Vets on the Balkans - an online journal for veterinarians from the Balkans

Learn and Travel with Vets on The Balkans…. vets speak about it!

June 26, 2018

Dr Ivana Jovandin, veterinarian from Serbia, attened our education program Learn and Travel with Vets on The Balkans. She did her externship at Central Vet Clinic in Sofia, Bulgaria. Let her tell more about it:

Thanks to Vets from Balkan and Luba Gancheva, I had a chance to spend a week in April at a great Central Veterinary Clinic in Sofia, Bulgaria. The clinic is spacious, well equipped and the place where you can see the “state of art” veterinary medicine, and colleagues who work there are exceptional in various fields and together make a great team that is capable of finding the best solutions even for the most serious and difficult situations. It was a special pleasure to get to know and spend time with Dr. Melinda De Mul and Dr. Georgina Georgieva who work with exotic animals that I am professionally interested in. It was great to exchange our experiences, since in Serbia number of colleagues who are interested in exotic animals is very low. In addition to the work that is closely related to the profession, it was extremely useful to see the organization of work in such a large team where every person knew their task at all times, and everything was managed in order to provide better quality prevention, diagnostics and therapy of pets. Although the time I spent at the clinic was short, it will serve as motivation to strive to improve myself constantly, since the knowledge I got from working there with my colleagues is the experience that cannot be measured. The acquaintances and contacts made during the stay at the clinic are also something that is invaluable and something that will last for a long time. Enriched with this wonderful and unique experience, I believe that I have moved in the direction of what we all strive for, and that is to be, above all, better people and only then better veterinarians. And that’s why I am so thankful to Dr. Ranko Georgiev, Luba Gancheva and Vets from Balkan on everything!

Companion animal vets worldwide voice concern about new ‘pug’ film

June 25, 2018

Health and welfare impact of extreme breeding

Brussels, 25 June 2018 – Extreme breeding causes serious health and welfare problems: veterinarians are voicing their concern about the promotion of flat-faced dogs in films and social media, as this is likely to boost consumer demand for such dogs. Recent reactions were prompted by the announcement of the upcoming Disney film ‘Patrick’, in which a pug plays a feature role.

‘Pugs are a so-called brachycephalic or flat-faced dog breed, just like French and English bulldogs. Due to their extreme conformation, they are prone to many health issues,’ stressed Wolfgang Dohne, president of the Federation of European Companion Animal Veterinary Associations (FECAVA). While pets are bred this way to make them more appealing to buyers, ‘the reality is that these exaggerated features can lead to breathing difficulties, recurring skin infections, eye diseases and spinal or neurological problems, severely impacting their health and welfare.’

To raise awareness about health and welfare issues in breeding, FECAVA recently adopted a position paper[1] on healthy breeding, jointly with the Federation of Veterinarians of Europe (FVE).

‘Celebrities, social media and filmmakers strongly contribute to increasing the popular demand of certain breeds. Over the past few years, this has led to a real explosion in the number of brachycephalic dogs such as the French bulldog,’ confirmed Monique Megens, FECAVA representative of the joint animal welfare committee of FVE and the Union of European Veterinary Practitioners. ‘This is a worrying trend, as the exaggerated features of these dogs means that many need invasive surgery to allow them to breathe normally.’

‘Our profession is very concerned about this development, which not only has an impact on dog health and welfare but also on consumer protection,’ stressed Rafael Laguens, FVE president. ‘As vets, it is our role to educate our clients and to speak up and raise awareness about the consequences of exaggerated breeding. The FVE general assembly recently adopted a joint FECAVA/FVE policy paper on this topic.’

He applauded the recent initiative by the UK Brachycephalic Working Group (BWG), which had contacted Disney to try reduce the negative impact of its upcoming film.

The BWG, comprised of vets, breed clubs, welfare charities and academics, also expressed concerns that the film could lead to a surge in demand for pugs. Steps agreed by Disney and BWG include:

– an added a welfare message to the credits section, explaining the health issues pugs face

– leaflet distribution to journalists and the public at UK cinemas, raising awareness of leading health issues in the breed and explaining that ownership should not be undertaken lightly

– images of pugs dressed in human clothing will not be used in marketing for the film

– no merchandising of Patrick pug memorabilia

BWG will also support development of film industry initiatives to ensure that potential animal welfare implications are considered prior to future movies that prominently feature animals

On 26 June, FECAVA and FVE representatives will furthermore join forces with the EU Dog and Cat Alliance to raise awareness about extreme breeding in the European Parliament[2].

‘This is not just a European issue,’ confirmed Walt Ingwersen, president of the World Small Animal Veterinary Association (WSAVA), ‘Extreme breeding is a global concern. Our members see the results of extreme brachycephalic confirmation in practice on a regular basis and it is one of our top animal welfare concerns. We have therefore been in discussions with FECAVA and FVE with a view to supporting this policy paper on healthy breeding.’

FECAVA, FVE and WSAVA fully support initiatives such as that of the BWG and urge filmmakers to refrain from using such animals – whether live-action, animated or online videos – as this will increase their popularity.

[1] https://www.fecava.org/files/ckfinder/files/2018_06_Extreme_breeding.pdf

[2] https://www.theparliamentmagazine.eu/event/animal-health-and-welfare-breeding-extremes-dogs-and-cats

Annual Congress of Romanian Feline Medicine Society and 3rd Anniversary Vets on The Balkans

June 24, 2018

On 24-25th of May 2018 in Bucharest, Romania, held 6th edition of annual congress of Romanian Society of Feline Medicine.
Vets on The Balkans was part of the congress to celebrate 3th birthday. It was an initiative organised by SRMF and Vets on The Balkans and 7 veterianrians from the region came to present their clinical cases, as they do in the journal in general.

The veterinarians who attend were:

Dr Elli Kalemntazki from Greece. She is a graduate the Faculty of Veterinary Medicine of Aristotle University in Greece and held postgraduate degree in Public Health from The National School of Public Health in Athens, Greece. She is also Profesional Coach accreditated by the International Coach Federation since 2010 and a Certified Practicioner of Neuro Linguistic programming since 2012. Her subject was “Management of communications with clients”.

Dr Mila Bobadova is graduate the Faculty of Veterinary Medicine of University of Foresty in Sofia , Bulgaria. She is head manager of „ Dobro Hrumvane” veterinary clinics in Bulgaria. Mila paricipate ESAVS Dermatology courses.Her subject was „ Dermatolgy Puzzle”.

Dr Zoran Loncar from Serbia. Workin as full time Doctor of Veterinary Medicine Regional refferal veterinarian in Neurology and Orthopedic field. Member of ECVN, ESVOT, SCIVAC, SITOT, AO-Active member, jounior speaker. Author of sciantific publications. Clinical research surgeon. I can say the she showed 40 % of the pathology in cats through the point of view of Neurology.

Dr Daniela Drumea from Romania. Veterinary doctor, Dr. Daniela Luciana Drumea graduated the University of Veterinary Medicine in Bucharest, promotion 2014. Became a member of the non-stop veterinary clinic Tazy Vet in 2011, working as a veterinary assistant during her student years. Her passion and ambition to learn as much as possible about veterinary dermatology and the ongoing training at numerous national and international congresses and workshops led to the experienced and dedicated doctor that she is today.

Dr Bianca Bofan, PhD student, veterinarian in Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Stgrongly involved in respiratory pathology in dogs and cats. Her subject was Interventional Treatment of Nasopharyngeal Stenosis- different approach on 2 cats.

Dr Constantin Ifteme, the head manager of Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Member of VES&VIRIES,speaker, owner and manager of Vet Traing Center in Bucharest, Romania. His subject was Esophageal stricture-it is not always easy.

Dr Luba Gancheva, owner of Vets on The Balkans presented dermatology case from Bulgaria, managed together with romanian vet Dr Rares Capitan, as a great job between balkans vets. Because we strongly believe that hand by hand we all be better.
On 24th as a precongress course, she present the difference between veterinary medicine between Romania and Bulgaria. Both countries has what to learn and in that way will be more easy and fast. The motto of the journal is „ Sharing is Caring”. 25 veterinarians participated the workshop.

The organization of the Congress was in high professional level and more than 200 veterinarians attended.

We would like to express our gratitude to SRMF and Dr Tache Epure and Dr Valentin Nicolae for the opportunity to be part of it and to share these moments together.

See you next year on th 7th edition!

Alternative anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats

June 21, 2018

Authors: Stroe M.S., DVM, Ionașcu I. DVM PhD, Ion L., DVM

Correspondence: Stroe Marina-Stefania, DVM, Marina-Stefania.Stroe-Giurca@uliege.be

Abstract

Cataracts may occur at any age and in any location in the lens. Cataracts can block tapetal reflection and fundic examination partially or completely and are often classified by stage of maturation and cause.

Cataract surgery are facilitated by a central position of the eye ball within the palpebral fissure. A centrally positioned eye is normally achieved by using of neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. Use of these agents necessitates intermittent positive pressure ventilation (IPPV).

Objective: Offering alternatives for anesthesia to perform cataract surgery in dogs and cats without using the neuromuscular block.

The safety of anesthetic protocols consisting of midazolam, tramadol, lidocaine, propofol, fentanyl, ketamine, isoflurane without using the neuromuscular block was studied in 16 cataract surgeries in dogs and cats. The protocol’s safety was expressed by monitoring heart rate, oxygen saturation and pulse rate using pulse oximetry, respiratory rate, end-tidal carbon dioxide provided by capnography, arterial blood pressure using oscillometric method. Assessments were made for quality of induction, maintenance and recovery from anesthesia.

Animals: Sixteen animals, eleven dogs and five cats, all client-owned.

Methods: All animals were examined prior to premedication, were performed blood tests hemoleucogram and biochemistry and monitored during induction, surgery and recovery. Blood samples were analyzed for standard biochemistry panel including glucose, creatinine, ureea, hepatic transaminases and hemoleucogram. Before anesthesia, HR was measured using cardiac auscultation and MAP was measured using automated oscillometry, respectively. Protocols consisting of midazolam, tramadol, or lidocaine iv was performed. IV propofol was administered to abolish the palpebral reflex, produce jaw relaxation and facilitate ETI. Topical ocular administration of oxybuprocaine (Benoxicaine®) 0.4% drops to anesthetize cornea was performed before general anesthesia. All patients received topically sprayed laryngeal 2% lidocaine. The cough response at ETI was recorded.

After intubation, auscultation of heart and lung sounds was possible by means of an oesophageal stethoscope. Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and pulse rate. The patient was connected to the inhalational anesthesia machine. The maintenance of anesthesia was achieved using isoflurane like inhalant agent and fentanyl or mixture of fentanyl, lidocaine and ketamine. Respiratory rate and end-tidal carbon dioxide was provided by capnography. Assessments were made for quality of induction, maintenance and recovery from anesthesia by evaluation of the animal’s eye position, jaw tone, heart and respiratory rates and autonomic responses to surgical stimulation.

Results: The purpose of this work was to perform anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats and make preliminary investigation into safety for patient and to record the advantages and disadvantages. Cataract surgery are facilitated by a central position of the globe within the palpebral fissure. A centrally positioned eye is normally achieved by using neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. But if there is no possibility of using NMBAs solutions must be found.

Conclusion: The aim of the project was to test several variants of anesthetic protocols to compare the various effects of molecules including lidocaine, ketamine, fentanyl, tramadol, propofol, isoflurane have on the organism.

The use of anesthetic drugs without using of neuromuscular block for cataract surgery may be challenging bringing both advantages and disadvantages. The recovery period after a classic anesthesia without neuromuscular block probably is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises for the surgery.

Keywords: cataract, anesthesia, phacoemulsification, cat, dog,

Introduction

Patients with ophthalmic disease, such as cataract, vary from young, healthy animals with congenital cataract to geriatric patients, which may have significant diseases like diabetus mellitus. When planning anesthesia for cataract surgery is important to consider the general health status because there are many patients with concurrent disease and that may present significant challenges for the anesthetist [4]. It required investigations before anesthesia like blood tests and if there are changes ideally their condition should be stabilized before anesthesia. Also need to consider that animals that are blind are more likely to be stressed and fearful compared with patients that have vision, especially if the onset of blindness was acute [4].

A complete ophthalmic examination should be performed and should include examination of PLR and menace response, Schirmmer tear test, fluorescein stain test, intraocular pressure (IOP) and a fundic examination if possible. A complete physical examination is also pertinent, as cataracts may be related to extra-ocular disease.

Electroretinography and ocular ultrasonography are standard pre-operative screening tools to confirm an eye’s candidacy for cataract surgery. Although pre-operative preparation and postoperative management can be intensive, canine cataract surgery is often successful and rewarding. Risks, time commitment, and financial demands of phacoemulsification should be discussed with the pet owner.

Materials and methods

Eleven dogs and five cats presenting to the ophthalmology service with ophtalmological conditions that cause blindness. All patients received the cataract diagnosis after a full ophthalmic examination. Once a cataract forms, surgery is the only treatment method to restore vision. Phacoemulsification uses ultrasonic energy to fragment and extract cataractous lens material from its capsular bag. Exclusion criteria of the patients were concurrent diseases that could not be stabilized before anesthesia. Any pre-existing medical conditions and drugs administered were recorded.

Food and water were withheld from all patients for a minimum of 12 hours prior to surgery

Animals were gently restrained in a sitting or standing position for drug administration and data collection.

Mydriasis is obtained with topical mydriatic agents (Tropicamide) applied with 2-3 hours before intraocular surgery. Also, topical ocular administration of oxybupracaine (Benoxicaine®) 0.4% drops to anesthetized cornea was performed before general anesthesia. Topical local anesthetics are effective because of a direct action on the cornea and minimizing systemic side effects but their use is limited to diagnostic procedures and intra-operatively as they delay corneal healing, are epitheliotoxic and have a short duration of action [5].

The position of the animals during surgery was in lateral position for unilateral cataract and dorsal for bilateral cataract (Fig.1). HR was measured using cardiac auscultation and MAP was measured using automated oscillometry.

Anesthesia was maintained with isoflurane in a oxygen delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. Oxygen saturation as measured by pulse oximetry, pulse rate and respiratory rate were recorded every 5 minutes after anesthetic induction until the end of anesthesia (vaporizer turned off). Pulse quality was established by manual palpation of the femoral artery and respiratory rate was recorded by observation of the capnogram and chest movement.

Measurement of rectal and esophageal temperature was performed by use of 2 thermistor probes. Rectal temperatures were measured at initial hospital intake and after the end of anesthesia. Once each patient had been induced esophageal temperature was measured by placement of an esophageal thermistor probe and was removed at the end of anesthesia.

The premedication has been achieved with lidocaine 2 mg/kg iv or tramadol 2 mg/kg iv (Fig. 2). All the patients received the propofol-midazolam combination for anesthetic induction. The dose utilized for midazolam was 0,4 mg/kg iv.

The use of ketamine was accomplished in combination with lidocaine and fentanyl for dogs and for one cat was used the ketamine-propofol combination. There is significant interest in this combination of propofol and ketamine because has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery [6]. The ketamine dose that was used was low at 0,6 mg/kg iv and was mixed in the same syringe with propofol 3 mg/kg.

The extubation was performed when the coughing and swallowing reflexes had returned.

Steroidal anti-inflammatory drug (Betametazone, Diprophos®) was administered intraconjuctival at the end of the surgery.

Results

In total sixteen animals (eleven dogs and five cats) were enrolled in the project.

All patients were in good condition of general health just 2/11 dogs were stable diabetic patients and for they measurements have been taken to monitoring the blood glucose level before, during and after surgery.

Premedication with lidocaine 2 mg/kg was performed for 6 dogs and was made observation about cough during endotracheal intubation. IV lidocaine can decrease the incidence of cough during endotracheal intubation but does not appear to have a sparing effect on the dose of propofol required for endotracheal intubation.

Two patients receive tramadol 2 mg/kg iv in premedication, one in combination with lidocaine 2 mg/kg iv and the other just the tramadol. For the patient that receive just tramadol was not observed any changes in the propofol dose.

One dog received fentanyl in premedication and after induction was observed significant respiratory depression compared with the others. Two dogs and 6 cats did not receive anything for premedication.

The diabetic protocol for phacoemulsification consist in tramadol 2 mg/kg iv for premedication, induction with midazolam 0,4 mg/kg and propofol at effect. Maintenance of anesthesia has been achieved using isoflurane like inhalant agent and mixture of fentanyl, lidocaine and ketamine. The glucose level was measured before and every hour during anesthesia.

For all patients, cats and dogs, the induction was performed with propofol and midazolam 0,4 mg/kg and topical laryngeal lidocaine was used prior to intubation. One cat received the ketamine-propofol combination for induction.

The cough response at ETI was observed for 3 dogs, the patient that receive tramadol in premedication and the others that was not premedicated and 2 cats. In propofol anaesthetized dogs iv and topical laryngeal lidocaine attenuated the pressor response to ETI where iv lidocaine reduced the cough response.

Duration of the anesthesia from intubation to extubation was 80 min ±10 min depending of the surgical procedure, unilateral/bilateral cataract.

After induction, a rotation of the eyes towards the internal angle was observed. To achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.

Cardiovascular and respiratory parameters were well maintained during induction, maintenance and recovery periods for all patients. All patients receive Ringer Lactate infusion at 5 ml/kg/h. The anesthesia was maintained with isoflurane delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. This was completed by analgesia offered by combination of fentanyl-lidocaine-ketamine for dogs and fentanyl CRI for cats. The doses utilized for fentanyl was 4 μg/kg/h in combination with lidocaine 2 mg/kg/h and ketamine 0,6 mg/kg/h and when fentanyl was used alone, the dose was between 5-10 μg/kg/h.

Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and was maintained at >95%. MAP was measured using automated oscillometry and was stabilized at 80-110 mmHg.

Respiratory rate, end-tidal carbon dioxide was provided by capnography. The respiratory rate was maintained at 10 ± 5 rpm and the level of CO2 was 45-60 mmHg. All patients breathed themselves spontaneously, just one cat need the controlled ventilation because of the elevated level of EtCO2, up to 65 mmHg and the low respiratory rate.

For all patients the recovery from anesthesia was fast and without any complication. The temperature at the end of anesthesia was 37,2 ± 5ºC.

Discussions

The ideal anesthetic protocol for cataract surgery should provide central position of the eye, decrease the ocular muscle tone, provide analgesia and narcosis for optimal operating conditions, be safe for the patient and comfortable for the surgeon [4] (Fig. 5).

Good communication with the surgeon before the procedure and an understanding of the surgeon’s requirements are essential when formulating an anesthesia plan. The patient position with the head lower than the heart should also be avoided and at 15 degrees head-up position during intraocular surgery has been recommended in humans.

Also, the position of the animal during surgery may influence the choice of breathing system and endotracheal tube (ETT). Related to intubation should be remembered that the mouth during tracheal intubation can increase IOP as the choroid process of the mandible moves into the orbit. Care must be taken when positioning patients for tracheal intubation, as pressure may be exerted on the globe while the maxilla is held; this is especially the case for brachycephalic breeds. An armored ETT is recommended to use[4].

The ability to influence IOP is very important part of anesthesia management. Is necessary to avoid increased IOP because in these circumstances may result in a globe rupture, risk for intraocular bleeding or retinal detachment.

The use of ketamine, a dissociative anesthetic, for ophthalmologic procedures is controversial. Ketamine used alone is likely to significantly increase IOP because it causes an increase in extraocular muscle tone [4]. The good benefits of ketamine administration consist in increased of the amount of circulating norepinephrine, increase in peripheral arteriolar resistance and muscle activity and decrease the extent of redistribution hypothermia [3]. The use of ketamine has beneficial effects on the blood pressure, cardiac output, corporal temperature and contributes to realization of a balanced anesthesia based on a multimodal analgesia. On the other hand, ketamine can increase IOP but considering that in the protocols used in this study was never used alone and the fact that the surgical procedure involves making a break through the incision of the cornea and penetrating the eye globe this pressure can be adjusted naturally without becoming hazardous for the structures of the eye.

Is mandatory to avoid coughing, sneezing, vomits when there is a risk of globe rupture because this can result in an increased central venous pressure [2]. Therefore, drugs like morphine that causes vomiting should be avoided. On the other hand, the use of alpha 2 adrenergic agonist is not prohibited; although may induce vomiting especially in cats the alpha 2 adrenergic agonist can be very useful when we are dealing with uncooperative patients and the risk of globe rupture is bigger because of the stress and manipulation. In this study, for avoiding the coughing response was used lidocaine. Both iv and topical laryngeal lidocaine attenuated the pressor response to ETI and iv lidocaine 2 mg/kg reduced the cough response to ETI in propofol anaesthetized dogs [1] [2].

Intraocular blood volume is influenced by intraocular vascular tone (vasodilatation or vasoconstriction), arterial blood pressure (ABP) and outflow of the blood from the globe [4]. Is well known that exist an inverse proportional relationship between arterial carbon dioxide tension (PaCO2) and vascular tone. Increased carbon dioxide tension causes choroidal vessel vasodilatation and an increase in IOP. Hypoxaemia can be detect using pulse oximetry and should be avoided by oxygen supplementation and ventilation. PaCO2 can be monitored by capnography or arterial blood gas analysis and controlled using IPPV. However, inappropriate use of IPPV can increase CVP by increasing intrathoracic pressure during inspiration, resulting in an increase in IOP.

Cataract phacoemulsification is not a very painful procedure except during the incision and suturing of the corneal limbus. Traditionally, most anesthetic molecules mildly decrease IOP by increasing the outflow of aqueous humor. The use of anesthetic induction agents such as propofol, alfaxalone, ketamine and etomidate may all increase IOP. All are ameliorated by co-induction agents like opioids, midazolam or diazepam [4].

One limitation to the present study was the small number of the patients (sixteen animals – eleven dogs and five cats) used.

In conclusion, if the realization of the neuromuscular block for phacoemulsification is not possible, we can perform anesthesia for this procedure using just the standard molecules like lidocaine, propofol, midazolam, fentanyl, ketamine and tramadol. The recovery period after a classic anesthesia without neuromuscular block is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, after induction, a basculation of the eyes towards the internal angle was observed for all studied cases. In order to achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.

The great disadvantage is the fact that without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises from the surgeon.

Acknowledgments

The project was provided by Di-Vet Medical – pet emergency and critical care clinic, Bucharest, Romania.

Support Grows for WSAVA Campaign to Secure Global Access to Veterinary Therapeutics

June 16, 2018

The World Veterinary Association (WVA), the Federation of Veterinarians of Europe (FVE) and the Federation of Companion Animal Francophone Veterinary Associations (FAFVAC) have all thrown their weight behind a campaign led by the World Small Animal Veterinary Association (WSAVA) to secure equal access to veterinary therapeutics for veterinarians around the world. Ten WSAVA member associations have also endorsed it.

The WSAVA’s new Therapeutics Guidelines Group (TGG), which spearheads the campaign, has also appointed its first Chair, Dr Luca Guardabassi DVM, PhD, ECVPH. Dr Guardabassi is Professor of One Health Antimicrobial Resistance at the University of Copenhagen, Denmark.

In a survey of its members conducted by the WSAVA during 2016-2017, 75% of respondents confirmed that that problems in accessing veterinary medical products hampered their ability to meet the needs of their patients and 20% assessed the impact of this issue as resulting in a severe restriction on their ability to provide a high level of care.

Dr Olatunji Nasir, Medical Director and CEO of the Truthmiles Animal Hospital in south west Nigeria, one of the countries affected, explained: “We face a Herculean task in trying access everything from basic medical consumables, such as syringes and needles, right up to veterinary drugs. Registration fees are very high because they are the equivalent of what is charged for human drugs despite the fact that the volume used is much lower. The process of registering a new drug can also take up to 36 months which feeds demand for sub-standard products which are smuggled into the country. The procedures for importing drugs are also cumbersome and impractical.”

The WSAVA launched its campaign earlier this year to tackle these problems and is calling on all of its member associations to endorse its Position Statement on the issue and to support its campaign. It is also calling on other veterinary associations to become co-signatories of the Position Statement.

Commenting, Dr Luca Guardabassi said: “Difficulty in accessing therapeutics to treat patients is a critical issue for companion animal veterinarians in many parts of the world. It causes huge frustration and means that many thousands – probably millions – of animals do not receive optimum care. It’s a situation which requires urgent change and we are determined to bring this about.

“We’re delighted that so many veterinary associations are supporting our campaign and are now preparing for a high-level summit meeting which will be held during WSAVA World Congress in Singapore in September. At this meeting, we will bring together stakeholders from around the world to discuss the issues and recommend practical solutions.”

The WSAVA represents more than 200,000 veterinarians worldwide through its 105 member associations and works to enhance standards of clinical care for companion animals. Its core activities include the development of WSAVA Global Guidelines in key areas of veterinary practice and lobbying on important issues affecting companion animal care worldwide.

Note to editors:

The following veterinary associations are co-signatories of the WSAVA’s Position Statement on therapeutic access:

Commonwealth Veterinary Association
FAFVAC
FVE
Federation of Asian Veterinary Associations
Federation of Asian Small Animal Veterinary Associations
Federation of European Companion Animal Veterinary Associations
Federacion Iberoamericana de Asociaciones Veterinarias de Animales de Compania
HealthforAnimals
World Veterinary Association

The following WSAVA member associations have endorsed its Position Statement on therapeutic access:

Estonian Small Animal Veterinary Association
Federation of Small Animal Practitioners Association, India
Ghana Private Veterinary Surgeons Association
Hellenic Companion Animal Veterinary Society
Kenyan Small Companion Animal Association
The Netherlands Association of Companion Animal Medicine
North American Veterinary Congress
The Philippines Animal Hospital Association

The Polish Small Animal Veterinary Association

Nutritional management of canine atopic dermatitis

June 16, 2018

Author: H.P. Meyer, DVM, PhD, Dipl-ECVIM-CA

Director, Professional & Veterinary Affairs, Hill’s Pet Nutrition

Co-author: Iveta Becvarova, DVM, MS, Dipl-ACVN

Director, Global Academic & Professional Affairs, Hill’s Pet Nutrition

Introduction

It has long been accepted that canine atopic dermatitis (CAD), much like human atopic dermatitis is underpinned by dysfunction of the patients’ adaptive immune response. Specifically, inappropriate production of immunoglobulins and activation of an inflammatory response as a result of sensitisation to environmental allergens. However, newer research into the pathophysiology of the condition has also discovered an important deficiency in the skin of patients with CAD. It has been suggested that dogs have reduced skin barrier function allowing increased allergen permeation (1). These two mechanisms are not mutually exclusive and it is possible that both play a role in the development of atopy. The abnormal presence of allergens that have permeated the epidermis may be a potential trigger for cell sensitisation during development of CAD.

Structural changes in the skin of atopic dogs are notably a reduction in the intercellular lipid layer with disorganised lipid lamellae (1). Studies also show differences in the barrier function of skin in atopic and non-atopic patients (2). Transepidermal water loss (TEWL) has been used as a measure of skin barrier function to demonstrate this effect. A study using an experimental model of CAD showed increased TEWL assumed to be as a result of altered skin barrier function in patients with an experimental model of atopy (2). This finding has also been noted in dogs with naturally occurring AD (3). Importantly, in both of these studies the changes in barrier function could be measured in both lesional and non lesional skin.

This improved understanding of affected skin barrier function whether cause or consequence is highly relevant to the management of CAD. These deficiencies have been shown to be present both in lesional and non lesional skin and structural changes are constant and present both during and between episodes of clinical signs. The International Task Force on Canine Atopic Dermatitis (4) has recommended a gold standard approach to management of CAD, which is to use more aggressive therapy for periods of clinical signs or atopic flares in addition to long-term maintenance therapy between flares that aims to reduce the incidence and severity of clinical episodes. One of the big considerations for clinicians when selecting such long-term management therapies for CAD patients is interventions with mild or no side effects. Use of carefully selected nutrients that can support the skin and coat could fit this brief. Considering the importance of maintaining barrier function as well as tempering the inflammatory response to allergens there are nutrients that may play an important role in these areas of recent interest.

Nutrients of interest in CAD

There are two nutrients to consider that can be utilised for their effects on cell sensitisation and cell activation during the induction and effector phases of CAD. The first is the use of egg, which has multiple potential benefits, including antioxidant and immunomodulatory properties (5,6). The immunomodulatory benefit of egg has been explored in skin sensitisation in dogs (7). Three groups of dogs were exposed to a novel antigen (keyhole limpet hemocyanin (KLH) in weeks 9 and 11 of a controlled food trial. The three groups were a control food, the control food and prednisone (at 2.2mg/kg bodyweight orally per day) and a food containing egg. An intradermal skin test (with KLH) was performed at week 12 and the results were as follows: both the prednisone treated group and the egg fed group had statistically significant reductions in the immediate and delayed-type (cell-mediated) hypersensitivity reactions compared to the control group. This response was similar between the egg and prednisone groups. These results support the findings that egg have immunomodulating properties (5,6), in particular in reducing allergen-induced hypersensitivity reactions. This nutrient may be of use when considering a food for patients with CAD.

The other important nutrient group to consider are polyphenols, which are sourced from plant ingredients such as green tea, herbs and green vegetables. Polyphenols do also have strong antioxidant properties. Antioxidants are beneficial in foods for patients with CAD as it is a markedly inflammatory condition. Supplementation can support the patient’s own antioxidant defences in the face of free radical cellular injury caused by inflammation. Polyphenols, like egg, have also been shown to have specific effects tempering cell-mediated immune responses. Notably, they may inhibit antigen presentation, T cell cytokine release, B cell IgE production and mast cell degranulation (8-13). Use of these ingredients in pilot feeding studies of botanicals, containing polyphenols and antioxidants, in CAD has yielded reductions in levels of IL-31, IL-12p40 and other cytokines as well as reduced itching, hair loss and erythema (14).

Image 1. Fast and simple completion of the CADESI-4 skin scoring for CAD in the ‘Atopy Index’ APP developed by Hill’s. Download in your phone’s APP store .

Following the identification of impaired barrier function in patients with CAD, studies have been conducted to identify nutrients to support the skin barrier. A key area has been to target the deficiencies noted in the intercellular lipid layer. A major component of this layer is ceramide; lower ceramide levels have been identified in the stratum corneum (SC) of patients with CAD compared to normal dogs (15,16). Oral supplementation of polyunsaturated fatty acids (PUFAs) appears to support improvement in at least some of these structural changes. One study found supplementation of AD dogs with PUFAs resulted in increased ceramide content in the SC and improved organisation of lamellae in the SC to be comparable to that of normal dogs (17).

PUFAs have been widely trialed in both research and clinically as a management strategy for CAD for their anti-inflammatory effect and to nourish the skin and coat. The benefits of using PUFAs as an anti-inflammatory are through a reduction in production of pro-inflammatory eicosanoids and a reduction in stimulation of inflammatory cells. (18). This effect is largely mediated through Ω-3 PUFAs in contrast to the epidermal barrier support described above which is considered to be a factor of total Ω-6 intake.

This requirement for both Ω-3 and Ω-6 fatty acids can complicate the interpretation of research findings in relation to PUFAs. Further work is required to completely understand PUFAs in this regard. From the current literature it is advisable to consider both the level of Ω-3 and Ω-6 PUFAs and their ratio to one another for optimum support. A low Ω-6 to Ω-3 ratio is considered anti-inflammatory, with an inclusion of sufficient total Ω-6 for skin barrier support. For this reason their inclusion in a complete food rather than supplementation on top of the patient’s own food will give better control.

To complete the review of nutrients there are also macro and micro nutrients that can be added to the food and optimised for skin and coat support. These nutrients are applicable to all dogs not just patients with CAD. Protein, vitamins A and E, Ω-3 and Ω-6 fatty acids, zinc and copper all contribute to maintenance and repair of skin and coat. These benefits are well described in more detail in nutrition texts (19).

Figure 1. Median (range) dermatological scores in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline.

To assess the holistic impact of the discussed nutrients a study was conducted using a food indicated for patients with CAD. The food is a complete canine food optimised for skin support to include zinc, copper, antioxidant vitamins E and C and also containing egg, polyphenols and supplemented with both Ω-3 and 6 PUFAs. The study was constructed as an open label non-controlled feeding study of adult dogs with pre-existing AD. Patients were included on the basis of presenting with 5 or more of Favrot’s criteria for the diagnosis of AD (20). The dogs could be maintained during the study on standard therapy for AD including allergen avoidance, allergen-specific immunotherapy, symptomatic anti-inflammatory therapy and antimicrobial therapy as long as drugs, doses, and frequency of administration remained constant from the time of previous food administration through to completion of the study . Dogs were excluded on the basis of untreated infectious or parasitic dermatitis or concurrent skin or major systemic conditions. Also dogs were excluded if they had been fed with either food or supplements with high levels of Ω-3 fatty acids in the 12 weeks preceding the study. Dogs using oclacitinib were also excluded from the study.

The owners were instructed to feed the dogs the food exclusively for 8 weeks and discontinue all any homeopathic remedies and other supplements. The dogs were assessed at 0, 4 and 8 weeks and at each assessment the attending vet completed a dermatological evaluation based on the Canine Atopic Dermatitis Extent and Severity Index (CADESI) (21) and owners completed an evaluation form at each visit and gave their opinion on their dog’s quality of life, skin and coat appearance, and food acceptance. The CADESI-4 scoring system is an important tool to provide an objective assessment of the situation and to monitor progress. Hill’s has developed a simple in-clinic APP to facilitate CADESI-4 scoring completion, storage and visualisation to the pet owner. It can be downloaded via your app store on your mobile phone (Image 1).

20 dogs were included in the data analysis, 28 dogs were excluded prior to this due to various medication and supplement changes or missing data and 3 were excluded due to food refusal. For the analysed patient group both mean BCS and mean weight were stable during the study. The results shown below show the median dermatological scores for the dogs decreased significantly at both 4 and 8 weeks when compared to the baseline (Fig 1).

Owner assessments also showed significant improvements at the end of the study compared to baseline in the following categories: scratching, licking, scratching of ears, disruption to the family redness of skin and overall condition of skin and hair coat (Fig 2).

Figure 2. Owner assessments (Least square mean (range); Scale from 0 (not present) – 10 (always present) of various skin parameters in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline

Overall food acceptance was good with 90% of dogs eating the food for the entire study duration. Many dogs had to be excluded due to medication changes. The number that started and stopped medication was almost equal during the study removing selection bias towards milder or more severe cases. This results suggest use of these nutrients in a complete food shows improvement from both an owner perspective and in reducing dermatological scores for patients. The application of a food designed for use in patients with AD to reduce the inflammatory response, support skin barrier function and optimise skin and coat health could be considered as part of a multimodal approach to managing the patient with AD. Particularly considering that nutrition can be used simply on a daily basis both during and between clinical flares with no adverse effects to the patient.

C2 FRACTURE AND CENTRAL CORD SYNDROME

June 9, 2018

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Dr Svetoslav Penchev

United Veterinary Clinic

Varna, Bulgaria

Case is about a 6 months , male cocker spaniel named Michael.Michael was brought in the clinic from another city in very bad candition.The owners report for a trauma in cervical region.Radiography and neurological examinations were made. Results revealed –Tetraplegie and atalnto-axial instability.It was made a CBCT on cervical region.The image show C2-Fracture .

It was maked a surgary to stabilize cervical spine. Ten days after surgery Michael starts moving the pelvic limbs first and tries to stand on them. Twenty one days after surgary Micheal start to moving and thoracic limb , but have ataxia and destroys proprioception on his four leg. Michael`s recovery begin first with the hind limbs and then with the thoracic limbs .In human literature, the symptom in which the thoracic limb is in a dysfunctional state with minimal to no deficit in the pelvic limbs has been referred to as CCS (Central Cord Syndrome ). The spinal cords that travel to the pelvic limbs are minimally affected because the lesion is centralized in the cervical region, which only affects the thoracic limbs. In general, CCS has a good prognosis for functional recovery and its common etiology is traumatic disease in human medicine. CCS treatments with nonsurgical management include cervical spine restriction with a neck collar, rehabilitation followed by physical therapy and occupational therapy. Surgical management is provided for patients who cannot be treated by conservative management alone.

Diagnosis and therapeutic management in a a dog with severe cardiac dilatation associated with complex arrhythmias – A case report.

May 29, 2018

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Dr Vasile Vulpe

33023039_1831545640221964_5476404995450470400_n

Dr Andrei Baisan

Radu Andrei BAISAN, Vasile VULPE

Clinics Department, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine “Ion Ionescu de la Brad”, Iași, Romania

Baisan.andrei_mv@yahoo.com

Cardiac dilatation is a common finding in dogs with heart disease. Chronic myocardial stress and volume overload are the main reasons for cardiac remodeling. These changes are encountered in most of chronic diseases such as dilated cardiomyopathy, mitral valve disease or congenital disease that develop volume overload. Cardiac dilatation should not be confused with dilated cardiomyopathy (DCM), which is known to be a myocardial disease induced by several specific factors such as genetic or familial predispositions. In the absence of specific signs, such as mitral valve degeneration or congenital heart diseases, cardiac dilatation should be carefully evaluated and additional tests must be performed before deciding the diagnosis and therapy. In veterinary medicine, there is insufficient data regarding the differential diagnosis of cardiac dilatation when specific sins are absent.

The aim of this paper is to report and discuss a patient with congestive heart failure due to severe cardiac dilatation associated with multiple arrhythmias and to describe the diagnostic protocol, therapy and evolution of the disease.

Case presentation

An eleven years male, German Shorthaired Pointer dog, weighing 38 kg, was referred for a second opinion to our Cardiology Service from the Teaching Hospital of the Veterinary Faculty of Iași, because of chronic abdominal fluid accumulation, severe effort intolerance and weight loss for the past few months. The dog was receiving cardiac therapy assigned by the referring clinician and consisted of pimobendane (Vetmedin^® Boehringer Ingelheim), 0.25 mg/kg P.O. BID and furosemide (Furosoral, Artesan Pharma GmbH & Co.), 2 mg/kg P.O. BID. The owner reported that the dog had been treated for Babesia canis for four times in the past few years.

During the first visit, the dog was subjected for complete cardiologic examination consisting of physical examination, five minutes six leads electrocardiography (PolySpectrum veterinary device), blood pressure measurement (Vet-HDO blood pressure device), cardiac ultrasonography (Logiq V5, General Electric), cardio-thoracic radiography (Intermedical Basic 4006 X-ray machine and Examion X-CR smart digital developing machine) and biochemical and CBC blood analyses as previously described [1-4].

Physical examination showed pink mucosal membranes, with a CRT of 3 seconds, abdominal distension, breathlessness, with a normal respiratory rate (28 bpm), strong and arrhythmic cardiac beats, without precordial thrill. The palpation of the femoral artery revealed weak asynchronous arterial pulse. Auscultation revealed an arrhythmic rhythm and III/VI systolic plateau left apical murmur. Auscultation of the lungs revealed crackles in both sides of the caudal lung lobes.

Electrocardiography revealed an arrhythmic rhythm with a median heart rate of 130 bpm, with more types of arrhythmias present over the five minutes ECG tracing. The predominant rhythm was accelerated idioventricular rhythm, with a heart rate of 168 bpm, interrupted by runs of supraventricular tachycardia, with a heart rate of 240 bpm and sinus tachycardia with a heart rate of 165 bpm (Fig no 1).

Fig 1. Six leads ECG at 50 mm/sec and 5 mm/mV of an eleven years old dog with signs of congestive heart failure. The main rhythm is represented by an accelerated idioventricular rhythm (black arrowhead), with a heart rate of 168 bpm, interrupted by left ventricular premature complexes (red arrowhead) and fusion beats (star)

Fig 2. Six leads ECG at 50 mm/sec and 5 mm/mV of the same dog with signs of congestive heart failure. Sequences of supraventricular rhythm are visible, with a heart rate of 240 bpm and sparse sinus complexes (star); also, one left ventricular premature complex is present on the tracing (diamond) and junctional beats with retro-conducted P’-waves (arrow);

Fig 3. Six leads ECG at 50 mm/sec and 5 mm/mV of the same dog with signs of congestive heart failure. An atrial beat is present with a small P-wave (star), followed by 3 RBBB aspect complexes and a fusion beat. The black horizontal arrow marks the beginning and the end of fast supraventricular tachycardia consistent with atrial fibrillation, followed by another fusion beat (diamond);

There were also present runs o junctional beats with a retro-conducted P-wave. Between these sequences of arrhythmias, there were present 25 left ventricular premature complexes, with the same morphology, with a negative polarity in DII, DIII, and aV_F and positive polarity aV_R and aV_L. These complexes had a length of 120 msec and a tall, opposed T-wave. Multiple fusion beats were also present (Fig no 2 and 3).

The blood pressure measurement was performed with a D1 cuff placed on the tail and simultaneous recording of the pulsating-wave graphic. However, measurements of the blood pressure were not accurate due to the differences in the pulsating wave.

Fig nr. 6 Echocardiographic M-mode in right parasternal short axis view through the papillary muscles of the left ventricle of the same dog with signs of congestive heart failure. Arrhythmic contractions of the left ventricle are visible. The free wall and septum appear thinned and the ventricular cavity is enlarged in both systole and diastole. The measurements were performed when the rhythm was supraventricular. The shortening (SF%) and ejection (EF%) fractions are within normal limits.

Fig 4

Fig 5

Cardiac ultrasonography revealed severe left ventricular dilatation during systole (39.6 mm 95%CI 15.8-17.18 mm) and diastole (64.2 mm, 95% CI 37.64-39.1 mm), with thinned interventricular septum and ventricular free wall and severe left atrial dilatation, with a LA/Ao ratio of 2.54 (normal upper limit 1.6). Also, the left auricular cavity was visibly enlarged. The mitral valve was thin with normal echoic appearance and abnormal motion due to the hemodynamic changes induced by the underlying arrhythmia and a regurgitating jet was observed by color doppler. The left ventricle systolic function was within normal limit, when assessed during supraventricular rhythm (SF%=38, EF%=67). The pulmonary and aortic flow were laminar, within normal ranges. There were no signs of pulmonary hypertension. The pericardium was normal, without fluid accumulation (Fig no 4-6).

Fig nr. 4 Echocardiographic left parasternal long axis apical four chamber view of an eleven years old dog with signs of congestive heart failure. The LA and LV are visible enlarged and the mitral valve leaflets appear normal. LV-left ventricle; LA-left atrium; RV-right ventricle; RA-right atrium;

Fig nr. 5 Echocardiographic right parasternal long axis oblique four chamber view optimized for the left atrium of the same dog with signs of congestive heart failure. The LA and Lau appear visible enlarged. LV-left ventricle; LA-left atrium; LAu-left auricle

Fig nr. 7 Left lateral chest radiography of an eleven years old dog with signs of congestive heart failure. The cardiac silhouette is visibly enlarged with dorsal displacement of the trachea and a perihilar pulmonary interstitial and alveolar pattern is visible extending in the caudal lung lobes. A round radiopaque mass is visible on the lower cranial abdomen

A left lateral thoracic X-ray was available for examination and revealed severe cardiomegaly, with a VHS of 13.3v. The trachea was dorsally displaced and a perihilar pulmonary interstitial and alveolar pattern was visible in the caudal lung lobes consistent with moderate cardiogenic pulmonary edema. A round radiopaque area was present over the gallbladder topography and a gallbladder stone was suspected (Fig no 7).

Blood biochemical analyses were within normal ranges except a moderate hypoalbuminemia (2.5 g/dL normal ranges 2.6-4 g/dL) and moderate increased alanine aminotransferase (58 UI/L, normal ranges 8-57 UI/L). Cell blood count was within normal ranges.

The diagnosis consisted of idiopathic dilated cardiomyopathy with supraventricular and ventricular arrhythmias. The current therapy was maintained and amiodarone (Amiodaronă LPH, LABORMED PHARMA S.A.), was added as following: 15 mg/kg P.O. BID for 7 days, followed by 7.5 mg/kg P.O. BID for the next seven days and 7.5 mg/kg P.O. QD for the next fourteen days. The dog was released from the hospital the same day with effort and salt restriction. The reevaluation was scheduled after 2 weeks if no event required a sooner visit.

Three weeks later, the owner called for a reevaluation. The medication was administered according to recommendation and no events were observed during this period. aA significant improvement in the quality of life of the patient was reported.

The dog was alert and active during physical examination, with pink mucosal membranes, CRT of 3 seconds, moderate decreased respiratory rate (36 bpm) and effort, and a less distended abdomen. Palpation of the thorax revealed a strong cardiac beat and the arterial pulse was synchronous with the cardiac beat. Cardiac auscultation showed rhythmic rhythm, with a heart rate of 114 bpm and III/VI systolic plateau left apical murmur.

Fig 8. Six leads ECG at 50 mm/sec and 5 mm/mV of the same dog with signs of congestive heart failure, performed during reevaluation, 3 weeks later. The predominance of sinus rhythm is visible, with a heart rate of 115 bpm, interrupted by one right ventricular premature complex (star) and one supraventricular complex (arrowhead);

The five minutes six lead ECG tracing revealed a predominant sinus rhythm, interrupted by 107 single supraventricular complexes and only one right ventricular premature complex with positive polarity in DII, DIII and aV_F and negative in DI, aV_R and aV_L. No sequences of supraventricular tachycardia or accelerated idioventricular rhythm were present on the five minutes tracing. The abnormalities in morphology of the sinus beats revealed a mitral P-wave (78 msec), increased amplitude of the R-wave (3.34 mV) and increased length of the QRS complex (91 msec) (Fig no 8).

There were no improvements seen during the echocardiographic examination. The owners were instructed to administer the therapy with pimobendane and furosemide continuously and amiodarone until the end of protocol. Eight weeks after the first examination, owners reported by telephone that the patient is alive and the quality of life remained improved.

Discussions

Dilated cardiomyopathy (DCM) can occur as a primary cardiomyopathy such as genetic, or familial DCM [5], or secondary to myocardial stress, such as drug- or toxin-induced, infiltrative, ischaemic, metabolic, nutritional, or inflammatory myocardial diseases [6]. In both cases, DCM is expressed through a disease of the myocardium associated with ventricular systolic and diastolic dysfunction and development of congestive heart failure [5]. According to ESVC Taskforce for Dilated Cardiomyopathy, 2003, scoring system, the score in this dog was above 6 points, which is consistent with the presence of DCM [5]. The left ventricular internal diameter in both systole and diastole were above the 95% CI based on the regression formula [7], the sphericity index was under the lowest recommended limit and left atrial enlargement was present. However, there were some changes that did not seem to be associated with primary DCM. The shortening and ejection fraction were within normal ranges and the large range of arrhythmias was not consistent with specific morphologic and rhythm changes in primary DCM. It has been suggested that atrial fibrillation is the most common arrhythmia in dogs with DCM and also, increased number of ventricular premature complexes may have diagnostic value [5, 8]. Nevertheless, it must be considered that the dog was treated with positive inotropic medication which may have influenced the systolic function of the heart. Another unexpected result was the intense positive response to arrhythmic therapy. Amiodarone is an antiarrhythmic agent with primarily class 3 action, but also potent class one. This agent prolongs the action potential duration and the effective refractory period in all cardiac tissues. It is recommended in dogs with ventricular arrhythmias and has also been used to convert atrial fibrillation to sinus rhythm [9].

The differential diagnosis for cardiac dilatation should include secondary DCM due to cardio-toxicosis, drug-induced, metabolic or nutritional factors, chronic myocarditis or tachycardia-induced cardiomyopathy (TIC). Secondary DCM is difficult to diagnose due to the multiple factors of environment and microclimate. A large series of pathogens have been reported to induce chronic myocarditis, including canine babesiosis [10-15]. However, in most studies, the etiological diagnosis was reached through histopathological examination of the cardiac tissue after patient’s death [16]. Considering the four episodes of clinical manifestation of canine babesiosis in this patient, cardiac enlargement may be related to this. Tachycardia-induced cardiomyopathy is characterized by cardiac dilatation and systolic and diastolic dysfunction due to long-term increased heart rate, however these changes may be easily confused with DCM. Clinical studies in human medicine have suggested that the left ventricle internal diameter and volume are significantly smaller in patients with TIC than in those with DCM [17]. Another difference between the two pathologies is that the ventricle remodeling during TIC may benefit from partial or total reversibility once the arrhythmia control is achieved [18]. In the patient discussed in this paper, we observed a significant improvement in controlling the rhythm and heart rate after the antiarrhythmic therapy but not in the cardiac remodeling. It remains unclear whether the arrhythmias were induced by the myocardial structural changes during the progression of heart remodeling or if the dilatation was induced by a chronic supraventricular tachyarrhythmia which later developed ventricular complexes and accelerated idioventricular rhythm.

Conclusions

Dilated cardiomyopathy is a common cardiac disease in large breed dogs, however differential diagnosis must be considered when cardiac dilatation is present, in the absence of any certain factors. The dog from this report had cardiac dilatation associated with severe arrhythmia. Although an etiologic diagnosis could not be established, we succeeded to improve the quality of life by controlling the heart rate and the rhythm.

The reference list is available at baisan.andrei_mv@yahoo.com

Multimodal treatment approach to canine oral malignant melanoma: a clinical case

May 3, 2018

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Dr Ana Nemec

Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC; Ana Rejec, DVM, PhD, Resident, Veterinary dentistry

Animal Hospital Postojna, Cesta v Staro vas 20, 6230 Postojna, Slovenia

Case history and clinical signs

Figure 1: Amelanotic malignant melanoma affecting right rostral maxilla in a 4-year-old female German shepherd at presentation.

A 4-year-old 30-kg female spayed German shepherd was presented due to rapidly growing rostral maxillary mass. At presentation, the proliferative mass, located around right maxillary third incisor and canine tooth was ulcerated and bleeding (Fig. 1). The patient was otherwise healthy with physical exam findings, CBC and biochemistry all within normal limits. Staging options were discussed and the client elected computed tomography (CT) of the head and neck as well as chest CT together with biopsy of the lesion and an abdominal ultrasound.

Imaging and histopathology findings

Figure 2: A CT image taken at the level of maxillary canine teeth at presentation. Note an invasive lesion occupying majority of the right nasal cavity and crossing the midline

Pre- and post-contrast CT images revealed an invasive lesion, located primarily around the maxillary canine tooth and extending from the right maxillary second incisor tooth to the mesial root of the right maxillary second premolar tooth, occupying majority of the right nasal cavity and crossing the midline (Fig. 2). CT of the neck and chest revealed no metastatic disease to the regional lymph nodes and lungs, and abdominal ultrasound was also within normal limits.

Histopathology of the lesion revealed spindle-cell neoplasm, with differential diagnoses being fibrosarcoma or spindle-cell amelanotic melanoma, and further immunohistochemistry using Melan A and PNL-2 antibodies was performed and was suggestive of amelanotic melanoma.

A stage III (with no detectable metastasis based on the diagnostics performed) amelanotic melanoma was diagnosed.

Treatment and follow-up

Figure 3: With the dog under general anaesthesia in dorsal recumbency an incision is planned to remove the tumor with narrow margins (“debulking surgery”).

Figure 4: Once the right rostral maxilla and left incisive bone are en-block removed together with the tumor, hemostasis is achieved by ligation of major palatine arteries. Note macroscopically-visible tumor remnants in the right nasal cavity.

Figure 5: Immediate post-operative photograph of the 4 years old dog with OMM.

Due to an extensive involvement of the nasal cavity, wide resection was impossible to achieve without significantly impairing the cosmetic appearance and function of the animal, and the client elected palliative-intent extended unilateral rostral maxillectomy to reduce tumor burden (Figs. 3-5), followed by a course of adjuvant hypo-fractionated radiotherapy of the surgical area (6 x 6 Gy twice weekly) 3 weeks after the surgery (Figs. 6-9).

Figure 6: Three weeks post surgery the mucosal flaps have healed and any remaining sutures are removed to minimize irritation and inflammation before radiation therapy is initiated

Figures 7: Radiotherapy is performed 3 weeks after surgical resection of amelanotic malignant melanoma with the dog under general anesthesia. Note a lead plate positioned in the mouth to prevent irradiation (exit dose) of the healthy mandibles. A bolus is used on the maxilla to achieve optimal dose distribution in the irradiation field.

Figure 8: Radiation therapy technologist adjusting the patient and equipment to correctly apply the radiation treatment plan.

Figure 9: Acute side affects of radiotherapy (radiomucosititis) 2 weeks after completion of radiotherapy, which diminished with supportive antibiotic, local antiseptic and anti-inflammatory treatment.

Melanoma vaccine treatment (4-dose, biweekly protocol, then boosters in 6-month intervals) was added to the treatment protocol as an immunotherapy approach to multimodal treatment approach. At all re-checks, the patient was clinically healthy and the most recent re-check head and neck and chest CT revealed no metastases 5 years after the diagnosis (Fig. 10).

Discussion

Figure 10: 5-year follow up – no clinical nor CT evidence of local tumor recurrence

Malignant melanoma (OMM) is the most common nonodontogenic oral tumour in dogs. Clinical signs may vary greatly; the tumour is not necessarily pigmented (black). Histopathological diagnostics may be complicated as a tumour may present as amelanotic variant and/or as epithelioid-cell OMM, spindle-cell OMM or mixed-cell OMM. Therefore, immunohistochemistry is often needed to determine the diagnosis. OMM is locally invasive, with 50% of tumours being associated with surrounding bone invasion. Metastases are also common: in 74% of cases, OMM metastasise in regional lymph nodes and in up to 92% of cases in the lungs.

Hence, before any treatment is attempted, a patient with an OMM needs to be properly staged. To evaluate local disease, tumor location is noted and the lesion measured. Diagnostic imaging of the local lesion should include pre- and post-contrast CT of the head, as skull radiographs and/or intraoral dental radiographs will underestimate the extent of the lesion and especially invasion of maxillary tumor into adjacent structures. Magnetic resonance imaging (MRI) can also be considered and PET/CT is becoming available in veterinary medicine as well.

Evaluation of regional lymph nodes may be challenging. Although palpation of the mandibular lymph nodes should be routinely performed, it needs to be realized, that 40% of palpably normal lymph nodes contain metastases. Fine needle aspiration of the regional lymph nodes may be helpful, but reaching the main draining center of the head – retropharyngeal lymph nodes – requires ultrasound-guided approach. Also, it has recently been described, that consensus between cytology and histopathology for staging of lymph nodes in patients with melanocytic neoplasms is poor, and negative result does not rule out metastases. Evaluation of size and contrast-enhancement pattern on post-contrast CT images can be very helpful in evaluating regional lymph nodes for metastases, and PET/CT is also very promising. Excisional biopsy of the lymph nodes is debatable, as complete staging requires removal of all lymph nodes of the head and neck. Excisional biopsy of the sentinel lymph node – technique which is well developed in human medicine – is the goal and determination of the sentinel node will hopefully become easier with advanced imaging techniques.

Staging is completed with evaluation of distant organs for possible metastatic disease, where chest CT is much more sensitive to diagnose pulmonary metastases compared to thoracic radiographs. Full body CT may be recommended, if involvement of abdominal organs is suspected, which is rare in cases of canine OMM, and abdominal ultrasound is usually performed.

Once the stage of the OMM is determined, the treatment approach(es) and prognosis can be discussed with the client. It is worth mentioning here, that scientific data on treatment outcomes for specific stage OMM, especially when several treatment approaches are combined, are scarce. Hence, proper communication with the client is extremely important to present as much as possible information and keep realistic expectations. Generally, prognosis for animals, especially if the tumour arises from dentate areas, is guarded due to early and common metastases. Dogs with small OMM (smaller than 2 cm in diameter, stage I) located rostrally and those without metastases, have the best prognosis. With radical tumour resection (tumour with associated 1 cm of healthy tissues as determined by CT) median survival time was reported to be 723 days and related to tumor stage. It has also been reported, that even incomplete tumour resection (dirty margins) increases survival time. When complete resection cannot be achieved (as was expected in the presented case), or the client declines surgical treatment, or when surgery has resulted in incomplete removal of the tumor, or when regional metastases are present, other treatment options exist, although some studies questioned the benefits of adjuvant therapies. When recommending an adjuvant treatment, most commonly suggested is radiation therapy, which can also be the sole treatment for OMM (local and regional disease). The outcome of radiation therapy depends, as with surgery, on the stage of the tumor as well as on the radiation protocol; most commonly hypo-fractionated radiation protocols are recommended and, when used as a sole treatment of OMM, can result in median survival times a bit shorter than those achieved with surgical treatment. Acute side effects, such as radiomucositis are common, expected and usually resolve with supportive treatment, while late life-threatening side effects, such as osteoradionecrosis or secondary tumors, are rare, but need to be discussed with the client in advance, especially when long-term survival of irradiated patients is expected.

OMM is considered poorly responsive to chemotherapy, but is a highly immunogenic tumor. Although the exact immune mechanisms are not completely understood and are likely individually-specific, several immunotherapy and/or gene-electrotransfer therapy approaches have been suggested for canine OMM patients. Most (clinical) research has been performed on a canine melanoma vaccine (xenogeneic plasmid DNA with a cDNA insert encoding human tyrosinase), which has been shown to be safe, but data on its’ efficacy are conflicting. Although it remains unclear, what (if any) role melanoma vaccine and other treatments played in the prevention of metastatic disease in the case described in this report, it is important to realize, that the outcome of canine OMM treatment may not neccessary be poor. In addition, new multimodal approaches are being developed to treat canine OMM and are changing this disease with historically poor outocme into a chronic disease, at least in selected cases.

Clinical study at Animal Hospital Postojna

At Animal Hospital Postojna we recently began a study titled “Evaluation of immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous or digital melanoma’ together with the Oncovet Clinical Research Centre in France. The study aims to evaluate immune system response to hypo-fractionated radiotherapy in canine non-operable oral, cutaneous, or digital melanoma and to assess the ability of this therapy to improve the response to immunotherapy in combined treatment. With the client’s agreement, we include dogs (males and females) with malignant melanoma when the tumour cannot be surgically removed, either due to its localisation preventing the recommended wide excision, or the client’s refusal to approve such a procedure. In that case, hypo-fractionated radiotherapy remains the preferred treatment. If you or anyone you know are interested in participating in the study and would like to know more about the study protocol and obligations, risks and potential constraints as well as benefits that we offer if you decide to participate, please, contact us at info@ahp.si

2018 Hill’s Global Symposium on ageing pets

April 30, 2018

Over 5,000 viewers at 24-hour educational live-stream
connecting veterinarians around the world

Lisbon (April 28, 2018) – The number of veterinary professionals viewing the 24-hour educational live-stream of Hill’s Global Symposium 2018 has exceeded five thousand three hundred unique viewers worldwide, in addition to some 200 veterinarians who travelled from over 35 countries to attend the symposium in person. In total, they viewed over 7,500 hours of quality continuing education.

‘We are very proud of this achievement for our first-ever global live event in the veterinary sector,’ commented Dr Jolle Kirpensteijn, Chief Professional Veterinary Officer at Hill’s US. ‘It is a particularly fitting result as today we are celebrating World Veterinary Day.’

Thanks to the great attendance, Hill’s will donate £10,000 (approximately €11,300 / U$13,800) to Dogs for Goods a UK-based charity that trains and provides accredited assistance dogs to people with physical or mental disabilities.

The unique 24-hour educational live-stream allowed veterinarians and veterinary students anywhere in the world to join the conference directly from the comfort of their clinic or home.

In addition, the symposium will be made available for on-demand content between June 1, 2018, and May 31, 2019. Registered veterinarians will be able to view and review all recordings in the website.

The theme of this year’s Global Symposium was ‘Adventures of Ageing: Early Chronic Kidney Disease & Growing Older.’ Veterinarians are treating an ever-increasing number of elderly dogs and cats, many of whose lives have been prolonged through advances in veterinary medicine. ‘Helping these animals age healthily is a rapidly growing area of practice and one in which nutrition plays a key role,’ stressed Dr Iveta Becvarova, Director of Global Academic and Professional Affairs at Hill’s Pet Nutrition, and organizer of this year’s event.