthetized patients, access for IV medications, fluid therapy and aid in euthanasia. PLACEMENT OF PERIPHERAL IV CATHETERS As the most common type of IV catheters placed in veterinary medicine, we will take a significant portion of our lecture to discuss tips and tricks to their placement. These tips will be augmented with photos and video, so we will only discuss them briefly in this manuscript. In short, here are some things to keep in mind: The cephalic and saphenous veins are desirable as they are both very shallow veins that can readily be seen. (if you can “see” it, you have a much better chance of hitting it) The saphenous vein requires some stabilization, usually with a clean thumb on the skin or tension on the skin. This does require caution to avoid contaminating the catheter site and catheter. A clean gauze placed at the bottom of the prep site can be used to posi- tion the vessel and hold it firmly, in addition to keeping the catheter from tracking through hair. Remember that entry to the skin should be a 30° angle, then once through, you can flatten out to enter the vein. 30° allows you to use the sharpest point of the catheter, and makes it more comfortable for the patient Remember that the catheter is not right at the end of the stylet! Thus, in 73

13–15 NOVEMBER, 2021 0037 Complete blood cell count (CBC) is important to identify anemia which has been reported to be associate with decreased survival and response CLINICAL PATHOLOGIC APPROACH TO CANINE to therapy. Both leukocytosis and leukopenia may be found in lymphoma LYMPHOMA and during chemotherapy. Neutrophilia has been reported to be a negative prognostic factor with decreased survival time in dogs with lymphoma by S. Comazzi several papers. In human medicine, several leukocyte ratios have been introduced for a better evaluation of leukocyte patterns. Recently, similar Lodi/Italy ratios have been also suggested in veterinary medicine. They help to de- fine a cutoff value potentially useful for clinical purposes but are strongly Qualifications: biased by analytical variability which may affect the clinical decision being often similar or higher than total acceptable error. Stefano Comazzi Results of clinical chemistry may be useful to check organ status (hepatic DVM, PhD, dipl ECVCP damage/failure, kidney failure) or used as possible prognostic markers. Hypercalcemia is frequent in T cell lymphoma and often requires a rapid [email protected] intervention; high serum LDH activity and thymidine kinase activity may be The diagnostic approach to canine lymphoma is based on a diagnostic al- potentially useful to early predict recurrences. gorithm that generally starts from the detection of enlarged lymph nodes or lymphoid tissue. Fine needle aspirate biopsy plays a central role in this The clinical importance of staging infiltration from lymphoma cells is de- algorithm since it easily allows to differentiate putative neoplastic condi- bated and discordant among studies. In particular, the need of evaluating tions from non-neoplastic ones such as infectious diseases. Cytology is a bone marrow infiltration is controversial since some authors considered powerful diagnostic tool mainly for canine lymphoma since it is minimally it an invasive procedure and limit its necessity to cases with peripheral invasive and easy to perform, it is cheap and highly accurate. Lymphoma blood abnormalities (thrombocytopenia, presence of circulating blasts). with diffuse architecture is highly prevalent in dogs, in comparison with However, a correlation between peripheral blood abnormalities and bone humans and this makes sampling of neoplastic cells and collection of rep- marrow infiltration is not constant and minimal infiltration (although po- resentative neoplastic cells easy by using a fine needle biopsy. In addition, tentially linked to a worst prognosis) is often not associated with CBC al- some studies identified a correlation between some cytological entities terations. In these cases, flow cytometry may help to accurately quantitate and clinical behavior and accuracy may be further implemented by the use lymphoma infiltration on bone marrow aspirates. Other tests potentially of some ancillary techniques. Differently from humans cytology may help useful to check lymphoma staging are ultrasonography and fine needle not only for differentiating lymphoma vs non-lymphoma but may help for biopsy of spleen and liver although evidences on the real utility of this test subclassification of lymphoma subtypes, useful for clinical purposes. on clinical choices are lacking. Cytology via fine needle aspirate biopsy has demonstrated good sen- One of the most important tests useful to refine lymphoma diagnosis is sitivity (73.3%) and specificity (89.5%) in differentiating neoplastic vs immunophenotyping. T immunophenotype (IP) has been identified as a non-neoplastic disease in dogs, but data on the diagnostic performances negative prognostic factor in high-grade lymphoma and some specific in identifying lymphoma and classify its subtypes are currently lacking. immunotypes related to aggressive behavior have been described. Flow cytometry is likely the most powerful tool to identify IP in canine lympho- Among the classification schemes used for canine lymphoma, the updat- ma and help to differentiate main lymphoma subtypes. In addition, it may ed Kiel and the WHO classifications are considered the most accurate. help to identify and accurately quantify tissue infiltration mainly in diffuse Updated Kiel is mainly based on cytological criteria and immunopheno- large B cell lymphoma. type while nodal architecture is less important. In addition, according to some studies some entities correlate with prognosis. On the other side Different from human medicine, detection of clonality, which is strongly WHO classification is mainly based on histological criteria and immuno- supportive of neoplastic expansion, is not possible by flow cytometry and phenotyping and the evaluation of nodal architecture (diffuse vs nodular) is mainly evaluated via molecular biology (PCR for antigen receptor rear- is important. This classification demonstrated a good reproducibility rangement). However, in some cases detection of some aberrant patterns (87%) among readers and some subtypes has been correlated to specific or expansion of a poorly represented population may be a suggestion prognoses. An attempt of correlating this two classifications has been of pseudoclonality thus allowing differentiation between neoplastic and done in the past. non-neoplastic diseases. To try to evaluate the diagnostic performances of cytology for canine Histopathology and immunohistochemistry remain the gold standard tech- lymphoma, we recently started a study in which 161 lymph node cyto- nique to final classify canine lymphoma. Different laboratory tests help to logical slides were blindly submitted to readers. Readers were asked to better frame the case and add important prognostic information. report 1) diagnosis of lymphoma vs non-lymphoma, 2) diagnosis of grade and putative immunophenotype, 3) putative WHO subtype. The results from readings were compared with those of histopathology, used as a gold standard, and with those of other readers , to test reproducibility. Results showed high values of sensitivity (92.6%) and specificity (89.4%) to differentiate lymphoma vs non-lymphoma with a moderate reproduc- ibility among readers. As expected, diagnostic performance decreases when more detailed subclassification were asked. The main diagnostic challenges were a misinterpretation of different B cell lymphoma subtypes and over-interpretation of high-grade T cell lymphomas. Apart from cytology, some other ancillary laboratory tests are useful to re- fine the diagnosis of canine lymphoma. These tests are intended to frame the patient’s health status, predict side effects of therapy, identify possi- ble prognostic factors and monitor therapy and anticipate recurrences. 74 WSAVA GLOBAL COMMUNITY CONGRESS

0038 chain reaction targeting the calmodulin gene.5 In its mycelial form, the colony has small and white or pale orange to orange-gray colonies with no FELINE SPOROTRICHOSIS IN A NUTSHELL cottony aerial hyphae. Some colonies are however black from the onset. Later, it is moist, wrinkled, leathery or velvety with narrow white border. H. Hock Siew Once phase transitioned to its yeast form, yeast colonies are cream or tan and smooth.2 Cytologically, the yeasts are found in abundance from Kuala Lumpur/Malaysia feline impression smears where they are located intra and extracellularly, in pleomorphic shapes ranging from the classical cigar-shaped to round or Qualifications: oval yeast, measuring 3 – 5 micrometer in diameter with a thin, clear halo around a pale-blue cytoplasm.14 Han Hock Siew On histology, diffuse pyogranulomatous inflammation with large foci DVM, MRCVS, Dip. AiCVD, Dip. ECVD of necrosis is seen throughout the superficial and deep dermis which may even extend to the deeper subcutis. There is abundant round to [email protected] cigar-shaped organism, 3-10 micrometer in length to 1-2 micrometer in FELINE SPOROTRICHOSIS, IN A NUTSHELL diameter seen both free and within macrophages. Commonly, organisms in cytoplasm of macrophages creates large clear pockets full of yeast due Introduction to poorly visualized yeast cell wall.15 Sporothrix schenckii sensu lato and the disease it causes, sporotrichosis Treatment is characterized by a chronic, granulomatous, cutaneous, or subcutaneous infection. Since its description by Dr. Benjamin Schenk in 1896, Sporothrix Treatment of feline sporotrichosis requires several months and must be schenckii sensu lato is known to exist as saprophytes in plant debris or continued for at least 1 month beyond clinical cure. This translates to high decaying organic soil matter in its asexual filamentous form (25-30°C) and cost of treatment, high risk of therapeutic side effects, high risk of zoono- converts into its yeast form when temperature favours (35-37°C).1 Com- sis and with the existence of lowly susceptible strains confers the disease plete growth inhibition is achieved at 40°C, with no sexual reproduction a guarded to poor prognosis. Despite a protracted treatment course, it observed to date. 2 Historically, the most common route of infection can is current understanding that the fungus does not develop resistance de be traced to the inoculation of conidia into broken skin via contaminated novo during treatment, although lowly susceptible/ resistant strains has soil during horticultural activities. It is only in recent times that the percep- been isolated.16-18 Currently, potassium iodide, azolic antifungals (ke- tion of the disease shifted to cats as an important risk factor and disease toconazole, itraconazole), amphotericin B, terbinafine, local heat therapy, propagators.3-7 cryosurgery and surgical resection has been documented as treatment options in the feline patient. Potassium iodide has traditionally been the Sporothrix schenckii is currently recognized as a species complex consist- treatment of choice despite its exact mechanism of antifungal property ing of Sporothrix brasiliensis, Sporothrix schenckii sensu stricto, Sporo- remains poorly elucidated. Potassium iodide either in its saturated form thrix globosa, Sporothrix luriei, Sporothrix mexicana and Sporothrix pallida (saturated salt of potassium iodide, SSKI) or in its powder form re-pack- with each species having its own distinct virulence profiles and geograph- aged into capsules has been described to treat feline sporotrichosis ical niches. 8, 9 S. brasiliensis, S. s. sensu stricto and S. globosa are the at dosages that ranges from 10-20 mg/kg every 24 hours. Side effects main species identified to cause pathology in cats with S. brasiliensis includes iodism (lacrimation, salivation, coughing, facial swelling, tachy- and S. s. sensu stricto being the most and second most virulent species, cardia) and thyroid hormone abnormalities. Due to its low cost, potassium followed by S. globosa.9 S. brasiliensis, currently regionally restricted to iodide is still often used either singularly or in conjunction with azole Brazil and Argentina, and characterised by its ability to cause systemic antifungals to treat feline sporotrichosis. spread.10-12 S. s. sensu stricto is the second most pathogenic species to infect cats with incidence reports mainly in Brazil and Malaysia. S. Imidazoles such as ketoconazole and itraconazole, currently consti- globosa is commonly identified as the species responsible for clinical tute the cornerstone therapy for feline sporotrichosis with itraconazole sporotrichosis in humans mainly in Asia and Europe, but a rare cause of favoured over ketoconazole as the latter is commonly associated with sporotrichosis in cats, with only one report from Japan.13 higher rate of side effects such as vomiting, hepatic dysfunction and altered cortisol metabolism. Itraconazole at 5-10mg/kg has been used Clinical Signs successfully to treat feline sporotrichosis. It is only recent that higher dosages of itraconazole and/or its combination with other antifungals has Feline sporotrichosis occurs most commonly in young adult, free roaming been explored to treat these refractory cases. intact male cats associated with fights with no known breed predispo- sition.4 Chronic non-healing lesions with nodules, ulcers and crusts are Cryosurgery, used in conjunction with itraconazole has been used commonly found on the head especially at the bridge of the nose, ear successfully to treat and cure 11 of 13 cats with sporotrichosis, with treat- tips, distal limbs or tail base region with the preponderance of lesions to ment lasting 3-16 months and a median of 8 months. Surgical resection accrue at cooler regions of the host body such as at the nasal passages is possible for localized singular lesions but not practical for generalized, and ear tips. If nasal passages are affected, extra cutaneous signs such disseminated forms. as sneezing, dyspnoea and respiratory distress is commonly reported in tandem with cutaneous manifestations. 5 Fatal disseminated form of Conclusion the disease is associated S. brasiliensis infection and co-infections with either feline immunodeficiency virus (FIV) or feline leukemia virus (FeLV) The prognosis of feline sporotrichosis remains guarded to poor and has no significant effect on the final clinical manifestations or the progno- current issues of lowly susceptible strains of Sporothrix schenckii sensu sis of the disease. lato remains unresolved. Diagnosis Reference Definitive diagnosis of feline sporotrichosis requires the isolation and Schenck BR. On refractory subcutaneous abscess caused by a fun- identification of agent in culture and its species identification by mor- gus possibly related to the Sporotricha. Bull. Johns Hopkins Hosp. phologic studies and physiologic phenotyping, as well as polymerase 75

13–15 NOVEMBER, 2021 1898;9:286–290. 0039 Larone DH. Identification of fungi in culture. In: Medically Important Fungi. TIPS AND TRICKS FOR INTUBATION OF THE A guide to identification. 5th edition. Washington, DC: ASM Press; 2011. DIFFICULT AIRWAY p.166-7. C. Braun1,2 Schubach A, Schubach TM, Barros MB, Wanke B. Cat-transmitted sporo- 1Vienna/Austria, 2Baton Rouge/United States of America trichosis, Rio de Janeiro, Brazil. Emerg Infect Dis 2005;11:(1)952–1,954. Qualifications: Rodrigues AM, Hoog GS, de Camargo ZP. Sporothrix Species Causing Out- Christina Braun breaks in Animals and Humans Driven by Animal–Animal Transmission. PLoSPathog. 2016;12:e1005638. doi:10.1371/journal.ppat.100 Dr.med.vet., ACVAA board-certified specialists in veterinary anesthesia and analgesia® Gremião ID, Menezes RC, Schubach TM, Figueiredo AB, Cavalcanti MC, Pereira SA. Feline sporotrichosis: epidemiological and clinical aspects. [email protected] Med Mycol. 2015;53(1):15–21 1. What constitutes a difficult airway? Gremião IDF, Miranda LHM, Reis EG, Rodrigues AM, Pereira AS. Zoonotic There is no single definition for the difficult airway. The (human) American epidemic of sporotrichosis: Cat to Human Transmission. PLoS Pathog. Society of Anesthesiologists Task Force on Management of the Difficult 2017; 13(1): 1-7. Airway defines in their practice guidelines the difficult airway as “(…)the clinical situation in which a conventionally trained anesthesiologist expe- Tang MM, Tang JJ, Gill P, Chang CC, Baba R. Cutaneous sporotrichosis: a riences difficulty with facemask ventilation of the upper airway, difficulty six-year review of 19 cases in a tertiary referral center in Malaysia. Int J with tracheal intubation, or both.”1 Dermatol 2012;51:702-8. In veterinary medicine no such task force (or definition) exists, however, Oliveira MM, Almeida-Paes R, Gutierrez-Galhardo MC, Zancope-Oliveira we know from morbidity and mortality studies that airway management, or RM. Molecular identification of the Sporothrix schenckii complex. Rev lack thereof, can lead to complications and/or even death.2,3 Iberoam Micol 2014;31:2-6. Thus, the best approach to any airway is to assume it will be a difficult Arrillaga-Moncrieff, Capilla J, Mayayo E, Marimon R, Marine M, Gene J airway. et al. Different virulence levels of the species of Sporothrix in a murine model. Clin Microbiol Infect 2009;15:651-655. 2.Prepardness Prepardness means not only anticipating complications, but also to have Rodrigues AM, deMelo Teixeira M, deHoog GS, Schubach TMP, Pereira the proper resources at hand. SA, Fernandes GF, et al. Phylogenetic analysis reveals a high prevalence of Sporothrix brasiliensis in feline sporotrichosis outbreaks. PLoS Negl This includes, but is not limited to: TropDis.2013;7(6):e2281 Mask with good seal - pre-oxygenate Oliveira MME, Almeida-Paes R, Muniz MM, Barros MBL, Gutierrez-Galhardo MC, Zancope´-Oliveira RM. Sporotrichosis caused by Sporothrix globosa in Laryngoscope(s) with good (!) light source Rio de Janeiro, Brazil: case report. Mycopathol. 2010;169:359–63. Bougie (pliable, small diameter stylet to guide the endotracheal tube into Oliveira MME, Almeida-Paes R, Muniz MM, Gutierrez-Galhardo MC, Zan- the trachea) cope-Oliveira RM. Phenotypic and molecular identification of Sporothrix isolates from an epidemic area of sporotrichosis in Brazil. Mycopathol. Bands to help open the mouth 2011; 172(4): 257-67. Lidocaine spray to desensitize the larynx (careful in cats! Most commer- Suzuki R, Yikelamu A, Tanaka R, Igawa K, Yokodeki H, Yaguchi T. Studies cially available sprays are too strong) in phylogeny, development of rapid identification methods, antifungal susceptibility and growth rates of clinical strains of Sporothrix schenckii Drugs (your anesthetic drugs as well as emergency drugs) Complex in Japan. Med. Mycol J. 2016; 57E:E47-E57. Lubricant to help with a better seal of the ETT cuff and /or help with nasal Raskin RE, Meyer DJ. Skin and subcutaneous tissue. In: Canine and feline intubation cytology. 2nd edition. St. Louis, MO: Saunders Elsevier; 2010. p. 41-4. Cotton tips to wipe of saliva or other content in the way of extubation Gross TL, Ihrke PJ, Walder EJ et al. Infectious nodular and diffuse granu- lomatous and pyogranulomatous diseases of the dermis. In: Skin disease Suction of the dog and cat. 2nd edition. Oxford, UK, Blackwell Science; 2005. p. 298-301. Tongue spatula Han HS, Kano R, Chen C, Noli C. Comparisons of two in vitro antifungal Laryngeal airway mask sensitivity tests and monitoring during therapy of Sporothrix schenckii sensu stricto in Malaysian cats. Vet Dermatol 2017;28:156-e32. Fiberoptic scope Nakasu CCT, Waller SB, Ripoll MK, et al. Feline sporotrichosis: a case Help of another experienced person series of itraconazole-resistant Sporothrix brasiliensis infection. Braz J Microbiol. 2021;52(1):163-171. doi:10.1007/s42770-020-00290-5. Emergency tracheostomy kit Vettorato R, Heidrich D, Fraga F, et al. Sporotrichosis by Sporothrix …. schenckii senso stricto with itraconazole resistance and terbinafine sensitivity observed in vitro and in vivo: Case report. Med Mycol Case Rep. 2017;19:18-20. Published 2017 Oct 28. doi:10.1016/j.mmcr.2017.10.001. 76 WSAVA GLOBAL COMMUNITY CONGRESS

3. When things fail anyway 0040 • Call for help! Like any other emergency your better off in a team! CLINICAL REASONING IN DOGS WITH ACUTE SPINAL CORD INJURY, WHAT SHOULD I KNOW? • Communication - say clearly what goes to your mind, don’t assume others to read your mind. E. Beltran • Stay calm! Under stress we sometimes get so stressed that we become London/United Kingdom paralyzed or we just do anything, but necessarily the correct thing. Take a deep breath, way your option and communicate with your team before Qualifications: proceeding. Elsa Beltran, Ldo Vet, DipECVN, PGDiptVetEd FHEA, MRCVS, European and • Abandonment - know when to stop. Yes, not intubating is an option, too. RCVS Specialist in Veterinary Neurology, Fellow of the Higher Education You might proceed by mask or let the patient recover without procedure. Academy, Associate Professor in Veterinary Neurology & Neurosurgery, Royal Veterinary College, University of London 4. Conclusion [email protected] • Be prepared CLINICAL REASONING IN DOGS WITH ACUTE SPINAL CORD • Know your limits INJURY, WHAT SHOULD I KNOW? • Stay calm Clinical reasoning is a fundamental skill in veterinary medicine and a learning process that will never stop throughout the life of a veterinar- • Consider your options (over and over) ian. It requires the acquisition of both veterinary medical knowledge (i.e. content-oriented learning) and appropriate clinical experience (i.e. • Proceed or abort process-oriented learning). In the lecture we will cover some specific examples and how to potentially There are several possible underlying causes for dogs presented with solve them. Know, there is usually more than one way :-) acute spinal cord injury (acute myelopathy) and it is important to apply a good physical, orthopaedic and neurologic examination to determine if the References origin could be due to a systemic, orthopaedic or neurologic dysfunction. During this lecture we will focus on how to best approach these patients, 1Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich and how to differentiate the most likely underlying causes using clinical DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, reasoning. Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A; Amer- ican Society of Anesthesiologists Task Force on Management of the A list of aetiologic diagnoses (vascular, inflammatory/infectious, trauma, Difficult Airway. Practice guidelines for management of the difficult anomaly, metabolic, idiopathic, neoplasia, degenerative) in veterinary airway: an updated report by the American Society of Anesthesiologists neurology is usually developed using the mnemonic VITAMIN D (or DAM- Task Force on Management of the Difficult Airway. Anesthesiology. NIT V), considering the severity of the clinical signs at the onset and the 2013 Feb;118(2):251-70. doi: 10.1097/ALN.0b013e31827773b2. PMID: progression over time. 23364566. However, this type of approach may not work for all the clinical cases and 2Dyson DH, Maxie MG, Schnurr D. Morbidity and mortality associated with other parameters that have to be taken into account to narrow down the anesthetic management in small animal veterinary practice in Ontario. J differential diagnoses. Am Anim Hosp Assoc 1998; 34(4): 325–335. Although, the neurological examination remains the cornerstone for 3Brodbelt DC, Pfeiffer DU, Young LE, Wood JL. Risk factors for anaes- clinical reasoning in veterinary neurology, other significant parameters thetic‐related death in cats: results from the Confidential Enquiry into must be considered to improve clinical decision-making in evaluating Perioperative Small Animal Fatalities (CEPSAF). Br J Anaesth 2007; 99(5): dogs with neurological diseases. All these parameters can be captured 617–623. using a five-finger rule, considering the signalment at the level of the wrist. The signalment should always be the first information you gather on the presenting case (species, breed, age, sex and coat colour), followed by the information acquired during the history taking (onset, clinical course, lateralization, pain), physical examination, orthopaedic examination (in cases with gait abnormalities) and finalizing by performing the neurologi- cal examination Spinal cord disease (myelopathies) resulting in peracute (< 6 hours) or acute (7-24 hours) onset of clinical signs in dogs are commonly encoun- tered in clinical practice. After gathering the essential information as described above, the neurological examination is performed: Neurologic examination and neuroanatomic localisation Unless an dog has been involved in a physical traumatic event and priority needs to be given to stabilisation of vital functions, the clinical approach to a dog with acute myelopathy involves taking a detailed history (includ- ing details on the rapidity of onset, the progression of the clinical signs, and the presence of hyperalgesia), preforming a general physical exam- 77

13–15 NOVEMBER, 2021 ination, orthoapedic examination and a complete neurologic examination. Ipsilateral spontaneous knuck- The goals of the neurologic examination are: ling, kyphosis, lordosis, scoliosis, Schiff-Sherrington posture with to determine if the nervous system is affected acute and severe myelopathy to establish an accurate anatomic diagnosis paraparesis/plegia, monopare- sis/plegia of one pelvic limb to assess the severity of the neurologic dysfunction and predict prognosis if possible Delayed to absent in pelvic limbs In dogs with acute myelopathy, mental status and cranial nerve examina- (ipsilateral to the lesion). Thorac- Normal spinal reflexes/muscle tion are normal, unless a multisystemic dysfunction is present or unre- ic limbs normal tone in the thoracic limbs lated neurological deficits. Based on evaluation of posture, gait, postural reactions, resting muscle tone, spinal nerve reflexes, spinal palpation and Thoracolumbar hyperaesthesia Normal or increased spinal nociception the lesion can be then be localised to one these regions (table if surrounding structures to the reflexes/muscle tone in the 1). spinal cord are involved pelvic limbs Spinal cord Resting muscle tone and spinal T3-L3 Decreased to absent nociception Increased muscle tone in the tho- segments Signs of dysfunction that could nerve reflexes in the limbs L4-S3 on plegic pelvic limb/s racic limbs if Schiff-Sherrington (localisa- be present posture is present tion) This reflex can be lost caudal to the spinal cord segment Decreased spinal reflexes/ Ipsilateral spontaneous knuck- affected. Pinching the skin muscle tone in the pelvic limbs ling, low head carriage, cervical (dermatome) at the level of two (ipsilateral) if spinal shock is ventroflexion (dysfunction of the vertebrae caudal to the lesion present grey matter with preservation does not elicit any reflex of the white matter function), torticollis, scoliosis Normal to increased muscle tone Ipsilateral Horner’s syndrome in the ipsilateral limbs. No mus- with cranial thoracic severe Hemiparesis/plegia, tetrapare- cle atrophy in any of the limbs myelopathies (at the level of T3 sis/plegia [ spinal cord segment) Normal to increased spinal Delayed to absent postural reflexes in all four limbs. The Faecal and urinary incontinence reactions in all four limbs or withdrawal reflex in dogs with possible with lesions affecting ipsilateral to the lesion (thoracic C1--C5 myelopathy might be the dorsal funiculus and pelvic limbs) decreased Non-bearing lameness Cervical hyperaesthesia if sur- One exception to these clinical C1-C5 rounding structures to the spinal signs is that dogs with acute and paraparesis/plegia, monopare- cord are involved severe myelopathies can present sis/plegia on one pelvic limb, with spinal shock. Spinal shock lameness (nerve root signature) Respiratory difficulties in tetra- is a transient loss (<48h) of mus- plegic patients due to involve- cle tone and segmental spinal Delayed to absent postural reac- Normal spinal reflexes/muscle ment on the axons that lead reflexes in the limbs caudal to tions in pelvic limbs (ipsilateral tone in the thoracic limbs to the phrenic and intercostal an acute and severe spinal cord to the lesion). Thoracic limbs nerves injury normal Decreased to absent spinal reflexes/muscle tone one pelvic Decreased to absent nociception (ipisilateral) or both pelvic limbs on plegic pelvic limb/s Ipsilateral Horner’s syndrome with severe myelopathies hyperaesthesia if surrounding structures to the spinal cord are involved Ipsilateral spontaneous Bladder dysfunction (L4-L6 upper knuckling, praying posture if motor neuron; L6-S3 lower motor dysfunction of the grey matter neuron) with preservation of the white matter function C6-T2 Hemiparesis/plegia, tetrapare- Decreased to absent muscle tone The clinical neuroanatomic localization may be challenging in animals sis/plegia, lameness (nerve root in the thoracic limbs, increased presenting with Schiff-Sherrington posture and spinal shock. signature), two-engine gait in the pelvic limbs The Schiff-Sherrington posture can be observed in animals with acute Delayed to absent in all four Decreased to absent spinal and severe thoracolumbar spinal cord injuries and consists of extensor limbs or ipsilateral to the lesion reflexes in the thoracic limbs. hypertonia in the thoracic limbs (as the only neurologic abnormality) and (thoracic and pelvic limbs) Normal to increased in the pelvic paraplegia o severely non ambulatory paraparesis (which often present limbs signs of spinal shock). Cervicothoracic hyperaesthesia if surrounding structures to the This posture is caused by sudden loss of inhibitory input from the border spinal cord are involved cells (which are located in the L1 to L5 spinal cord segments) to the ex- tensor motor neurons in the cervical intumescence. The Schiff-Sherrington Decreased to absent nociception posture spontaneously resolves within 14 days of onset. of plegic limbs, particularly with lateralized C6-T2 grey matter Spinal shock is a transient loss of muscle tone and segmental spinal re- lesions (for instance ischaemic flexes in the limbs caudal to an acute and severe spinal cord injury (SCI). myelopathy) causing absent This phenomenon is caused by loss of descending facilitatory inputs, nociception only in the ipsilateral hyperpolarization and decreased excitability of the intumescence motor thoracic limb 78 WSAVA GLOBAL COMMUNITY CONGRESS

neurons. Generally in dogs, the first reflex to reappear is the perineal The clinical presentations of some underlying causes of acute myelopathy reflex, followed by the patellar reflex and by the flexor withdrawal reflex are highly consistent when clinical reasoning is applied (such as acute up to 12 hours later, although this timing can be variable. The pelvic limb non compressive nucleous pulposus extrusion or ischaemic myelopathy). muscle hypotonia can persist for 10 to 14 days, when it is replaced by We would encourage to apply clinical reasoning in your daily practice as normal muscle tone and subsequently by hypertonia. The site of spinal this may aid decision making in a clinical setting. hyperalgesia (if present), evaluation of the cutaneous trunci muscle reflex, and repeated neurological examinations can aid to perform a correct clini- References cal neuroanatomic localisation in animals presented with spinal shock. Cardy TJA, De Decker S, Kenny PJ et al. (2015) Clinical reasoning in canine Spinal hyperalgesia can arise from a disorder affecting any of the spinal disease: What combination of clinical information is useful? Veteri- following structures: meninges, vertebral periosteum, spinal nerve roots nary Record 177, 171 or nerves, vertebral diarthroidal joints, and epaxial muscles Therefore the differential diagnosis list should include disorders involving all these Grapes NJ, Packer RMA and De Decker S (2020a) Clinical reasoning in structures in animals presenting with spinal hyperalgesia as the only canine cervical hyperaesthesia: which presenting features are important? clinical abnormality. Veterinary Record 187, 448 Differential diagnoses Humm KR and May SA (2018) Clinical reasoning by veterinary students in the first-opinion setting: Is it encouraged? Is it practiced? Journal of Developing a list of differential diagnoses relays on these important pa- Veterinary Medica rameters: history, signalment, clinical course, lateralization, the presence of pain and neuroanatomical localization The differential diagnoses for peracute and acute spinal diseases in dogs, as well as typical anamnestic and clinical findings, and disease progres- sion are summarized: 79

13–15 NOVEMBER, 2021 0041 parasite control can also allow the veterinarian to not only practice better medicine, but also to capitalize on feline business. Finally, it is hoped that THE ART OF FELINE PRACTICE the conclusion of this presentation will be that good feline medicine does M. Cousins create good business. New Orleans/United States of America Qualifications: W. Mark Cousins Doctor of Veterinary Medicine (DVM) Diplomate, The American Board of Veterinary Practitioners (Feline Medi- cine) Certified Veterinary Pain Practitioner Certified Veterinary Acupuncturist [email protected] The Art of Feline Medicine W. Mark Cousins, DVM Dipl. American Board of Veterinary Practitioners (feline) Certified Veterinary Pain Practitioner Certified Veterinary Acupuncturist The premise of this presentation is that feline medicine is good business. And, to that end, the practice of good, high-quality medicine will reap financial rewards in the veterinary practice. The entirety of the feline veterinary market is dependent upon the bond our clients have with their feline family members. The keys to tapping into this market are several: understanding the significance of the feline market in your practice today and its future potential, analyzing the financial potential of your practice’s feline market, understanding the psyche of the feline client, recognizing the different psychographic profile of cat vs. dog owners, practicing ag- gressive preventative medicine, including feline total parasite control, as a pathway to practice better feline medicine. The feline market segment is, therefore, a different segment than is the canine segment; and it should be examined differently. The practitioner’s goal should be to realize an increased feline average per client charge by practicing a higher quality fe- line medicine; making the feline market segment a more viable and robust segment of your hospital’s financial profile. The mechanics of how to create a more “cat-friendly” environment in your hospital are discussed. Some changes are as a result of alteration in the physical design of the facility; yet, some are as simple as changing small decorative aspects of the veterinary hospital. Some changes are also related to client educational programs. The sum total is to present to the cat owning public a hospital that presents a “cat-friendly” persona. The American Association of Feline Practitioners (AAFP) has a modeled pathway to help most veterinary hospitals achieve a “Cat Friendly Certifi- cation” (https://catvets.com/mbrdash/cfp-application/). The point will be made that, as good medicine equals good business, a conscious effort should be made to institute a preventative medicine program for cats that will not only allow the hospital to be considered a “cat-friendly” facility, but also to increase the monthly business income of the practice of as well. To this end, a discussion of some preventative medical practices will ensue with the ultimate aim of helping the practitioner to not only be a better feline practitioner, but also to increase the feline business of the hospital. Senior profiles (https://journals.sagepub.com/doi/pd- f/10.1177/1098612X211021538), adult wellness profiles, and parasite control are some of the ways the practitioner can not only increase the quality of feline medicine practiced, but can add to the financial strength of the hospital. Educational efforts aimed at clients regarding total 80 WSAVA GLOBAL COMMUNITY CONGRESS

0042 sions can be observed in any area of the oral cavity mucosa, especially on palatoglossal arches, but also on the lip and buccal area, gingiva, lingual FELINE CAUDAL STOMATITIS and sublingual tissues while the soft palate and pharynx can also be af- fected. Teeth are not affected, but dental (tooth resorption) or periodontal S. Papadimitriou, M. Kouki disease can coexist. Athens/Greece Typical clinical signs include severe oral pain, oral dysphagia and loss of body weight, reduced grooming behavior, halitosis and salivation. Behav- Qualifications: ior changes can also be observed. Serafeim Papadimitriou, DVM, DDS, PhD, Professor of Veterinary Surgery FCS seems to affect the body as a whole and not just the oral cavity. It and Dentistry, Faculty of Veterinary Medicine, A.U.Th., Greece, WSAVA seems that cats with FCS show elevated values of the parameters related GDC member. to a systemic inflammatory response. The esophagus is also one of the organs that can be affected. Maria Kouki, DVM, Msc, PhD, Clinician, own practice, Greece Diagnostic approach FELINE CAUDAL STOMATITIS The clinical signs are quite typical and together with history are usually Feline Caudal Stomatitis (FCS) as defined in AVDC’s Nomenclature, sufficient for the diagnosis. Caudal stomatitis must be differentiated from or Feline Chronic Gingivostomatitis (FCGS) as often referred to, is a gingivitis and periodontitis, as well as from squamous cell carcinoma destructive, but ill defined, painful severe, immune-mediated, oral mucosa and eosinophilic complex of the oral cavity, and from metabolic diseas- inflammatory disease of cats. The typical location of the ulcerative and/or es. When necessary biopsy is essential for the diagnosis. Viral profile is proliferative inflammatory lesions is lateral to the palatoglossal folds. FCS required, although in case of a positive test for FIV or FeLV the prognosis is quite common with a reported prevalence ranging from 0.7% to 12.0% does not change. Hematological and biochemical profiles are required depending on the article. Etiology and pathogenesis are largely unknown. before general anesthesia, as well as detailed oral and dental examination The disease probably results due to an abnormal immune response to oral and recording of the findings. Intraoral radiological examination for root antigenic irritation. It has been suggested that systemic pathogens (FIV, pathology must also be performed. FLV, FHV, FCV, Bartonella), dental diseases (tooth resorption, periodontal disease) and/or hypersensitivity (to microbial plaque or food allergy) are Therapeutic approach involved. Many studies have been performed with the aim of suggesting one or more of the factors mentioned above as the causative factor of A significant number of suffering cats will not be completely cured, re- FCS. Common conclusion is that no statistically significant difference gardless of the type of therapeutic treatment. So the goal of the treatment was found, between the groups of animals suffering from the disease must be the control of the recurrence of the disease, pain management and controls, for none of the microbial agents except Feline Calicivirus. and above all a good quality of life. In general, there is the surgical and the A recent study also showed that cats living together with other cats have medical approach of FCS. However, medical treatment on its own does an increased possibility of developing FCS. Another study showed that not have favorable long-term outcomes, making dental extractions, with the load of the virus in the oral cavity is not related to the severity of the additional medical management, the current standard of care. lesions or the prognosis. So is FCV the possible causative factor of the disease? A recent study suggested that FCS has a viral component. In this Medical treatment: study, the use of unbiased mNGS and transcriptomic analysis showed a strong positive association between FCS and FCV. In conclusion, the role Corticosteroids: Though initially they are quite effective, it has not been of FCV in FCS pathogenesis is possible, probably due to dysregulation of proven whether their immunosuppressive or anti-inflammatory action is the immune system, but there is not enough evidence to be considered as beneficial. Side effects: polyuria, polydipsia, secondary diabetes mellitus, the main causative factor of the disease. loss of body weight and fragility of the skin, and reduced efficiency or ineffectiveness over time. In both an earlier and in a recent study it was found that cats suffering from FCS had a higher rate of anaerobic and Gram-negative bacteria in Cyclosporine: Two studies have been carried out, both in relatively small their oral cavity than healthy cats. groups of cats in which total mouth tooth extractions had preceded. A substantial number of animals showed significant improvement (intervals Other studies suggested that the dysregulation of the immune system and of 6 months and 6 weeks). The use of veterinary cyclosporine products is significant changes in various parameters of this system, like neutrophil- recommended. ia, increase in T lymphocytes (CD8 +) and proinflammatory cytokines in the blood circulation, play a significant role in the pathogenesis of the Recombinant omega interferons have been administered orally or subcu- disease. In addition, dysregulation of genes associated with cytokine pro- taneously and a noteworthy number of cats showed significant improve- duction, T, and B cell growth, activity, and interaction has been mentioned. ment. So, the consensus opinion on the pathogenesis of FCS today leads to the Surgical treatment conclusion that the disease results due to a combination of abnormal im- mune response to chronic oral antigenic irritation (especially from anaer- Dental extractions obic and Gram-negative bacteria), on the basis of a clinical or subclinical viral infection (possibly FCV), probably resulting in dysregulation of the Dental extractions are performed to create an unfriendly environment immune system, especially an expression of local immunodeficiency in for anaerobic bacteria, with the aim of reducing antigenic irritation and the oral cavity, on a possible genetic background. inhibiting or limiting the immune response. It has been demonstrated that 70-80 % of cats with FCS will significantly improve following extraction of History and clinical signs all premolar and molar teeth. The average age of suffering animals is 7 years, regardless of gender, Disadvantages: Reduction of the functional capacity of the oral cavity, breed or vaccinations. Inflammatory, ulcerative and/or hyperplastic le- postoperative pain, psychological and financial burden on the owner. 81

13–15 NOVEMBER, 2021 Suggested therapeutic treatment Vapniarsky N, Simpson DL, Arzi B, Taechangam N, Walker NJ, Garrity C, Bulkeley E, Borjesson DL (2020). “Histological, Immunological and genetic Combination of dental extractions and pharmaceutical treatment: analysis of FCGS”. Frontiers in Vet. Science 7: 310. Published online 2020 Jun 3. doi: 10.3389/fvets.2020.00310. i) Selective teeth extraction, in combination with detailed professional cleaning and polishing Fried WA, Soltero-Rivera M, Ramesh A, Lommer MJ, Arzi B, DeRisi JL, Horst JA (2021). “Use of unbiased metagenomic and transcriptomic anal- ii) Extraction of the premolars and molar teeth yses to investigate the association between feline calicivirus and feline chronic gingivostomatitis in domestic cats”. Am J Vet Res: 82 (5):381- iii) Extraction of all teeth 394. doi: 10.2460/ajvr.82.5.381. Criteria: Animal/owner character, animal age, living conditions, severity/ Polidoro G, Galiazzo G, Giancola F, Papadimitriou S, Kouki M, Sabattini S, duration of clinical signs, diffusion-location of lesions, coexisting dental Rigillo A, Chiocchetti R (2021). “Expression of cannabinoid and can- or periodontal disease, previous treatments, experience of the surgeon. nabinoid-related receptors in the oral mucosa of healthy cats and cats with chronic gingivostomatitis” J Fel Med Surg. 23 (8): 679-691. doi: Pharmaceutical treatment 10.1177/1098612X20970510. Antibiotics: effective against anaerobic bacteria (clindamycin, amoxycil- lin-clavulanic acid, metronidazole, cefovecin for 4-6 weeks). NSAIDs and opioids: meloxicam, carprofen, tramadol, fentanyl patch, buprenorphine (injectable buprenorphine can also be used for per os administration). Corticosteroids, alternative to NSAIDs, prednisolone or dexamethasone, for 2-3 weeks, gradually decreasing thereafter. Oral antiseptics (chlorhexidine) or medical honey Treatment of esophagitis, especially in persistent cases or if there is a picture of esophageal dysphagia Cautery of proliferative lesions with surgical CO2 Laser (3-4 repetitive sessions with an interval of 2-3 weeks) Other treatments Cyclosporine, intravenous stem cell infusion, etc. Future objectives: further investigation of the etiology and new effective treatments -an interesting finding is the increase in cannabinoid receptors in the mucosa membrane of cats suffering from FCS. Prevention: recommendations for maintaining oral health and preventing viral infections. References Kouki ΜΙ, Papadimitriou SA, Kolokotronis A, Rallis TS (2017). “Chronic Gingivostomatitis with Esophagitis in Cats”. J Vet Intern Med. 31 (6): 1673–1679. doi: 10.1111/jvim.14850. Boaz Arzi B, Clark KC, Sundaram A, Spriet M, Verstraete FJM, Walker NJ, Loscar MR, Fazel N, Murphy WJ, Vapniarsky N, Borjesson DL (2017). “Therapeutic efficacy of fresh, allogeneic mesenchymal stem cells for severe refractory feline chronic gingivostomatitis”. Stem Cells Transl Med. 6 (8): 1710–22. https://doi.org/10.1002/sctm.17-0035. Stathopoulou TR, Kouki MI, Pypendop BH, Johnston A, Papadimitriou SA, Pelligand L (2018). “Evaluation of analgesic effect and absorption of buprenorphine after buccal administration in cats with oral disease”. J Fel Med Surg, 20 (8): 704-710. doi: 10.1177/1098612X17727234. Matsumoto H, Teshima T, Iizuka Y, Sakusabe A, Takahashi AD, Amimoto A, Koyama H (2018). “Evaluation of the efficacy of the subcutaneous low recombinant feline interferon-omega administration protocol for feline chronic gingivitis-stomatitis in feline calicivirus-positive cats”. Res in Vet. Sci, 121: 53-58. doi: 10.1016/j.rvsc.2018.10.003. Mestrinho LA, Rosa R, Ramalho P, Branco V, Iglésias L, Pissarra H, Duarte A, Niza M (2020). “A pilot study to evaluate the serum Alpha-1 acid glyco- protein response in cats suffering from feline chronic gingivostomatitis”. BMC Vet Res. 16 (1): 390. doi: 10.1186/s12917-020-02590-2. 82 WSAVA GLOBAL COMMUNITY CONGRESS

0043 Freedom from fear and distress WELFARE ASPECTS OF UNTREATED AND Freedom to express natural behaviours UNDERTREATED DENTAL DISEASE K. Mcleod By ensuring our clients understand what it means to provide good nutrition, a comfortable environment, excellent preventative healthcare, Toronto/Canada appropriate behavioural expression opportunities, and positive mental experiences, we can positively guide the way our clients care for their animals. Qualifications: WHY CONSIDER THE WELFARE ASPECTS OF DENTAL DISEASE? Dr Kymberley McLeod Because It’s Common: DVM Historically, veterinarians have believed that companion animals required [email protected] little if any dental care; however, we now know that dental disease is a very common medical condition in companion animals. 80% of dogs SUFFERING IN SILENCE: THE WELFARE IMPACTS OF DENTAL and 70% of cats have some form of periodontal disease by two years of DISEASE age. Increasing popularity of small and toy breed dogs, who often show increased dental crowding and rotation, decreased chewing behaviours, Dr. Kymberley Stewart DVM, BSc (Animal Welfare) and increased lifespan, is potentially increasing the prevalence of sub- gingival disease from previous studies. 10% of dogs have complicated Regular, clinically effective dental care is required for optimum health and crown fractures with painful direct pulp exposure and up to 75% of mature quality of life for our patients. Diseases of the oral cavity, when left un- cats are clinically affected with oral resorptive lesions, depending on diagnosed or untreated, can create significant pain, lead to serious local the population examined. It is estimated that 50% of large breed dogs or systemic disease, and prevent natural oral and facial behaviours from have uncomplicated crown fractures with dentin exposure. Overall, many being expressed. Veterinarians are respected leaders in the assessment veterinary patients are dealing with dental problems that may be causing and improvement of animal welfare globally, however veterinarians may significant pain, infection, or both daily. struggle to incorporate animal welfare conversations into their daily prac- tice, especially when the animal’s needs may differ from client desires. Because it Affects their Quality of Life: However for patients, the pain, infection, and emotional and/or physical distress of dental disease only changes when human intervention occurs. The ability to adequately manage pain and infection on a day to day basis are central to many of the currently utilized quality of life (QOL) While these welfare concerns are occasionally recognized by owners, assessment rubrics available for small animal practitioners. While QOL is most animals suffer in virtual silence as their owners are completely a commonly discussed issue when animals reach end of life situations, it unaware. Using the framework of the “Five Freedoms” (and more current is far less commonly addressed for younger animals facing the effects of “Five Animal Welfare Needs”) concept of animal welfare assessment, the their dental disease. challenges of dental conditions may be more easily evaluated, and can be discussed with clients in language they can understand and embrace. Pain is a well-established sequalae of many dental conditions, and while Only when an owner understands, accepts, and then incorporates the not all animals express oral pain in readily observable ways, it is well necessary changes do our patients truly benefit from the exercise. established that animals feel oral pain. Mammalian species are excellent models for dental pain in the human world. Research into human pulpitis, WHAT IS ANIMAL WELFARE? an incredibly painful condition, has found small rodents to be an excellent model. Repeatable and measurable behavioural changes due to purpose- The scientific definition of animal welfare centers around the desire to fully induced pulpal pain include decreased weight gain, increased time to assess how well an animal coping with the challenges it faces in daily life. complete meals, shaking, yawning, freezing and decreased activity . Dogs These challenges can be evaluated focusing on the animal’s health, on and cats have also been utilized to show behavioural changes with pulpal its resource or environmental needs, on the cognitive and/or emotional and non-pulpal pain. needs of the patient, or all three concurrently. Dental diseases have a wide variety of deleterious effects on the individual animal, and as such may be Interpreting behavioural signals of oral pain can be complex; however, ani- seen to pose a welfare concern to those affected. mals continue to eat despite debilitating and extreme dental pain. Animals require nourishment to survive, and the instinct to survive appears stron- MODERN ANIMAL WELFARE ASSESSMENT METHODS ger than the desire to avoid pain. Despite the common belief amongst vets and owners, dental pain rarely leads to dramatic decreases in appetite. Introduction to the Five Freedoms: Infectious aetiologies such as endodontic and periodontal disease incur The Five Freedoms were first formally published by the UK Farm Animal a significant bacterial disease burden on the body. Unchecked pain and Welfare Council in 1979, and have been further refined over years by infection can lead to potentially deleterious consequences as the body’s various groups and committees to their current form. They have since natural stress responses are activated. Stimulation of the sympathetic been adopted and endorsed by organizations such as the World Organi- nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA) axis to zation for Animal Health, the RSPCA and ASPCA. They represent an ideal release adrenalin, noradrenalin and cortisol respectively. Dentally, stimu- situation that should be strived for with each animal under care. They lation of an oral resorption lesion may create observable responses such currently encompass: as increased heart rate, trembling, vocalization, and attempts to escape. Longer term daily stimulation to such a lesion from salivating and eating Freedom from hunger, thirst and malnutrition may lead to more chronic stimulation of the HPA axis. Chronic stressors, as such, can negatively affect multiple body systems. Immune function Freedom from pain and injury impacts may be first noted with the development of an acute stress leuk- ogram, progressing to leukopenia and immunosuppressive inflammatory Freedom from infection and disease 83

13–15 NOVEMBER, 2021 cytokine changes with chronicity. Following this, significant decreases in 0044 both C reactive protein and creatinine, and increased nitric oxide levels are noted following appropriate dental therapy. Unchecked infection is an MORE THAN A NIBBLE: THE ESSENTIAL GUIDE TO ethically unacceptable condition to leave without appropriate therapy in BITE WOUNDS our veterinary patients. K. Thieman Because It Resonates with Clients: College Station/United States of America Clients report the same interest in maintaining the best of welfare for their animals, however many opinions are available to them as to how that is Qualifications: to be achieved. Most clients will identify they want to provide the best life possible for their pets within their abilities. Clients also report that they Kelley Thieman are happier to know their pets are not in pain. DVM, MS, Diplomate, ACVS (Small Animal) Assessing and communicating welfare concerns regarding a pet’s state of health can help an owner understand how the noted dental condition is [email protected] affecting their pet in a far more personal way. By going beyond a sterile, medical discussion to a patients’ potential experience of symptoms, we Objectives: may gain better owner understanding and compliance. While our clients may struggle with the more complex concepts of veterinary medicine, Dog bite wounds are common in veterinary medicine and are often not as pain, infection, and chronic physiological stress leading to systemic straight forward as they appear. Bite wound management requires patient disease are things clients do understand. When we can explain to them stabilization, wound exploration, wound debridement and (usually) open that their animal is unable to tell them how debilitating their daily chronic wound management. Decision making on when to close a wound will be conditions are, we move closer to helping clients care to make changes. discussed. Cases will be presented and management strategies offered, including lavage techniques and fluids, techniques for debridement and COMMUNICATING WITH CLIENTS SO THEY UNDERSTAND: options for wound dressings. Clients May Think It’s Normal: Dog bite wounds need to be explored. Crushed, necrotic tissue takes time to declare itself, but must be debrided. Many dog bite wounds should be There is a large difference between common and normal. Many clients opened and managed as an open wound until healthy granulation tissue is have historical experiences with animals that may lead them to believe forming. these conditions, or the clinical symptoms they elicit, are normal. Most brachycephalic animals demonstrate significant brachycephalic obstruc- INITIAL PATIENT WOUND ASSESSMENT tive airway syndrome (BOAS) related issues; however, many owners report it only in passing as they feel it’s “normal” for their breed. The patient must be assessed and emergent conditions must be ad- dressed before wound management. Hemorrhagic wounds should have Decades of normalization of dental disease (“doggy breath”, etc.) has left pressure applied with a gloved hand or with a pressure bandage. Once a large cohort of pet parents unaware, or unwilling to self-identify com- the patient is stabilized, a thorough physical examination should be mon conditions like fractured teeth, halitosis, or gingival inflammation to performed and the wound should be evaluated and covered. A protective their vet, nor consider them reasons to seek appropriate veterinary care. bandage, topical wound dressing or adhesive bandage can be used to Some may have been advised, either historically or recently, that it is ac- prevent further wound contamination. Radiographs are performed as indi- ceptable to “watch and wait” until these painful and debilitating conditions cated to assess the thorax, abdomen and spine, based on exam findings. progress into something more dramatic, such as a root abscess or tooth If free air is found within the abdomen, an abdominal exploratory surgery loss. Therefore, continuing to educate our clients that “common” isn’t is indicated. necessarily “normal” is essentially important. Analgesics should be provided to the painful patient before much Clients Don’t Understand the Impact on Their Pet: manipulation of the wound occurs. A neurologic examination should be performed before administration of analgesics if possible. Analgesics Helping our clients understand the ways in which their pet’s dental may cause respiratory depression. condition affects their day to day existence is very important. Sadly, veterinarians too may under-appreciate the impact therapy can have to When the patient is stabilized and thorough wound assessment can be improve a patient’s day to day life. Concern for anaesthetic risk can make performed, any initial bandage that was placed is removed. Analgesics us cautious when recommending dental care, especially if clients think ev- and sedation or general anesthesia are usually required depending on erything is ok. It is essential we talk to our clients about the positive and patient condition. Open wounds are filled with sterile, water-soluble jelly negative potential outcomes, as they affect the welfare of that specific to protect the wound from further contamination. A large area around patient, before making any automatic assumptions or judgements as to the wound should be clipped. The wound is lavaged with sterile saline or what is the right course to pursue. a dilute 0.05% chlorhexidine solution. If the wound is near the eye or a mucous membrane, sterile saline should be used and eye lubricant should SUMMARY be applied to the globe. The wound is lavaged with a copious amount of lavage solution. Ideally, the lavage solution is pressurized to approximate- Veterinarians need to change the way we discuss dental conditions with ly 8 psi. Many methods of lavage pressurization have been examined. A our clients. By helping our clients understand the pain, infection, and com- syringe with needle has been shown to develop approximately 16 psi. Ex- promises to their daily welfare companion animals face with inadequate cessively pressurized lavage solution is avoided as it can drive fluid, hair dental therapy, we increase the likelihood of compliance with medical and debris into tissues. A bottle with holes in the lid creates approximate- recommendations. ly 4 psi. A bag of fluid in a pressure cuff (cuff pressurized to 300mmHg) generates approximately 8 psi regardless of needle size. This is the most References available upon request reliable method of creating ideal lavage pressure. When gross debris is present, the quantity of lavage is more important than pressure (as long 84 WSAVA GLOBAL COMMUNITY CONGRESS

as the pressure is not too high). In these cases, normal tap water can be aesthetics of wound and decreases pain. Also, it does not increase the used or modified lavage bottles for the first lavage of a wound to easily, risk of infection when compared to dry therapies. inexpensively and quickly maximize lavage volume. Moist wound healing was introduced in the 1960s. A landmark study Wounds should be cultured when visibly infected or if they are not pro- was performed showing that pigs epithelialized wounds twice as fast in gressing as expected. a moist environment than when allowed to dry (Winter 1962). A human study was performed in 1963 with similar findings (Hinman and Mabach Once the wound is cleaned, it should be probed to assess the extent of 1963). Moist wound healing is now the standard of care in human medi- injury and to detect pockets or extension of injury. Aseptic technique and cine. sterile instrumentation should be used. The probing should be performed carefully as to not damage deeper structures. Communication of the REFERENCES: wound with body cavities and the degree of deep tissue involvement must be determined. Hosgood G. Wound repair and Specific tissue Response to Injury. In D Slatter (Ed.), Textbook of Small Animal Surgery DECISION TO CLOSE Third Edition (pp.66-87). Philadelphia, PA: Saunders Elsevier. The decision to close a wound is one of the most difficult of wound man- Hosgood G. Stages of wound healing. In SF Swaim, DJ Krahwinkel (Eds), agement. When dealing with dog bite wounds, it is unusual that the wound Veterinary Clinics of North America Small Animal Practice (pp. 667-687). should be closed immediately. The exceptions might be an open chest Philadelphia, PA: Saunders Elsevier. wound or an open abdomen. Even in those cases, the skin may remain open after the body cavity is closed. Pavletic MM (Ed.). (2010). Atlas of Small Animal Wound Management & Reconstructive Surgery Third Edition. Ames, IA: Wiley-Blackwell. If any question exists about the degree of contamination, tissue viability or vascular compromise, the wound is not closed but managed open. In Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for most dog bite wounds, you should question tissue viability because crush wound control and treatment: clinical experience. Ann Plast Surg 1997; injury leads to later-onset necrosis of tissues. Open wound management 38(6):563-577. will allow time for questionable tissues to declare themselves. Additional- ly, wound management will allow for the wound to be bandaged, debrided Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted clo- and cleaned, if appropriate. sure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997; 38(6):553-562. WOUND MANAGEMENT Venturi ML, Attinger CE, Mesbahi AN, et al. Mechanisms and clinical appli- Debridement: cations of the vacuum-assisted closure (VAC) device. Am J Clin Dermatol 2005; 6(3):185-194. Often, the first step in wound management is debridement of devitalized, dead, necrotic, or infected tissues and foreign debris. Surgical debride- Webb LX. New techniques in wound management: vacuum-assisted ment is often utilized for wound debridement. Sedation, general anesthe- wound closure. J Am Acad Orthop Surg 2002; 10:303-311. sia or a local nerve block will be required for any debridement beyond very superficial debridement. Argenta LC, Morykwas JM, Marks, MW. Vacuum-assisted closure: State of clinic art. Plast Reconstr Surg 2006; 117(Suppl):127S- 142S. Every dog bite wound should be explored. The crush injury is significant and under puncture wounds, there is often a large amount of devitalized Morykwas MJ, Simpson J, Punger K, et al. Vacuum-assited closure: State tissue and debris that needs to be debrided. of basic research and physiologic foundation. Plast Reconstr Surg 2006; 117 (Suppl) 121S- 126S. Surgical debridement is the most useful debridement for dog bite wounds. Surgical debridement can be performed as en bloc or layered debride- Ben-Amotz R, Lanz OI, Miller JM, et al. The use of vacuum-assisted clo- ment. Layered debridement is the most common approach to wound sure therapy for the treatment of distal extremity wounds in 15 dogs. Vet debridement and most appropriate for dog bite wounds. First, puncture Surg 2007; 36(7): 684-90. wounds are probed with a sterile instrument and an incision is made in the direction of the most significant pocketing. The most superficial devital- Guille AE, Tseng LW, Orsher RJ. Use of vacuum-assisted closure for ized tissues are removed and debridement proceeds into deeper tissues management of a large skin wound in a cat. J Am Vet Med Assoc 2007; as indicated. The decision to debride or leave tissue is based mainly 230(11): 1669-73. on color of the tissue with black, grey, green or very pale tissues being removed. Bleeding cut skin edges may indicate survivability. Typically, Kirkby KA, Wheeler J, Farese J, et al. Vacuum-assisted wound closure: multiple debridments are performed and questionable tissue can be left application and mechanism of action. Compendium. 2009; 31(12): 568-76. for later assessment. Swaim SF, Hinkle SH, Bradley DM. Wound contraction: Basic and clinical Mechanical debridement and interactive dressings to promote autolytic factors. Compendium. 2001; 23(1): 20-34. debridement are other commonly used mechanisms of debridement. Forms of bandaging that can help with debridement are hydrogels, hydro- colloids, and alginates. A main benefit of hydrogels, hydrocolloids and alginate bandages over wet-to-dry is that they maintain moisture over the wound. These wound dressings enhance autolytic debridement of wounds and, by keeping the wound moist, stimulate healing. Moist wound healing: A moist wound environment facilitates healing of the wound by preventing dehydration, enhancing angiogenesis and collagen synthesis and increas- ing break down of dead tissue and fibrin. Moist wound healing improves 85

13–15 NOVEMBER, 2021 0045 functions as a team, the group feels empowered and more motivated. A study looking at a surgical group one year after commencement of a SURGICAL SAFETY CHECKLISTS checklist showed that the participants had an improvement in interdisci- plinary team building, an increased sense of responsibility, and a positive K. Thieman change in failure culture.7 The checklist helps to empower the individual. College Station/United States of America Development of your own checklist can be accomplished following five steps: content and formatting, timing, trial and feedback, formal testing Qualifications: and evaluation, and local modification.8 The WHO has designed a basic checklist for physicians which can be altered. The checklist should be Kelley Thieman short, easy to read and succinct. It should not take longer than a few min- utes to complete. You will likely add and delete portions of your checklist DVM, MS, Diplomate ACVS (Small Animal) as you use it. Be open to change. Local modification is an important part of checklisting. Checklists can be used in non-surgical situations as well, [email protected] such as IV catheter placement, urinary catheter placement, or ensuring that all necessary procedures are performed before an animal is sent Checklist: A type of aid used to reduce failure by home. compensating for potential limits of human memory and attention. As part of the study performed by Gawande’s group, a survey was request- ed 3 months after commencement of the checklist. The nurses, surgeons, Human error is inevitable, particularly under stressful work condi- anesthesiologists and others filled out the surveys. After three months, tions.1,2 Increasing stress, fatigue and the complexity of a situation lead 80% of the respondents reported that the checklist was easy to use, did to cognitive function decreases and errors.2 Hospitals and operating not take long to complete and improved the safety of patients. 78% of re- rooms are considered very stressful, complex environments that require spondents reported that they physically observed the checklist prevent an multiple, precise actions. Because of this, it is understandable that error in the OR. A final question on the survey asked, “If you were having medical mistakes occur. Each year, many people die as a consequence of an operation, would you want the checklist to be used?” 93% said yes. medical mistakes, making medical errors one of the top leading cause of death in the United States.3 Mistakes occur in 1% of actions performed by References: doctors, nurses and other hospital staff, which accounts for two mistakes per patient per day.4 In human medicine, over half of the reported medical 1.Error, stress and teamwork in medicine and aviation: cross sectional mistakes are surgical.9 Medical mistakes also occur in veterinary medi- surveys. Sexton JB, Thomas EJ, Helmreich RI. BMJ 320: 745-76, 2000. cine. It is easy to understand how mistakes occur when you consider the complexity of our profession. Surgical procedures (routine or emergent) 2.Stress and congnition: A cognitive psychological perspective. Bourne require coordination of an entire team. LE, Yaroush RA. NASA: 1-121, 2003. A study in the New England Journal of Medicine has shown what pilots 3.To Err is Human; Building a Safer Health System. In Kohn, Corrigan, Don- have known for decades; a simple checklist can significantly decrease aldson, (eds): Institute of Medicine – Washington DC: National Academy mistakes.5 Introduction of surgical checklists has had a profound impact Press, 1999. on human medicine. Complications, including mortality, surgical site infection and blood loss, were compared before and after the implemen- 4.Error in Medicine. Leape LL. JAMA 272: 1851-1857, 1994. tation of a surgical checklist in hospitals around the world. They showed that the implementation of the checklist decreased the mortality rate in 5.Effect of a 19-item surgical safety checklist during urgent operations in surgical patients by nearly 50%. Surgical site infection decreased from a global patient population. Weiser TG, Haynes AB, Dziekan G, et al. Ann 11.2% to 6.6% and blood loss over 500 mL decreased from 20.2% to Surg 251: 976-980, 2010. 13.2%.5 Subsequent studies have presented variable results, as have veterinary studies. 6.The checklist – a tool for error management and performance improve- ment. Pronovost P. J Crit Care 21: 231-235, 2006. The checklist works the patient through the system starting prior to the induction of anesthesia. All patients are correctly identified and the pro- 7.Patient safety in orthopaedics: Implementation and first experience with cedure to be performed is established. Necessary blood work is reviewed CIRS and team time-out. Wingenfeld C, Abbara-Czardybon M, Arbab D, et or run if needed. The patient is anesthetized and prepped, and moved to al. Z Orthop Unfall 148: 525-531, 2010. the OR. Prior to the commencement of surgery, a “Time Out” is performed. This is a moment for the team to stop and reflect on what they are about 8.Perspectives in quality: designing the WHO Surgical Safety Checklist. to do. All of the team members introduce themselves and their role. The Weiser TG, Haynes AB, Lashoher A, et al. Int J Qual Health Care 22: 365- patient is identified, the procedure is reiterated, the equipment is checked, 370, 2010. the sponges and instruments are counted, and potential problems are anticipated and discussed. Finally, the surgery may begin. After the 9.The incidence and nature of in-hospital adverse events: a systematic procedure is completed and prior to wound closure, the final section of the review, deVries EN, Ramrattan MA, Smorenburg SM, et al. Qual Saf Health checklist is administered. Post-operative sponge and instrument counts Care 17: 216-223, 2008. are completed, any specimens obtained during surgery are gathered and labeled, equipment concerns are addressed and the post-operative plan is discussed amongst the team members. One of the major benefits of the checklist is communication among the group. The checklist helps to change a surgical “group” into a surgical “team”. The checklist helps a group of people to perform like a team. The systems approach assumes individuals will make mistakes but the system around them should provide a safety net to prevent mistakes. When the group 86 WSAVA GLOBAL COMMUNITY CONGRESS

0046 0047 FILTER SYSTEMS - THE INS AND OUTS OF KOI AQUATIC CLINICAL CASES IN A MIXED ANIMAL VET POND LIFE SUPPORT PRACTICE J. Tepper J. Questen Manorville/United States of America Conifer/United States of America Qualifications: Qualifications: Julius M. Tepper, DVM, CertAqV Jena Questen [email protected] Doctor of Veterinary Medicine Koi are maintained in closed aquasystems that rely on recirculating filter systems to purify the water and aid in gas exchange. Some factors that Certified Veterinary Acupuncturist help to determine the type of filter system that should be employed are the stocking density, feed rate, ease of maintenance and the budget of the CertAqV (Certified Aquatic Vet) owner. Some examples of the components of these systems currently in use are prefilter solids separators and sedimentation areas, internal and Professional Animal Trainer external box filters, and pressurized canister filters. Additionally, to pro- mote gas exchange, will be found waterfalls, spillways and air bubblers. [email protected] Skimmers, designed to remove surface floating debris, also play a role in This presentation discusses the Subjective, Objective, Assessment and gas exchange. Each of these components will be discussed, along with Plan for several aquatic animal cases that were presented to Aspen Park the issues each may display that can lead to clinical problems. Veterinary Hospital over the past 3 years. We discuss the challenges of getting an accurate history from the client, as well as attempting to advise clients with at times not being able to directly examine the animals and only having the option of Telemedicine. The first case is that of a Freshwater Puffer fish that presented with a swelling on it’s lower left jaw. The swelling had been present for several weeks before presentation, and was already much smaller in size since before seeking veterinary care. Radiographs reveal facial bone damage. Sedated oral exam reveals an abnormal mass inside the mouth. Aspiration of the mass did not reveal any neoplastic cells. An antibiotics and antiin- flammatory injection were given and the animal discharged to go home with a diagnosis of trauma likely from a tank mate. Another case is a phone consultation for a large pond of koi fish in a neighboring state. There were several issues going on, from a discovery of low levels of uranium in the water, to high naturally occuring salt concen- trations in the well water, and then several fish deaths all seemingly unre- lated with differing symptoms, some with wounds, some from “pine cone” disorder, and others with no symptoms just death. Advice was given to the client regarding how to properly address water quality, and a suggestion of medicated (antibiotic) fish food for a period of 4-6 weeks. Often cases such as this can be difficult to diagnose and treat correctly without the ability to examine and sample the fish patients. The next case is that of a female Betta fish with a buoyancy disorder. Included is the entire Subjective description directly from the client. This is to demonstrate how it can be difficult to interpret what is actually occuring with the animal based simply on what the client reports, as the description is full of discrepancies, including at times reporting the fish is both negatively, and then positively buoyant. Also of interest is that the client reports having no test kit for testing water quality and never does so. The client was advised to begin water quality testing, and how to maintain good husbandry for the fish going forward. Next was presented a case of an Axolotl with “Red-Leg” Septicemia with multiple images, including images of the color of the animal just before and after handling, to demonstrate how dramatically their color can change with stress. The animal was treated with antibiotics for 5 days and chilled in a refrigerator. The animal was on the road to recovery as of this writing. Another case of 4 Axolotl’s belonging to a public aquarium is discussed. The animals were donated to the facility with an unknown history and were in poor condition. With good care they dramtically improved, yet still 87

13–15 NOVEMBER, 2021 the facility was targeted for an animal cruelty case due to the still less 0048 than ideal (although dramatically improved) condition of the animals. We discuss the struggles that public aquarium facilities can face, such as in a ARTIFICIAL INTELLIGENCE 101 FOR case such as this. VETERINARIANS R. Appleby We then discuss the successful surgical removal of a facial mass on a 3 gram Tetra fish. This is a testament to the lengths clients will go for their guelph/Canada pet fish, and also shows the potential for expansion of any vet hospital to include aquatic animal cases. Qualifications: Next we follow the radiograph progress of a goldfish with dramatic sand Ryan Appleby impaction as we attempt to save it’s life and help alleviate it’s discomfort so it can resume eating normally. DVM DACVR Also we discuss a mysterious case of a Koi shop with fish dying of a [email protected] seemingly unknown neurological cause, for which advances testing all Introduction to Artificial Intelligence for Veterinarians showed up as negative. Eventually it was discovered the fish were dying from zinc toxicity from the galvanized steel tanks they were housed in. Ryan Appleby DVM DACVR Throughout the presentation there are also images of other cases of fish Ontario Veterinary College, Guelph, Ontario, Canada with wounds and injuries for general discussion. Artificial intelligence (AI) is everywhere in our society. From powering our In conclusion, a mixed animal veterinary practice can easily have a robust favourite applications, to streamlining our text messaging, AI is finding number of aquatic animal cases, providing both variety and interest for its way into most of the technologies we interact with. Medicine is being the practitioner, as well as income for the practice. changed by AI and veterinary medicine is no exception. While early in its implementation, AI will have profound impacts on our profession in the years to come. Therefore, it is vital that all veterinarians understand AI, its promise, limitations, and the challenges we will face in implementing it effectively in veterinary practice. Background: Artificial intelligence is the branch of computer science devoted to creating systems to perform tasks that would normally require human intelligence. This is a broad umbrella term encompassing a wide variety of subfields and techniques. Before the 1950s, AI was the providence of science fiction. But in the late 40s and early 50s scientists began to make fiction reality. In 1950 Alan Turing was one of the first to introduce the concept of computers performing intelligent tasks. In 1954 the first AI program, Logic Theorist was created by Allen Newell and colleagues, before the term even AI existed. The term artificial intelligence was coined by John McCarthy in 1955. While AI was heavily researched in the second half of the 20th century, it has really been with major advances in computer processing power, availability and importantly digitization of enormous amounts of data that AI has taken off. Types of AI Artificial narrow intelligence: AI designed for a specific task. This encom- passes every AI in existence today. Since it only does a specific task, it is considered narrow or weak. An example of this is whether a radiograph has pulmonary nodules. Artificial general intelligence: AI with human like intelligence. Also known as strong AI. This does not exist yet, and some researchers argue it may never exist. Artificial super intelligence: AI which surpasses human intelligence. Like artificial general intelligence this also does not exist and is the work of science fiction and a source behind a lot of the fear about AI. Uses of AI in Veterinary Medicine: • Diagnosis • Animal care 88 WSAVA GLOBAL COMMUNITY CONGRESS

• Research sated. Ethically, commercial entities should not have veterinarians label data without any compensation. For all of this to occur there must be an • Business established digital infrastructure for data to be stored, labeled, and used. • Education Ground Truth: Given the breadth of application for AI it is not hard to imagine a future in In cases of supervised learning, labels applied to data must have an un- which every step of our daily professional life is touched by AI. derlying truth. This raises the concern of what determines the truth. Is this based on a veterinarian’s opinion? Is it based in histology? If it is based Definitions: on histology or radiology reports, consensus among how many specialists is considered truth? An AI solution can only be as good as the truth it is Machine Learning (ML): a subfield of artificial intelligence in which algo- trained on. rithms are trained to perform tasks by learning patterns from data rather than by explicit programming Ethics: Machine learning is good where there is clear data and simple questions. There are many ethical questions that arise with AI in veterinary medicine. An example of this is spam filters on emails. Initially as discussed above, a question exists as to who owns the data. This is important to consider as data in the world of AI has immense Artificial Neural Network (ANN): a computer system which mimics the value. It is also important to consider confidentiality and security as it biological process of neurons. Input data is multiplied by weights applied relates to patient information. There will inevitably be bias in AI. This may by the ANN. Like neurons, which require a threshold activation to trigger arise from training sets which have strong breed distributions, geographic a response, ANNs function similarly and will use data from various inputs distributions or imposed by the veterinarians behind the algorithm. In the to reach a conclusion. In image analysis a specific type of ANN called a case of veterinary radiology, patient positioning and radiograph quality will convolutional neural network (CNN) is used. play a significant role in the performance and bias of algorithms. Deep learning (DL): a subset of machine learning where an algorithm Regulation: leans on its own which features are best rather than requiring a human to teach is which features are best. Deep learning occurs on an artificial While AI products for medical applications in people are regulated by the neural network with typically many more than 10 layers (hence deep). FDA (Food and Drug Administration) in the USA and other similar bodies worldwide, there is no current regulation of AI in veterinary medicine. These terms can be challenging to understand how they all fit together. Regulation will be critical for the success of AI in veterinary medicine to The Russian nesting dolls analogy is one offered by IBM in its IBM cloud encourage ethical, responsible, and directed uses. learn hub. In this way, the concepts of AI can be thought of as Russian nesting dolls, each fitting inside one another. Machine learning is a Implementation: subfield of artificial intelligence. Deep learning is a subfield of machine learning, and neural networks make up the backbone of deep learning While there is much promise behind AI, implementation to use AI most algorithms. effectively in practice has proven to be a challenge in the human medical field. While hurdles such as FDA approval are not currently in place for vet- Natural Language Processing (NLP): subset of AI in which computers erinary medicine, the other challenges to implementation will be similar. can understand text and spoken words. These programs draw from ML Dedicated infrastructure to allow data to be used for the purpose of AI will techniques and linguistics. be needed. A well thought out vision for the application of AI in veterinary medicine will involve deploying the infrastructure (both hardware and Methods of learning: software) and using it for specific use cases. This implementation will require veterinary professionals to have a basic understanding of AI and Supervised – labeled datasets are used to train algorithms to classify data partner with appropriate groups. There should be ongoing quality control or predict outcomes. Goal is to predict outcomes from new data. to promote the responsible implementation of AI. Unsupervised - AI which analyzes data without human intervention (no Client Acceptance: labels). The goal of unsupervised learning is to uncover patterns which are not immediately apparent. While somewhat outside the control of veterinarians, client acceptance of AI will be vital for its success. Veterinary professionals can promote Semi-supervised - combination of both supervised and unsupervised. acceptance with transparency and client education. Considerations and Challenges: Veterinarians and AI Use Cases: Veterinarians will be responsible for the outcome of AI solutions deployed in practice. This means that veterinarians must understand how the AI AI requires a directed purpose which should be determined by veterinar- works to be able to recognize errors and employ checks and balances on ians. Veterinarians provide a level of expertise which determines which the AI. The veterinarian will use cases are most valuable for the profession. The goal of AI should be to improve veterinary practice and the lives of veterinarians. This requires Resources well thought out use cases. Veterinary professionals would do well to seek out additional educational Data: opportunities with respect to artificial intelligence as the information here only scratches the surface. Some resources include: Data is any digital information. Some examples in veterinary practice include radiographs, images, lab work, electronic medical records, or pa- Coursera or LinkedIn Learning tient demographics. It is important that data is accessible but secure. The ownership of data should be well established at the outset of AI projects. Data must in most cases be labeled which represents a role for veterinar- ians. If veterinarians are employed to label data they should be compen- 89

13–15 NOVEMBER, 2021 Courses on general AI 0049 AI for healthcare (e.g., Stanford Specialization on Coursera) APPLICATIONS OF ARTIFICIAL INTELLIGENCE IN VETERINARY RADIOLOGY Google R. Appleby ai.google/education Guelph/Canada IBM Qualifications: ibm.com/cloud/learn Ryan Appleby The ACVR – educational resource list DVM DACVR https://acvr.org/artificial-intelligence-in-veterinary-diagnostic-imag- ing-and-radiation-oncology/ [email protected] References A History of Radiology: • IBM cloud learn hub: Artificial Intelligence. https://www.ibm.com/cloud/ Wilhelm Conrad Rontgen discovered x-rays in 1895, which set the ball learn/artificial-intelligence in motion for the modern field of diagnostic radiology. By the 1920s, diagnostic radiology was in use. Other imaging modalities soon follow- • Chartrand, G., Cheng, P. M., Vorontsov, E., Drozdzal, M., Turcotte, S., Pal, ing including diagnostic ultrasound beginning in the 1940s, computed C. J., Tang, A. (2017). Deep learning: A primer for radiologists. Radio- tomography (CT) in the 70s and magnetic resonance imaging (MRI) in the graphics, 37(7), 2113–2131. https://doi.org/10.1148/rg.2017170077 late 70s and 80s. • Ranchaert, E., Morozov, S., & Algra, P. (2019). Artificial Intelligence In the 1980s imaging began a digital revolution where images moved in Medical Imaging (E. R. Ranschaert, S. Morozov, & P. R. Algra, eds.). from film to screen. The digital imaging and communications in medicine https://doi.org/10.1007/978-3-319-94878-2 (DICOM) standard was put into place to allow the effective sharing and viewing of images across platforms and vendors. By the 1990s, most • Waljee, A. K., & Higgins, P. D. R. (2010). Machine Learning in Medicine: modalities were digital and by the mid-2000s digital imaging was adopted A Primer for Physicians. American Journal of Gastroenterology, 105(6), in many veterinary practices. The transition to digital imaging has allowed 1224–1226. https://doi.org/10.1038/ajg.2010.173 an increase in efficiency, image quality and has facilitated teleradiology consultations. • Tang A, Tam R, Cadrin-Chênevert A, Guest W, Chong J, Barfett J, Chepelev L, Cairns R, Mitchell JR, Cicero MD, Poudrette MG, Jaremko JL, Teleradiology has allowed access to specialist interpretation of veterinary Reinhold C, Gallix B, Gray B, Geis R; Canadian Association of Radiologists medical images for veterinary practices across the globe. However, in (CAR) Artificial Intelligence Working Group. Canadian Association of turn, the demand for radiology interpretations pushes the limits of what Radiologists White Paper on Artificial Intelligence in Radiology. Can Assoc teleradiology services can offer. This is in part the promise of artificial Radiol J. 2018 May;69(2):120-135. doi: 10.1016/j.carj.2018.02.002. Epub intelligence (AI). In the same way AI has improved efficiencies and bet- 2018 Apr 11. PMID: 29655580. tered performance in other sectors, its role in veterinary medicine offers to improve efficiencies (increasing the number of radiology consults) and • Jaremko JL, Azar M, Bromwich R, Lum A, Alicia Cheong LH, Gibert M, improve interpretations of images (increasing accuracy of interpretation). Laviolette F, Gray B, Reinhold C, Cicero M, Chong J, Shaw J, Rybicki FJ, Hurrell C, Lee E, Tang A; Canadian Association of Radiologists (CAR) Artifi- As of writing, in October 2021, commercial AI products have been re- cial Intelligence Working Group. Canadian Association of Radiologists leased in the veterinary market. However, no literature has been published White Paper on Ethical and Legal Issues Related to Artificial Intelligence in supporting the claims of these products. As we will see, initial research Radiology. Can Assoc Radiol J. 2019 May;70(2):107-118. doi: 10.1016/j. into AI has shown promise, however, it is not ready for clinical implemen- carj.2019.03.001. Epub 2019 Apr 5. PMID: 30962048. tation. While it may be seen as the next stage in diagnostics, it must be held to the same standards as other diagnostic methods. AI can help • history-computer.com elevate veterinary medicine if it is implemented ethically, responsibly and purposefully. Evaluating AI products: To begin to understand the current state of the art of AI in veterinary imaging we must first consider how to evaluate AI solutions. Literature on AI will, or should, assess its pre-clinical ability, that is, a proof of concept of how the AI can function. This is a necessary first step. Following a pre-clinical assessment, clinical evaluation can evaluate the tool in a clini- cal setting. As with other scientific studies, guidelines for practicing good science and thorough publication exist for AI in medical imaging. The CLAIM guidelines published in the journal Radiology: Artificial Intelligence are modeled after the STARD system and provide guidelines for research- ers looking to publish in the field. As there is no regulatory body for AI use as a diagnostic tool for animals, a thorough and critical examination by veterinary professionals is vital. 90 WSAVA GLOBAL COMMUNITY CONGRESS

In order to evaluate AI products we should ask ourselves 6 questions: improve patient outcomes, improve efficiency, improve diagnostics or provide any value whatsoever in a clinical setting. • Who is involved? As of writing, veterinarians must take caution in using AI products in • What does the AI propose to answer? practice. When errors occur with the AI the responsibility lies with the veterinarian. • What methods does the AI use? References: • How was the AI trained? • Mongan, J., Moy, L., & Kahn, C. E. (2020). Checklist for Artificial Intelli- • How was the AI tested? gence and Medical Imaging (Claim). Radiology: Artificial Intelligence. • How did the model perform? • Morozov, S. P., Vladzymyrskyy, A. V., Klyashtornyy, V. G., Andreychenko, A. E., Kulberg, N. S., Gombolevsky, V. A., & Sergunova, K. A. (2019). Clin- After considering individuals involved and the purpose behind the AI, ical acceptance of software based on artificial intelligence technologies which can alert the veterinarian to different biases in the AI software, the (radiology). Retrieved from http://arxiv.org/abs/1908.00381 remaining questions are technical in nature. • Bercovich E, Javitt MC. Medical Imaging: From Roentgen to the Digital The methods the AI use is important to understand so that we can under- Revolution, and Beyond. Rambam Maimonides Med J. 2018;9(4):e0034. stand a little bit more about how the AI came to its conclusion. Addition- Published 2018 Oct 4. doi:10.5041/RMMJ.10355 ally, information on the training and testing of the algorithm is vital to understand its biases, strengths and weaknesses. The AI must be trained • Langlotz, C. P. (2019). Will Artificial Intelligence Replace Radiologists? and tested on different data sets. If possible a testing set should come Radiology: Artificial Intelligence, 1(3), e190058. https://doi.org/10.1148/ from a completely different institution or using different parameters in ryai.2019190058 order to prove that the AI will response well to diverse imaging conditions. • Li S, Wang Z, Visser LC, Wisner ER, Cheng H. Pilot study: Application of Methods of performance: artificial intelligence for detecting left atrial enlargement on canine thorac- ic radiographs. Vet Radiol Ultrasound. 2020;61(6):611-618. doi:10.1111/ Sensitivity vru.12901 Specificity • Burti S, Longhin Osti V, Zotti A, Banzato T. Use of deep learning to detect cardiomegaly on thoracic radiographs in dogs. Vet J. 2020 Accuracy (Recall) Aug;262:105505. doi: 10.1016/j.tvjl.2020.105505. Epub 2020 Jul 7. PMID: 32792095. Precision (PPV) • Boissady, E, de La Comble, A, Zhu, X, Hespel, A-M. Artificial intelligence Area under curve for receiver operating characteristic curves – closer to 1 evaluating primary thoracic lesions has an overall lower error rate com- is better pared to veterinarians or veterinarians in conjunction with the artificial intelligence. Vet Radiol Ultrasound. 2020; 61: 619– 627. https://doi. F1 Score – higher score is more robust org/10.1111/vru.12912 Balanced accuracy • Banzato, T., Wodzinski, M., Burti, S. et al. Automatic classification of canine thoracic radiographs using deep learning. Sci Rep 11, 3964 (2021). Current AI in Veterinary Diagnostic Imaging https://doi.org/10.1038/s41598-021-83515-3 Current publications on AI methods are all pre-clinical evaluations. These • Banzato, T., Wodzinski, M., Tauceri, F., Donà, C., Scavazza, F., Müller, have shown promise that AI can accurately identify a number of common H., & Zotti, A. An AI-based algorithm for the automatic classification of abnormalities. A number of different groups have published on convolu- thoracic radiographs in cats. Frontiers in Veterinary Science, 1215. tion neural networks (CNNs) for evaluation of thoracic abnormalities. Only one of these has been compared to radiologists. In that case it performed • Banzato T, Bernardini M, Cherubini GB, Zotti A. Texture analysis of similarly for identifying left atrial enlargement on radiographs. The re- magnetic resonance images to predict histologic grade of meningio- mainder use the radiologists report as ground truth. Two studies evaluate mas in dogs. Am J Vet Res. 2017 Oct;78(10):1156-1162. doi: 10.2460/ different AI solutions to identify hip dysplasia and a variety of other ajvr.78.10.1156. PMID: 28945125. musculoskeletal abnormalities. No work has been done on the evaluation of abdominal radiographs with AI to date. No commercial products have • Banzato, T., Bernardini, M., Cherubini, G.B. et al. A methodological published on their pre-clinical or clinical utility. approach for deep learning to distinguish between meningiomas and gliomas on canine MR-images. BMC Vet Res 14, 317 (2018). https://doi. Some research groups, notable Dr. Banzato and colleagues, from the Uni- org/10.1186/s12917-018-1638-2 versity of Padua, have published not only on CNNs for thoracic radiograph evaluation but also on AI to differentiate brain tumors. This form of AI • Banzato T, Bonsembiante F, Aresu L, Gelain ME, Burti S, Zotti A. Use known as radiomics, has promise in improving the diagnostic capabilities, of transfer learning to detect diffuse degenerative hepatic diseases by identifying features of images that the human eye cannot detect. from ultrasound images in dogs: A methodological study. Vet J. 2018 Mar;233:35-40. doi: 10.1016/j.tvjl.2017.12.026. Epub 2018 Jan 3. PMID: Early work has also identified promise in streamlining radiation oncology. 29486877. The process of radiation oncology requires manually segmenting parts of the body. In doing so the oncologist tells the computer which parts are • Banzato T, Cherubini GB, Atzori M, Zotti A. Development of a deep con- tumor and which are healthy tissue. This means that dose of radiation can volutional neural network to predict grading of canine meningiomas from be reduced on the healthy tissue and targeted at the tumor alone. At least magnetic resonance images. Vet J. 2018 May;235:90-92. doi: 10.1016/j. one publication has shown that AI can accurately segment structures in tvjl.2018.04.001. Epub 2018 Apr 4. PMID: 29704946. the head and neck for radiation planning. • van Leeuwen, K.G., Schalekamp, S., Rutten, M.J.C.M., van Ginneken, B., In all instances it is important to remember that no clinical evaluation has been performed. That is, no one has noted whether these technologies 91

13–15 NOVEMBER, 2021 de Rooij, M., 2021. Artificial intelligence in radiology: 100 commercially 0050 available products and their scientific evidence. Eur Radiol 31, 3797– 3804. BRACHYCEPHALIC OBSTRUCTIVE AIRWAY SYNDROME: SURGICAL APPROACH J. Ladlow1,2 1High Wycombe/United Kingdom, 2Cambridge/United Kingdom Qualifications: Jane Ladlow MA VetMB, CertVR, CertSAS, FHEA, DipECVS MRCVS [email protected] BOAS: Treatment Life-style management Weight A number of studies have shown a correlation between BOAS status and weight. Excessive fat around the neck, pharynx and thoracic wall increas- es respiratory obstruction and decreases tidal volume. Reducing an obese dog’s weight is very likely to improve respiratory function though this has not yet been proven. Gastrointestinal Medication One study1 reported a positive statistical correlation between severity of respiratory and GI signs. In 80% of these cases GI signs resolved after BOAS surgery and immediate post-operative vomiting and regurgitation were reduced if the dogs were given 0.7mg/kg omeprazole, 0.2mg/kg cisapride and 1g sucralfate2. We currently use 1mg/kg omeprazole, initially once or twice daily in frequent regurgitators. A small number of dogs will develop vomiting and diarrhoea on omeprazole, in which case we switch to famotidine or rantitidine. Surgical options If lifestyle management is not sufficient, we have surgical options for this disease. Preparation If the animal is a frequent regurgitator then starting an antacid such as omeprazole or ranitidine 5-7 days prior to surgery may improve clinical signs. Stressed animals are more difficult to treat effectively, and we are using trazodone as an anxiolytic to relax any dogs which have kennel or owner separation anxiety. Intravenous dexamethasone is given at induc- tion to try and avoid airway swelling. Nerve blocks (maxillary) are effective at reducing arousal during nasoplasty. Tonsillectomy Most dogs with clinical signs of BOAS have hypertrophic tonsils that may not look particularly important when the dog’s mouth is open with an elevated head. Whilst the evidence for the tonsillectomy is weak, removal of additional tissue in an overcrowded pharynx is a reasonable strategy. By removing only the extruded part of the tonsil, less haemorrhage occurs, although we do use either bipolar coagulation, a harmonic scalpel or a laser for this procedure The palate can then be sutured to the tonsillar crypts, which avoids excessive pendulous lateral tissue. 92 WSAVA GLOBAL COMMUNITY CONGRESS

Soft Palate Resection If the dog recovers from traditional surgery and is still obstructed, we initially place a temporary tracheostomy tube, which is usually left in place There are a variety of palatoplasties being performed, with the recent for 24–48 hours while the surgical swelling resolves. We use temporary developments in surgical technique to thin the palate if thickened, in tracheostomy tubes in less than 5% of our cases, the majority of which addition to shortening it. The staphylectomy has become more radical then go on to have a reasonable recovery. Many of the tracheostomy over the years and now an extended staphylectomy involves trimming the tubes are placed pre-emptively in the grade 3 laryngeal collapse cases to palate in a smooth U-shape to the rostral tip of the tonsils. Carbon dioxide allow a smooth and less distressing recovery for the dog. laser resection techniques have been reported- the results are very similar to incisional techniques. The combination of the modified folding flap palatoplasty, trader tech- nique and alar fold resection and cuneiformectomy resulted in a better When shortening the soft palate, the aim is for the palate to be at rostral/ airway function longer term after surgery than the traditional staphylec- mid edge of tonsils in most brachycephalics. The original folding flap pal- tomy and wedge resection nasoplasty5. Dogs that present at a younger atoplasty3 had the rostral cut 1-2 cm caudal to the palatine process. We age (less than 6 months), are in a skinny body condition on presentation use Prof Oechetering’s modified folding flap with seemingly good results (usually with frequent regurgitation) or have Grade II-III laryngeal collapse which has the rostral incision a little further caudal. have a worse prognosis post-surgery5. Although the surgical techniques are relatively well described, including Laser Turbinectomy short term complications, there is little literature on the effectiveness of the different palatoplasties in the longer term, presumably due to the Another surgical technique that addresses the nasal obstruction is the difficulty of measuring a single component of airway surgery reliably. laser assisted turbinectomy (LATE). This was first reported by Oechtering Complications related to cutting too short are often mentioned in texts but in 20078 and he has published on a series of dogs that have had conven- not documented. tional surgery, tonsillar resection and LATE. The results are very encour- aging and we are using LATE for dogs that have little response to the Laryngeal Surgery conventional surgery or have WBBP data that indicates substantial airway obstruction is still present after initial surgery. Our initial experience with We find that most of our pugs have everted laryngeal saccules whilst in LATE is that the dogs recover remarkably quickly with usually only mild French bulldogs or bulldogs it occurs in the more severely affected dogs. post-operative complications. This may reflect the more elliptically-shaped and smaller rima glottidis in the pug or may be due to the seemingly softer cartilage which occurs in Surgical Results this breed. Conventional surgical results are, however, usually encouraging. Our We remove most everted saccules as the proportion of the rima glottidis objective assessment of improvement post-surgery is that about 50% of that they can occupy on inspiration can be dramatic. While performing dogs improve to an extent that we would consider them clinically unaf- sacculectomy may be considered controversial, a study by Cantatore et fected. The remainder of dogs remain clinically affected though usually al showed they did not regress 4-6 months after surgical treatment of improved5. LATE surgery for dogs that have little response to the first BOAS4. The long-term surgical effectiveness in cases where the saccules surgery results in a further 80% being classified as clinically unaffected are left in situ is, as yet, uncertain. after LATE9. Laryngeal collapse is a negative prognostic indicator for a good outcome The Brisk score developed by Tarricone 2019 also had previous airway post-surgery 5. Once there is significant collapse of the arytenoid cartilag- surgery, under and overweight, hypothermia, laryngeal collapse, state on es then an relatively benign option is cuneiformectomy6. If the dog is still admission and anaesthesia duration as factors that decrease progno- dyspnoeic after recovery and the owner wishes to pursue treatment we sis10. offer arytenoid lateralisation or a permanent tracheostomy if the budget is restricted. References Nasoplasty • Poncet CM et al. Prevalence of gastrointestinal tract lesions in brachy- cephalic dogs with upper respiratory syndrome: clinical study in 73 cases The nares surgery we perform now involves resection of the inner alar fold (2000-2003) . J Small Anim Pract 2005 within the vestibule (alar fold or second stenosis) along with resection of the wing of the nares (Oechtering personal communication). We use • Poncet CM et al. Long-term results of upper respiratory syndrome a Trader technique for the external nares and the combination of these surgery and gastrointestinal tract medical treatment in 51 brachycephalic two nares techniques results in a very much enlarged nostril. Although dogs. J Small Anim Pract 2006 the nostrils can look rather raw at first, in a few weeks they pigment and appear normal. • Findji, L., Dupré, G., 2008. Folded flap palatoplasty for the treatment of elongated soft palates in 55 dogs. Wien Tierärztl. Mschr 95, 56-63 Recovery • Cantatore M, et al. Medium term endoscopic assessment of the surgical As dogs are usually given steroids (dexamethasone) at induction we outcome following laryngeal saccule resection in brachycephalic dogs. usually chose paracetamol for analgesia, using an oral suspension (off Vet Rec. 2012 May 19;170(20):518 cascade) for the smaller dogs three times daily for 5 days. For large dogs Pardale V can be used. Antibiotics are not routinely used unless there was • Liu NC, Oechtering GU, Adams VJ, Kalmar L, Sargan DR, Ladlow JF. Out- evidence of aspiration pneumonia. Omeprazole is usually continued for comes and prognostic factors of surgical treatments for brachycephalic 5-7 days after surgery for frequent (daily) regurgitators. obstructive airway syndrome in 3 breeds. Vet Surg. 2017 Feb;46(2):271- 280 We nebulise the dogs with steam every 3-4 hours to moisten airways and prevent crusty secretions forming. If any dogs are showing respiratory • Pohl S, Roedler FS, Oechtering GU. How does multilevel upper airway effort after surgery nebulizing with adrenaline will reduce some airway surgery influence the lives of dogs with severe brachycephaly? Results of swelling and seems particularly effective in pugs7. a structured pre- and postoperative owner questionnaire. Vet J. 2016 Feb 1. pii: S1090-0233(16)00018-6. doi: 10.1016/j.tvjl.2016.01.017. 93

13–15 NOVEMBER, 2021 • Franklin PH, Liu NC, Ladlow JF. Nebulization of epinephrine to reduce 0051 the severity of brachycephalic obstructive airway syndrome in dogs. Vet Surg. 2021 Jan;50(1):62-70. doi: 10.1111/vsu.13523. ANESTHESIA CHALLENGES IN BRACHYCEPHALIC DOGS • Oechtering GU, Pohl S, Schlueter C, Schuenemann R. A Novel Approach to Brachycephalic Syndrome. 2. Laser-Assisted Turbinectomy (LATE). Vet P. Larenza Surg. 2016 Feb;45(2):173-81 Camperdown/Australia 9. Liu NC, Genain MA, Kalmar L, Sargan DR, Ladlow JF. Objective effec- tiveness of and indications for laser-assisted turbinectomy in brachyce- Qualifications: phalic obstructive airway syndrome. Vet Surg. 2019 Jan;48(1):79-87. doi: 10.1111 M. Paula Larenza Menzies • Tarricone J, Hayes GM, Singh A, Davis G. Development and validation of DVM, Dr.Med.Vet., PhD, EBVS® European Specialist in Veterinary Anaes- a brachycephalic risk (BRisk) score to predict the risk of complications in thesia and Analgesia dogs presenting for surgical treatment of brachycephalic obstructive air- way syndrome. Vet Surg. 2019;48(7):1253‐1261. doi:10.1111/vsu.13291 [email protected] Brachycephalic patients require special consideration when undergoing https://www.vet.cam.ac.uk/boas/about-boas anesthesia due to their particular anatomical features (i.e. stenotic nares, elongated soft palate, everted laryngeal saccules, hypoplastic trachea). They are prone to airway obstruction during the perianesthetic period, specially at induction and recovery from anesthesia which may be exacer- bated by anxiety, pain, regurgitation and aspiration pneumonia. Adequate preanesthetic planning for these patients is essential. A thorough history, physical examination and pertinent laboratory tests should be obtained. Pre-established anesthetic/surgical workflows are of great help and protocols when anesthetizing brachycephalic dogs. These protocols should be further adapted for each patient and all involved teams (e.g. anesthesia, surgery, internal medicine, ICU) should be familiar with the overall plan. Costa et al. (2020) showed that the implementation of a standardized perianesthetic protocol was associated with reduced in- cidence of postoperative regurgitation in brachycephalic dogs undergoing general anesthesia for airway surgery. In connection with this, all neces- sary anesthesia equipment and drugs, with particular emphasis on airway management material and a crash cart with emergency drugs, should be made ready before starting anesthesia. Preparation and vigilance are key factors for a successful management of these patients. Controversies exist regarding the ideal premedication and sedatives for these patients, and whether sedation should be given altogether. Brachy- cephalic dogs tend to learn to compensate for their respiratory insuffi- ciencies and sedation may remove these compensatory mechanisms. Deep sedation is associated with excessive relaxation of the upper airway muscles and worsening the airway obstruction. Contrastingly, pain and anxiety may cause tachypnea, intensify airway resistance and airway col- lapse. Therefore it is generally agreed that unless a patient is aggressive, the use of low doses of sedatives outweighs the benefits of no sedation at all. However, if animals arrive in a decompensated state (e.g. respira- tory obstruction or other emergency situation), the choice of no sedation followed by a rapid sequence induction protocol (e.g. propofol, potentially immediately anteceded by midazolam and/or fentanyl and/or lidocaine) may be a valid choice. In the case of the non-emergency brachycephalic patient, many opinions have been expressed over the years and some research studies carried out regarding what type of sedative should be used. Supporters of the use of acepromazine for premeditating brachycephalic dogs will argue that this agent provides adequate tranquilization before anesthesia induction, prevents emesis and due to its long duration of action (up to 6 hours), also allows for a calm recovery. Moreover the drug is known to have minimal actions on the cardiac rhythm (if anything, it has been associated with a reduction of ventricular arrhythmias). The addition of an opioid will ensure analgesia and potentiate the sedatives effects of aceproma- zine. Should bradycardia occur, anticholinergics can be administered to increase heart rate. Detractors of this agent will argue that acepromazine has no known reversal agent and relaxes soft palate and airway smooth 94 WSAVA GLOBAL COMMUNITY CONGRESS

muscles, exacerbating airway obstruction. Supporters of the use of mede- pulse-oximetry, body temperature, blood pressure) and may be extended tomidine (or dexmedetomidine) for premedicating brachycephalic patients in the postoperative period. If possible, an arterial catheter should be argue that these drugs provide reliable sedation and some degree of anal- placed to assess blood pressure invasively and monitor blood gases. As gesia. In case of side effects - or undesired prolonged sedation, a specific mentioned above, brachycephalic dogs have an increased vagal tone that reversal agent can be administered (i.e. atipamezole). Furthermore, small may cause bradycardia, atrioventricular blocks and ventricular escape doses of medetomidine (or dexmedetomidine) can be administered slowly rhythm. Other conditions that may lead to sudden decreases in heart rate either as IV boli increments (0.5-1 mcg/kg) or as a constant rate infusion include endotracheal intubation, ophthalmic and abdominal procedures, (0.5 - 2 mcg/kg/h) before anesthesia induction until the desired tranquil- hypothermia and hypoxemia. If bradycardia occurs, an anticholinergic ization/sedation is achieved. Detractors of the use of medetomidine-dex- (e.g. atropine 10 mcg/kg IV) may be indicated - if no alpha-2 agonist was medetomidine in brachycephalic patients concern about bradycardia administered or has been reversed - and the underlying cause should be produced by these drugs to animals with an already increased vagal tone. addressed. In addition, the association of anticholinergic with these agents is highly discouraged as they may cause severe hypertension. However, this may Anesthetic delivery should be discontinued at the end of surgical proce- carry the risk of reversing their sedative actions as well. Petruccione et dures, and the patient should be allowed to recover in a quiet environment al. (2021) compared dexmedetomidine 2 mcg/kg with acepromazine 20 in sternal recumbency. The endotracheal tube should be maintained in mcg/kg for premedication, both given intramuscularly and combined with place until the patient swallows repeatedly. Equipment to aspirate any methadone 0.3 mg/kg in 40 dogs undergoing brachycephalic obstructive regurgitate should be made available. Additional tranquilization (ace- airway syndrome (BOAS) surgery. The authors concluded that dexmedeto- promazine 0.01mg/kgIV) or sedation (medetomidine or dexmedetomidine midine produces more sedation but similar recovery quality to aceproma- 0.5-1 mcg/kgIV) may be required to prevent excitement or tachypnea that zine in these dogs. may worsen any laryngeal swelling. Steroids may also be required in to prevent or treat upper airway swallowing. Once the endotracheal tube is Close monitoring should be initiated after administration of premedica- removed, and if the patient allows, the tongue should be pulled out gently tion. Sedation combined with the possibility of vomiting may increase the to facilitate breathing. Supplemental oxygen is advisable (i.e. mask or risk for aspiration and asphyxia. The analgesic plan should also be con- nasal oxygen). If exaggerated abdominal movements with little actual air sidered before induction. For more details, refer to the “Perioperative pain movement and cyanosis are seen, the patient should be reanesthetized recognition and management” lecture and handouts of this conference. and reintubated immediately. A post anesthetic tracheostomy tube may Because brachycephalic breeds are at risk for perioperative aspiration be elected for these cases. Some veterinarians choose to recover these pneumonia, the administration of antiemetic and gastric protectants is of animals with their owners, however, this may be counterproductive in case special interest. Metoclopramide (0.5 mg/kg IV or SC) and famotidine (1.0 of an emergency. Overall, a vigilant monitoring and an stress-free environ- mg/kg IV or SC); or maropitant (1.0 mg/kg IV or SC) should be adminis- ment reduce the anesthetic challenges of these patients. tered at premedication. Before induction, the leads of an electrocardio- gram should be attached, non-invasive blood pressure connected (e.g. REFERENCES oscillometric or doppler devices) and a pulse oximeter probe placed either on the prepucium/vulva, ear or even the tongue of the patients. Keep in Costa et al. Postoperative regurgitation and respiratory complications in mind that excessive handling may cause stress and anxiety and precipi- brachycephalic dogs undergoing airway surgery before and after imple- tate a respiratory crisis. An oxygen saturation of 93% to 95% is not at all mentation of a standardized perianesthetic protocol. JAVMA; 256:899- uncommon in brachycephalic dogs breathing room air. Regardless, these 905; 2020. dogs should be preoxygenated for about 5 minutes before induction. Petruccione et al. Comparison between dexmedetomidine and aceproma- Placement of an intravenous catheter to provide patent venous access zine in combination with methadone for premedication in brachycephalic may present certain challenges in this patients (i.e. short legs with very dogs undergoing surgery for brachycephalic obstructive airway syndrome. loose skin). This author favors the insertion of an IV catheter into the VAA; 48:305-313; 2021. lateral saphenous vein in this dogs (e.g. easier to cannulize and to access in the case of BOAS). Induction is usually performed with short acting IV agents that allow for rapid intubation (i.e. propofol 2-4 mg/kg; alfaxalone 1-2 mg/kg). Immediately after induction, an endotracheal tube should be placed. Because brachycephaly dogs have small-diameter tracheas, an ar- ray of endotracheal tube sizes should be available. As an elongated palate may reduce the visibility of the laryngeal opening, the tip of the endotra- cheal tube can be used to hold the palate up in order to visualize the lar- ynx. In some cases, insertion of a tracheostomy tube may be indicated to facilitate surgery and recovery. For more details, refer to the “Temporary and permanent tracheostomy” and “Tips and tricks for intubation of the difficult airway” lectures and handouts of this conference. The anesthesia maintenance technique should be chosen according the the surgical pro- cedure. Isoflurane (1-1.5%) or sevoflurane (2-3%) in oxygen may be used for procedures that do not involve the airway. However, total intravenous anesthesia with propofol (0.2-0.6 mg/kg/min) or alfaxalone (0.05-0.25 mg/kg/min) may be preferred for procedures of the airway that require disconnection of the endotracheal tube, thus avoiding lightening of the an- esthetic plane and exposure of personnel to volatile agents. As mentioned earlier, analgesics should be incorporated in the overall anesthetic plan, in- cluding maintenance and recovery of anesthesia. Whenever possible (e.g. orthopedic surgeries), local anesthetic techniques should be incorporated as they provide excellent analgesia and recovery conditions. Standard anesthetic monitoring should be used (electrocardiography, capnography, 95

13–15 NOVEMBER, 2021 0052 IVDD on a DNA level. Mogensen et al., (2011) performed a Genome Wide Association Study (GWAS) with cases (≥ 6 calcifications or disc hernia- INTERVERTEBRAL DISC DISEASE IN tion) and controls (≤ 1 calcification) representing all three Dachshund hair CHONDRODYSTROPIC BREEDS – BACKGROUND, variants (smooth, wire and long). The most significant association was GENETICS AND SCREENING PROGRAMS identified on CFA 12 in the region 36.8 to 38.6 Mb (CanFam2). Another GWAS across breeds pointed at the same region on CFA12 where a H. Friis Proschowsky1, C. Bruun2, M. Fredholm2, C. Bru- fibroblast growth factor 4 (FGF4) retrogene insertion (Ins) was found to be un3, T. Marx4 associated with IVDD (Brown et al., 2017). Among the 73 genotyped cases (hereof 20 Dachshunds) in the study 72 had at least one copy of the FGF4 1Solroed/Denmark, 2Frederiksberg C/Denmark, 3Fredensborg/Den- insert on CFA12 (cases had at least one calcified disc or disc herniation). mark, 4Brabrand/Denmark A DNA test revealing the risk of developing IVDD based on the FGF4 insertion genotype is now offered at the UC Davis Veterinary Genetics Lab- Qualifications: oratory (https://vgl.ucdavis.edu/services/dog/CDDY.php). The mutation is reported to have an additive effect on disc calcification and a dominant Helle Friis Proschowsky effect on disc herniation (Batcher et al., 2019). DVM, Ph.D The FGF4-gene All dog breeds have two copies of the FGF4 gene on chromosome 18 but [email protected] the FGF4 gene has been copied and inserted to a new site in the genome INTERVERTEBRAL DISC DISEASE (IVDD) IN CHONDRODYSTROPHIC twice in the dog’s evolutionary history. Such an insertion is called a retro- BREEDS – BACKGROUND, GENETICS AND SCREENING gene. One time it has been inserted to a new position on chromosome 18 and the other time it was inserted on chromosome 12. The number and Background location of the FGF4 copies are important for length of the legs and has as well been associated with the risk of disc herniation. The phenotype of chondrodystrophic dog breeds like Dachshund and Welsh corgi is caused by a disturbance in the endochondral ossification Extra copies on chromosome 18 generates short legs and low to moderate leading to disproportionate dwarfism. In addition to the short-legged risk of disc herniation. This genotype/phenotype is seen in Cairn Terrier appearance, these breeds are prone to intervertebral disc disease (IVDD) and West Highland White Terrier. Extra copies on chromosome 12 give which can lead to intervertebral disc herniation (IVDH). This is a painful rise to less reduction of leg length but increased risk of disc herniation condition, and many cases call for surgery or even euthanasia. Dachshund as seen in breeds like French Bulldog and Beagle. Extra copies on both is the breed with the highest incidence of IVDH (Packer et al., 2013). chromosomes 18 and 12 will result in a dog with both short legs and high risk of disc herniation. This combination is found in breeds like Dachs- IVDD/IVDH has a multifactorial etiology involving both genetic and hund and Welsh Corgi environmental factors and disc herniation is nearly always preceded by calcification. The intervertebral disc consists of the centrally placed ge- The Danish study latinous nucleus pulposus, which is surrounded by a fibrous, lamellar ring, the annulus fibrosus. Within the first years of the dog’s life, the original A study was designed to evaluate the prevalence of disc herniation notochordal cells of the nucleus pulposus are replaced by chondrocyte- among Danish Dachshunds and to acquire the necessary knowledge to like cells and cartilaginous matrix (chondroid metaplasia). This leads to decide which screening program would be most beneficial for the breed. necrosis and calcification which is visible on an x-ray. The degenerative A questionnaire was sent to randomly selected owners of Dachshunds process may result in rupture of the annulus fibrosus, and the type of disc registered in the Danish Kennel Club. All dogs were ≥ 9 years at the time herniation referred to as “Hansen type 1” (Hansen 1952). the owner received the questionnaire where they were asked about their dog’s status with respect to disc herniation (symptoms, diagnosis, surgery The degeneration of nucleus pulposus occurs in all chondrodystrophic etc.). The same questionnaire was sent to a group of dog owners whose dog’s but the degree of degeneration varies from dog to dog. By taking an Dachshunds had been x-ray examined at the age of 24-48 months in x-ray and counting the number of calcified discs, one can get an estimate 2004-2006. The individual answers from the questionnaires were matched of the degree of degeneration in the individual dog. Studies have shown with information about number of calcifications and EBVs provided by the that there is a clear correlation between the number of calcified discs Danish Kennel Club. Finally, 151 dogs were genotyped for the FGF4 inser- and the risk of disc herniation (Jensen et al., 2008; Lappalainen et al., tion according to Brown et al. (2017). Blood samples for the genotyping 2014). The degree of degeneration has an estimated heritability of 0.6 were collected by veterinarians in relation to x-ray examinations at the age – 0.87 (Jensen and Christensen 2000) and breeding programs based on of 24-48 months. For all analyses, the dogs were divided in two groups an evaluation of the number of calcified discs is therefor used in several according to either the number of calcifications (≥ 5 calcifications or disc countries. Radiographic examination is recommended at 24 – 30 months herniation and < 5 calcifications) or EBV’s (<100 and ≥ 100). Association of age because the calcified disc material disappears over time - probably between the FGF4 retrogene insertion and number of calcifications was a result of an inflammatory response and phagocytic resorption (Jensen analyzed separately for each hair variant. and Arnbjerg 2001; Lappalainen et al., 2014). To reduce the prevalence of IVDH, the Danish Kennel Club has implemented a breeding program Results based on x-ray examination at the age of 24 to 48 months. The program is mandatory and only dogs with less than 5 calcifications are recommended The incidence of disc herniation in the three hair variants was 16 % (wire- for breeding. In addition, estimated breeding values (EBV) are calculated haired), 17% (long-haired) and 22 % (smooth-haired) and the difference using a BLUP Animal Model. The model includes gender, year of screen- between the hair variants was not significant (P > 0.05). There was a ing, hair variant and a fixed regression on age at screening. The breed clear association between the number of calcifications and the risk of average is set to 100 and the standard deviation is 15. An average EBV of developing disc herniation with a relative e risk of 11.87 for dogs with five the parents of 100 or above is recommended. or mode calcifications. The same trend was demonstrated for dogs with EBV’s below 100 – they had a relative risk of 15.4 compared to dogs with DNA studies EBV’s above 100. Several attempts have been made to unravel the genetic background of 96 WSAVA GLOBAL COMMUNITY CONGRESS

The allele frequency of the FGF4 insertion in the wire-haired Dachshunds 0053 was 0.74 whereas this allele was fixed/almost fixed in the other hair variants. Using the genotype as selection criteria all the long-haired and DEGENERATIVE MYELOPATHY - DIAGNOSIS AND almost all (31/32) of the smooth-haired Dachshunds would be excluded INHERITANCE from breeding. In addition, the correlation between FGF4 genotype and calcification status was not unambiguous so our results indicate that – in J. Bell the Danish population of Dachshunds - the FGF4 retrogene insertion on CFA12 is not a valid risk indicator on its own. Thus, calcification status Enfield/United States of America and estimated breeding values is at present a more reliable breeding scheme for disc herniation in Dachshunds in Denmark (Bruun et al 2020). Qualifications: References Jerold S Bell, DVM Batcher K, Dickinson P, Giuffrida M et al. Phenotypic Effects of FGF4 Adjunct Professor of Clinical Genetics Retrogenes on Intervertebral Disc Disease in Dogs. Genes (Basel). 2019; https://doi.org/10.3390/genes10060435 [email protected] Degenerative myelopathy (DM) is a specific, infrequently encountered, Brown EA, Dickinson PJ, Mansour T et al. FGF4 retrogene on CFA12 fatal inherited disorder of slowly progressive spinal cord degeneration. It is responsible for chondrodystrophy and intervertebral disc disease affects both sexes equally. Dogs present five years of age or older; with an in dogs. Proc Natl Acad Sci U S A. 2017; https://doi.org/10.1073/ average of nine years. Progression to euthanasia or death usually occurs pnas.1709082114 over six months to one year, however some affected dogs supported with a wheel-cart and excellent supportive care can sometimes be maintained Bruun, C.S; Bruun, C; Marx, T; Proschowsky, H.F and Fredholm, M (2020). longer. It presents most commonly in German Shepherd Dogs and Boxers. Breeding schemes for intervertebral disc disease in dachshunds: Is disc It is sporadically seen in Pembroke Welsh Corgis, Cardigan Welsh Corgis, calcification score preferable to genotyping of the FGF4 retrogene inser- Bernese Mountain Dogs, Rhodesian Ridgebacks, Borzoi and Chesapeake tion on CFA12? Canine Medicine and Genetics (2020) 7:18 https://doi. Bay Retrievers. It is rarely diagnosed in other breeds or mixed-breed dogs. org/10.1186/s40575-020-00096-6 Diagnosis can only be confirmed on post-mortem histopathological exam- ination of the spinal cord. The largest issue with DM is misdiagnosing it in Hansen HJ. A pathologic-anatomical study on disc degeneration in dog, a dog affected with another treatable disease. with special reference to the so-called enchondrosis intervertebralis. Acta Orthop Scand Suppl. 1952; https://doi.org/10.3109/ort.1952.23. CLINICAL SIGNS suppl-11.01 Clinically, DM is an upper motor neuron (UMN) disease relating to the Jensen VF, Christensen KA. Inheritance of disc calcification in the T3-L3 spinal cord. In dogs that can be maintained for extended periods Dachshund. J Vet Med A Physiol Pathol Clin Med. 2001; https://doi. of time (wheel cart and/or recumbency) the disease can progress to LMN org/10.1046/j.1439-0442.2000.00297.x signs, but this is extremely rare to encounter in practice. Jensen VF, Beck S, Christensen KA, Arnbjerg J. Quantification of the The earliest clinical signs of DM are insidious, and owners may not seek association between intervertebral disk calcification and disk herniation veterinary attention for some time – thinking they are age-related or due in Dachshunds. J Am Vet Med Assoc. 2008; https://doi.org/10.2460/jav- to arthritis. DM first presents with pelvic limb ataxia and paresis. With ma.233.7.1090 progression, knuckling of the hind paws, dragging of the toes (with asso- ciated wearing of the nails), dysmetria, crouching in the hind limbs and Jensen VF, Arnbjerg J. Development of intervertebral disk calcification in crossing of the hind limbs can occur. Swaying of the hind end and falling the Dachshund: a prospective longitudinal radiographic study. J Am Anim if forced to turn quickly can occur with gaiting. The clinical signs affect Hosp Assoc. 2001; https://doi.org/10.5326/15473317-37-3-274 both hind limbs, though there can be asymmetry in their severity. Urinary and fecal incontinence do not occur throughout most of the course of the Lappalainen AK, Vaittinen E, Junnila J, Laitinen-Vapaavuori O. Interverte- disease, although dogs can lose their housetraining if they cannot get out- bral disc disease in Dachshunds radiographically screened for interverte- side or position themselves for elimination. Hind limb muscle atrophy is bral disc calcifications. Acta Vet Scand. 2014; https://doi.org/10.1186/ from disuse and not neurogenic. Extremely rarely with advanced progres- s13028-014-0089-4 sion the clinical signs can progress to the forelimbs, and in the end stages can cause flaccid tetraparesis and affect the muscles of respiration and Mogensen MS, Karlskov-Mortensen P, Proschowsky HF et al. Genome-wide elimination. association study in Dachshund: identification of a major locus affecting intervertebral disc calcification. J Hered. 2011; https://doi.org/10.1093/ There is deficient hind limb proprioceptive placing and hopping and defi- jhered/esr021 cient extensor thrust. Pain and withdrawal responses are normal. Crossed extensor reflexes may be present. Patella reflexes are usually normal to Packer RM, Hendricks A, Volk HA, Shihab NK, Burn CC. How long and low exaggerated. Occasionally there can be a diminished patella reflex, but can you go? Effect of conformation on the risk of thoracolumbar inter- this would relate to involvement of the dorsal roots of the femoral nerve vertebral disc extrusion in domestic dogs. PLoS One. 2013; https://doi. (afferent), and not lower motor neuron involvement. Panniculus response org/10.1371/journal.pone.0069650 remains intact. Anal and tail tone remain normal. A significant signalment with DM is there is no pain or hyperesthesia. DIFFERENTIAL DIAGNOSIS There are many causes for hind end weakness in dogs. Most of the differentials to DM occur at much higher frequency and importantly many are treatable diseases. Differentials include significant hip dysplasia, type II intervertebral disc disease, discospondylitis, myelitis, spinal neoplasia 97

13–15 NOVEMBER, 2021 (intra or extra medullary), cauda equina syndrome, fibrocartilaginous the University of Uppsala. embolic myelopathy (FCEM), spinal arachnoid diverticula, and other rare or sporadically occurring myelopathies. Other diseases that may initially CORRELATING sod1 TESTING WITH CLINICAL DISEASE affect the pelvic limbs include caudal cervical spondylomyelopathy, and generalized neuromuscular, infectious, toxic, metabolic, ischemic and Canine DM is an animal model for human amyotrophic lateral sclerosis inflammatory diseases. (ALS; Lou Gehrig’s disease). In ALS over 25 identified genetic mutations cause disease liability; including a mutation in the sod1 gene. The differ- Dural ossification and spondylosis can be a common finding in older dogs ence between sod1 homozygous “at risk” dogs that do not develop clinical and should not be labeled as the cause for neurologic signs without fur- disease, and dogs with clinical DM may be due to additional unidentified ther workup. As an important non-painful differential, FCEM is peracute, genetic mutations. non-progressive and can affect anal and tail function. Myelography rules out compressive spinal cord disease. CSF analysis in DM is usually nor- It is difficult to determine the penetrance of homozygous sod1 testing mal. Electrophysiologic testing is normal – signifying normal motor reflex with dogs clinically affected with DM. The only published study of clinical- pathways. MRI may rarely show spinal cord changes, but is more useful to ly diagnosed DM at veterinary teaching hospitals between 1990-1999 was rule out other disease. Caution must be advised in over interpreting diag- by Dr. Roy Berghaus at UCDavis. Worldwide testing frequencies for the nostic findings as many of the differentials can be comorbidities with DM. sod1 variant are compiled by Mars/Genoscoper. Age, breed, progression, the absence of pain, and normal diagnostics as- Berghaus Mars Genosco- Mars Genosco- sist with the differential diagnosis. If a genetic test for the sod1 mutation per per is not homozygous “at risk” this rules out DM as a differential. However, a % clinically homozygous “at risk” result is NOT diagnostic and should NOT be used to Breed affected % homozygous % homozygous Positive pre- confirm a diagnosis of DM. for sod1 variant normal dictive value of sod1 homozy- Histopathological findings show degeneration of the myelinated axons in gosity to cilnical all funiculi, but especially in the T3-L3 dorsolateral funiculi. Pathognomon- disease ic to DM are cytoplasmic aggregates of sod1 in neurons identified through immunohistochemical staining with anti-sod1 antibodies. TREATMENT Boxer 0.6% 23.5% 38.8% 2.6% 3.7% 55.3% 54.0% DM is a fatal disease. Medical therapy does not relieve the clinical German 38.4% 31.5% 1.6% symptoms. As arthritis is often a comorbidity, a trial of NSAIDs should be Shepherd 2.0% offered to patients with presumptive DM. Steroids do not affect progres- Dog sion of DM and usually cause issues with polydipsia and polyuria. Physi- cal therapy and exercise to maintain muscle tone and to slow atropy are Pembroke 0.6% important supportive measures. Response to supplements and alternative Welsh Corgi therapies are anecdotal and lack controlled studies. It is obvious that the penetrance of sod1 variant homozygosity to clinical GENOMICS disease – even in breeds susceptible to DM is poor. The mode of inheritance of DM has always been considered to be com- GENETIC COUNSELING plex – involving more than one gene pair. In 2009, Drs. Gary Johnson & Joan Coates (UMo) discovered an autosomal recessive sod1 liability gene The high gene frequency of the sod1 mutation across breeds and the that must be present for clinical disease. All histopathologically confirmed infrequent clinical presentation of DM in any breed causes much confu- cases of DM are homozygous for the sod1 variant. (In only the Bernese sion in genetic counseling. With public acceptance of direct to consumer Mountain Dog, there is a low-frequency second variant in the sod1 gene multiplex panel testing for dogs, all panel tests include sod1 mutation test and if a BMD is being tested it should be for both variants.) results regardless of their relevance to individual breeds and dogs. Exacerbating the issue with sod1 mutation testing is that it is the most The high frequency of “at risk” and carrier testing dogs versus normal frequent mutation found in genetic testing of all dogs; at a frequency of dogs produces a very strong reaction to select against the sod1 mutation 7.77% in mixed-breed dogs and 5.41% in pure-bred dogs (identified in over in breeding dogs. This produces a significant loss of breed genetic diversi- 120 breeds). The frequency of the sod1 mutation is over 20-90% in more ty without a concomitant improvement of breed health. than 30 breeds, though no dogs in the majority of these breeds have ever been confirmed with DM. In all breeds (and mixed-breed dogs) a DM “at risk” result places a significant and unnecessary emotional burden on owners who believe Drs. Coates and Johnson hypothesize that the sod1 variant has age relat- that their family member will develop DM and die from the disease. The ed penetrance, and that most breeds do not live long enough to develop greatest issue with the misuse of sod1 genetic test results (both in breeds clinical signs. Their research has identified histopathologically affected with and without a repeatable frequency of confirmed affected DM dogs) dogs from 34 breeds and mixed-breed dogs. However, in the vast majority is where breeders are devastating their gene pool diversity by selecting of these often-populous breeds are only one or a handful of cases. Pop- against the sod1 mutation. The only situation where sod1 test results ulous breeds that live well into their teens and have high frequencies of should be considered in making treatment and breeding decisions is when sod1 homozygous dogs would be expected to have many confirmed dogs there are close relatives confirmed with clinical DM (and therefore a high with DM. Drs. Coates and Johnson’s research in Pembroke Welsh Corgis probability of carrying other unidentified but necessary mutations for identified a mutation in the SP110 gene that is present in 40% of DM clinical disease). confirmed dogs, but only in 4% of unaffected dogs, and causes an earlier age of onset. This mutation has not been found in other breeds, nor has a commercial test been developed. Other research into the genetic cause of clinical DM is currently being performed in the German Shepherd Dog at 98 WSAVA GLOBAL COMMUNITY CONGRESS

0054 retriever that presents after collapsing at home and has pale gums can lead the team to prepare monitoring and diagnostics before being asked CRITICALLY IMPORTANT CRITICAL THINKING by the veterinarian. SKILLS PLANNING allows the technician and nursing team to participate in M. Brashear prioritizing diagnostics and treatments. A dog that presents to the hos- pital in hypovolemic shock is ordered to receive pain medication, survey West Lafayette/United States of America radiographs, IV fluids, an IV catheter placed, and a minimum database of blood work drawn. These tasks must be prioritized for the best care of the Qualifications: patient and critical thinking and experience will aid in this step. Patients in the ICU setting will also have multiple treatments due or multiple patients Megan Brashear, BS, RVT, VTS (ECC) requiring treatments at the same time. The managing technician or nurse for these cases will need to think through the competing priorities to [email protected] determine which treatment or which patient needs to be completed first. Critical thinking involves putting together all knowledge sources to lead As information becomes available, these priorities may change. That to a decision. It involves book and school knowledge, asking intelligent same dog that presented in hypovolemic shock is receiving his IV fluid questions of those you work with, and thinking through past experiences. bolus when the blood results return showing hyponatremia, hypochlore- One who thinks critically can adapt to new situations and puzzles out mia, hyperkalemia, hypoglycemia, and azotemia. Suddenly the need for answers even when faced with unfamiliar information. Critical thinking radiographs decreases and the need to supply dextrose support and con- is not something that we are born with, it is a skill that must be taught tinued IV fluid therapy moves back to the top priority. Critically thinking and practiced. In school, many of us are taught to memorize facts and technicians and nurses must be aware of changes and remain flexible. regurgitate them on a test. With real patients, the answer is never that They must always be thinking ahead to potential problems that may occur simple; it requires thought. In medicine, critical thinking is a vital skill that and have a plan for how they will respond. How will it be determined that technicians should be practicing and perfecting every day. the patient is worsening? What can be done to confirm the concerns? This step in the process is beneficial for case studies and quizzing as it Veterinary technicians and nurses enter the field with an excitement to requires understanding and forethought. learn the technical aspects of our duties. Placing IV catheters, drawling blood, advancing to arterial catheters, central lines, urinary catheters, IMPLEMENTATION is exactly that – implementing the plan in the order feeding tubes, perfecting radiographs and learning new dentistry tech- deemed appropriate. Placing the catheters, drawing the blood, adminis- niques are obviously vital to the practice, and they are also the “fun” part. tering the anesthesia, taking the dental radiographs. This step will change Fewer want to put in the continued work and study required to cultivate with the planning step as more information becomes available and the the understanding and mastery of physiology, pharmacology, under- patient status changes. standing disease processes, and learning to look for subtle changes in the patient. These skills are what set stellar veterinary technicians and EVALUATION is an important step and one that should be carried out nurses apart from merely good ones. Anyone can be taught to place an along with the veterinarian. Is the patient improving? Is the information IV catheter in an afternoon. Not everyone understands the progression being received as planned? What has changed? What needs to change? of parvovirus, the signs of sepsis, and how to manage hypotension in a Each body system must be evaluated, and each hospital system must be puppy. Committing to continued learning contributes a large portion to the evaluated as well. How long did it take the lab work to come back? Is the ability to think critically. team properly trained on taking dental radiographs? How are the treat- ment sheets communicating with the team? Was the client kept apprised The nursing process, well-defined in human nursing, is a great model for of the changes with the plan? The nursing team is critical to all aspects of veterinary technicians and nurses to follow as they learn to think more patient care and the nursing process must reflect this, along with examin- deeply about the cases they are treating. The entire nursing process ing all areas of the hospital the nursing team affects. requires critical thinking at every step as nurses must have a basic understanding of medicine as well as technical skills and knowledge to Fully implementing the nursing process may seem tedious at first and take complete veterinarian orders. They need to understand diagnostic equip- more time than you may have available. The more you think through the ment, catheter placement, how to collect vitals, and how to administer process, the more second nature it becomes. Each step is an opportu- medications. Nursing also requires interpersonal skills and their devel- nity for learning, and each new skill learned or disease process better opment as one interacts not only with fellow nurses and technicians but understood adds to the bank of knowledge to be accessed with additional also veterinarians, assistants, client services, and especially pet owners. patients. This process can be discussed during nursing rounds, even if Participating in the nursing process will help to develop all of these skills it is just utilized for one or two patients, to showcase the importance of and is as follows: critical thinking. ASSESS is the first stage in the nursing process and is simply date In order to think critically, one has to understand both the problem and collection. In a hospital environment, data is gained from many sources how to solve that problem. It is not enough to simply know that anaphy- including the initial triage phone call, history taking with the client, through laxis can occur due to vaccines in a puppy, one must understand why and hospital rounds, and through a physical exam on the patient. Nurses and how and what to do to save that puppy’s life. In order to learn, questions technicians must always remember to perform a physical exam on their must be encouraged. Many hospitals perform rounds, whether formal patient each and every time they contact the animal, as the assessment and structured or informal and conversational, and these rounds are a phase can bring new information to light with each interaction. good opportunity to quiz employees and foster learning. The goal is not to embarrass employees and point out what they do not know, but to lead ANALYSIS is where all of the information gained is brought together to aid them through a case or disease process asking pointed questions along in the diagnosis. While veterinary technicians and nurses cannot make a the way. These questions should be evidence based and journal reading diagnosis, the information we provide is vital to the diagnosis process. encouraged to for research. As employees grow accustomed to these Palpating a large, turgid bladder on a male cat that is straining in the question and answer sessions, they will soon see them not as punish- litterbox allows the nurse to think ahead to the potential emergencies that ment, but look forward to the opportunity to learn and grow in their job. can occur and how they can either be mitigated or monitored. A golden Do not allow yourself to fall into the trap of cookbook medicine. ‘Because I 99

13–15 NOVEMBER, 2021 was told’ is never a good enough reason to perform a treatment on an ani- 0055 mal. As veterinary technicians and nurses it is the job description to carry out veterinarian orders, but perform that treatment because you under- NURSING CARE FOR THE CRITICAL PATIENT stand the motivation. What is happening in that patient that requires this medication? Why is it happening to that patient? How does this treatment M. Brashear or medication help this pet’s situation? Why was this treatment chosen now? Knowing the answers to these questions will help you become a West Lafayette/United States of America better technician and enrich your experiences with your patients. Critical thinking will lead you to the most right answer. Medicine is complex, often Qualifications: without a singular right answer; utilizing critical thinking skills can help wade through the potentials to understand the best answer at that time. Megan Brashear, BS, RVT, VTS (ECC) You may not have the authority to change orders, add medications, or [email protected] make a diagnosis, but those limits do not mean that you should not Veterinary technicians and nurses may be tasked with monitoring critical educate yourself in all of those areas. Even if you have been a veterinary patients at any time and at any hospital. Regardless of the patient and nurse for years you can still challenge yourself and learn more. Pick a dis- reason for hospitalization, the veterinary nursing team must remember ease process or type of cancer and learn all that you can about it. Choose to constantly triage these patients and utilize all of their monitoring and a breed of dog and learn about their inherited diseases. Cultivate your physical exam skills. critical thinking skills and you’ll be a valuable resource in your practice. If possible, flow-by oxygen should be provided to critical patients if References Available Upon Request there is concern for diseased lungs and or decreased ventilatory drive. Pulmonary edema and aspiration pneumonia can occur in critical patient populations and the respiratory system must be monitored frequently for changes. Patients on intravenous fluid therapy can develop fluid overload which can manifest as respiratory changes. The veterinary nursing team should be monitoring the respiratory rate and effort of all critical patients at least every 2 hours; every hour if there is concern for respiratory com- plications. In order to allow for the best respiratory opportunity, patients should be placed and supported in sternal recumbency, even if they cannot hold themselves up. Blankets can be rolled and utilized as support, and it is important to ensure the patient has enough padding to keep them comfortable as well as head support to keep the head and neck in a neutral position. Critical patients are at risk for developing ventricular premature contrac- tions. VPCs can be present due to reperfusion injury from hypovolemic or obstructive shock, due to trauma, hypoxia, anemia, pain, or with any surgery involving a splenectomy. When VPCs are encountered, the patient must be monitored and treated as needed. The nursing staff must first ensure that the patient has adequate perfusion; look at heart rate, mucous membrane color and capillary refill time, pulse quality, blood pressure, and mentation. In patients where perfusion is still normal and the heart rate is normal, specific treatment for VPCs may not be necessary. If the heart rate suddenly increases to >180bpm and only VPCs are noted or if the patient has poor blood pressure, pale mm, is weak or collapses, treatment with 1-2mg/kg of lidocaine is recommended. If the lidocaine is successful at converting the ventricular tachycardia, then a lidocaine CRI delivering 45-80mcg/kg/min may be administered. Many critically ill patients suffer from hypotension. The mainstay of hypovolemic hypotension treatment is fluid therapy. Crystalloids, in the form of balanced electrolyte solutions, are administered first. Crystalloids will provide a quick increase in intravascular volume, but these fluids will shift out of the intravascular space and into the interstitial space about 30 minutes after administration. Remember this when monitoring a hypotensive patient – a single normal blood pressure measurement does not equal “fixed”; if fluid shifts are occurring the blood pressure may drop again and it needs to be monitored frequently. If crystalloid fluid therapy is not working to correct the hypotension, the reason can be because not enough fluids have been administered (depending on the patient and their disease state, large quantities are needed before a change is noted), the patient has cardiac dysfunction, or the patient is battling vasodilation and may need additional drugs to restore normal blood flow. Colloids are made of larger molecules than crystalloids and will remain in the intravascular space longer than crystalloids. They will also help to draw fluids towards them thereby increasing intravascular volume. Blood products are natural colloids, synthetic colloids are products such as 100 WSAVA GLOBAL COMMUNITY CONGRESS