Luba Gancheva – Vets on the Balkans - an online journal for veterinarians from the Balkans

Anaesthetic management of a dog with pericardial effusion for pericardial window surgery

December 3, 2024

Dr Denica Djodjeva

Central Vet Clinic

Sofia, Bulgaria

Vigo, 9 years old, male, labrador, non castrаted, 39 kg at the last present in the clinic. After several pericardiocentesis was decided for subtotal pericardiectomy. On the clinical examination, the dog had rapid breathing, a fast heart rate, and a normal strong pulse. On the ultrasound examination, there are already ascites, not clinically significant pericardial effusion, and the pericardium is thickened. There was no need for pericardiocentesis. After the intravenous catheter placement, the patient was premedicated with methadone 0,1mg/ kg, ketamine 1mg/kg, midazolam 0,2 mg/ kg, and propofol 3mg/ kg to effect, intubated and pre-oxygenated at all times of surgical preparation. An arterial catheter was placed for invasive blood pressure monitoring and arterial blood sample collection. At the time of surgery, there was a dopamine infusion of 7mcg/ kg/ min for maintaining the blood pressure and heart contractility in normal ranges. Pain management was performed with opioid administration and intercostal block from the 4th to 7th ribs with Ropivacaine 1mg/ kg. There was fluid infusion with RLS all the time from 2- 5ml/ kg/ h depending on the personal need of the patient due to surgery. A rescue analgesia plan with CRI Lidocaine 1mg/kg/h, Ketamine 1mg/kg/h was ready and used. IPPV was performed immediately before the thoracic opening. The hemodynamic support, fluid resuscitation, and vital parameters were closely monitored during the pre-, surgical, and post-operative periods. maintaining the blood pressure in normal ranges. For the pain, there was performed intercostal block from 4th to 7th ribs with Ropivacaine 1mg/ kg. There was fluid infusion with RLS all the time from 2- 5ml/ kg/ h depending on the personal need of the patient. Rescue analgesia plan with CRI Lidocaine 1mg/kg/h, Ketamine 1mg/kg/h, Methadone 0,1 mg/kg/h was ready and used. IPPV was performed immediately before the thoracic opening. The hemodynamyc support, fluid resuscitation and the vital parameters was closely monitored during the post operative period.

The main hemodynamic goals in the anesthetic management of this patient included preservation of preload due to increased intrapericardial pressure and compromised cardiac chamber filling, control of HR to maintain atrial contribution to ventricular filling and avoid decreased CO. Another important goal was to maintain and improve contractility, which is important in patients with decreased myocardial function.

Introduction

Pericardial effusions associated with malignancy usually develop slowly, and when the volume of fluid exceeds the limit of stretch of the pericardial membrane, it results in cardiac tamponade. However cardiac effusion or tamponade may be relieved by pericardiocentesis. Malignant pericardial effusions being chronic and recurrent are best managed by pericardial window or total pericardiectomy. In this procedure, a passage is created between the pericardial sac and adjacent space, usually the pleural cavity for long-term drainage of pericardial fluid. Standard approaches for pericardial windows include a subxiphoid approach and right or left thoracotomy. In this situation, we approached through the left anterior thorax.

Physiology and pathophysiology

The pericardium is the natural covering of the heart, which consists of two layers. Inner visceral, which is thin and connects the epicardium of the heart, and outer, which is thicker and fibrous. The thickness of the healthy pericardium is 1-2 mm, and between the two layers, there is pericardial serous fluid, which is produced by the mesothelial cells and is drained through the lymphatic system in the right part of the heart. Normally, there is a very small amount of pericardial fluid in the pericardial sac 0, 25ml/kg in a dog. Anatomically, the pericardium is held by ligaments to the diaphragm and sternum. The heart can function normally even without its pericardial sheath because its main function is to stabilize the heart in its natural position and to limit the excess movements of the heart when the position of the body changes.

The pericardial fluid minimizes friction exerted on the epicardium from normal heart movements during the cardiac cycle and serves to balance hydrostatic pressures over the surface of the heart. The pressure exerted on the cardiac chambers by the pressure within the intra-pericardial space prevents acute distention of the chambers and helps optimize atrial and ventricular coupling and filling. The pericardial sac serves as a physical barrier against the spread of infection or neoplastic disease within the mediastinum.

There are several reasons why the function of the pericardium can be disturbed: birth defects, acute or chronic pericarditis, pericardial effusion, and tamponade. In pericardial effusion, as a consequence of an increase in the amount of fluid, the pericardial pressure also increases, which can lead to cardiac tamponade, decreased CO and blood pressure. Pericardial effusion can be caused by neoplasia, infectious organisms, congenital abnormality, or idiopathic disease. Pericardial effusion or tamponade is treated by pericardiocentesis to reduce the pressure created and ease the heart’s workload. In case of recurrent effusion, surgical removal of the pericardium is recommended.
When effusion accumulates slowly, the pericardium can enlarge to accommodate this increase in volume and, if intrapericardial pressure is low, clinical signs may not be present and cardiac function remains relatively normal. When effusion accumulates quickly or intrapericardial pressure rises quickly, surpasses the normal diastolic pressure in the right ventricle and cardiac tamponade occurs. Pericardial effusions of large volumes can also compress the lungs and trachea, causing respiratory difficulties and coughing.

In the case of developed pericarditis or a fibrosed and thickened pericardium, the work of the heart becomes difficult and limited by the harder “shell”. Once intrapericardial and intracardiac pressures increase beyond a certain limit, cardiac chamber filling and preload are reduced which causes a drop in stroke volume and cardiac output. This drop in cardiac output causes a reduction in organ perfusion, which triggers compensatory mechanisms including activation of the sympathetic nervous system and the renin-angiotensin-aldosterone axis. The resultant tachycardia, peripheral vasoconstriction, and fluid retention is an attempt to maintain systemic blood pressure, cardiac output, and organ perfusion.

Anaesthetic management

Management of pericardial effusion can be divided into two groups: the pre-tamponade patients, who are hemodynamically stable, and those with tamponade who are not. Unstable patients demand urgent intervention. Since pressure caused by fluid within the pericardial sac is the underlying problem, drainage of the pericardial fluid is a lifesaving procedure.

In pericardial effusion and cardiac tamponade, impaired ventricular diastolic filling leading to a decrease in stroke volume is compensated by an increase in heart rate, contractility, and systemic vascular resistance. Cardiovascular compromise can be worsened by mechanical ventilation and when it is required, it should be instituted cautiously with the minimal inspiration pressure required to provide adequate minute ventilation. The combination of positive pressure ventilation that decreases venous return as well as vasodilation and direct myocardial depression from the anesthetic agents themselves can result in significant hemodynamic deterioration. Anesthetic considerations in these patients focus on the increase of preload and maintenance of afterload, contractility, and heart rate, and the use of low positive end-expiratory pressure (PEEP) during positive pressure ventilation.

The optimal anesthetic plan varies with the patient’s clinical condition, especially the severity of effusion. Local anesthesia is preferred for pain management, as most of the opioids and general anesthetic agents cause myocardial depression and systemic vasodilation. For intravenous induction, ketamine, midazolam, and etomidate are preferred, as the former supports the heart rate, contractility, and systemic vascular tone, and the latter has minimal effects on blood pressure.

The hemodynamic goals are to maintain adequate cardiac output by increasing chronotropy, to decrease afterload, and to decrease right atrial pressures. Dopamine and dobutamine are all appropriate first-choice inotropes. But they all increase the oxygen and metabolic requirements of the myocardium and decrease its perfusion time and so close monitoring of the hemodynamic parameters is crucial.

The role of fluid resuscitation may have a big advantage. Successful volume expansion primarily depends on the outcome measures defining it (i.e. cardiac index, end-organ perfusion, or patient symptom relief), the type of tamponade, and the overall fluid status of the patient. The effects of hypovolaemia are very obvious. A single fluid challenge is beneficial, especially in the setting of hypotension. Excess fluid administration risks worsening ventricular correlation in the patient and decreasing their cardiac output. The use of fluid as a bridging management is important in those with a poor preload and a single fluid challenge is unlikely to cause harm. Subsequent fluid bolus needed to be carefully assessed with the knowledge that they may be not of benefit.

Anesthesia maintenance can be accomplished with various combinations of volatile inhalational agents; intravenous opioids, propofol, and ketamine have all been used successfully. Short- or intermediate-acting muscle relaxants may be used if necessary but ideally only when the patient does not tolerate positive pressure ventilation. Continuous intravenous infusions of vasopressor or inotropic agents may be required to maintain hemodynamic stability, but they should be considered with their adverse consequences due to excessive vasoconstriction, which may restrict cardiac output. Opioids can be used for postoperative analgesia. Consideration should be given to loco regional nerve blocks (i.e., intercostal nerve blocks, serratus plane block) preferably under ultrasound control.

The formulation of a perioperative management plan for patients undergoing pericardial drainage procedures should follow general principles common to all causes of pericardial effusion. The plan should be modified specifically according to the etiology, acuity of presentation, the presence of signs or symptoms of tamponade, and the planned surgical approach.

The general perioperative hemodynamic goals are:

Preload: Expand intravascular volume to maintain preload (despite the high central venous pressure observed in tamponade physiology).
Heart rate and rhythm: Avoid bradycardia and treat any bradyarrhythmias if they occur. Maintain sinus rhythm so that cardiac output remains optimal.
Afterload: Maintain systemic vascular resistance (SVR), which is high in patients with tamponade because of high sympathetic nervous activity. The compensatory cardiovascular mechanisms (tachycardia and raised SVR) must be maintained during the induction of anesthesia.
Contractility: Maintain optimal contractility and avoid myocardial depressants.

In patients who are in a decompensated hemodynamic state, pericardiocentesis may be performed under local anesthesia.

Clinical case

Clinical history

Vigo, 9 years old labrador for elective pericardiectomy. After two previous pericardiocentesis, the decision for pericardiectomy was made. Previous cytological and culture examinations were negative and the diagnosis was idiopathic pericarditis. On the day of surgery, he was admitted with minimal pericardial effusion and ascites, which do not require centesis.

Physical examination

On the day of surgery, Vigo was tachypneic, with tachycardia, CRT >2 sec, pink mucous membranes, strong pulse, conscious, adequate. The only significant abnormality in the preoperative blood tests was mild hypoproteinemia, explained by the patient’s condition and effusion. Lateral thoracic access and subtotal pericardiectomy were planned and a chest tube was placed.

Induction and maintenance of anesthesia

During preoperative preparation, the patient was premedicated with methadone 0.1mg/kg, diazepam 0.2mg/kg, and ketamine 1mg/kg. Induction was done with propofol 3 mg/kg until effect and intubated with ET 11. Preoxygenation throughout the presurgical preparation for 5-10 min. Two venous and one arterial catheters were placed. The operative field was prepared for left-sided thoracotomy and cleaned with an antiseptic solution. As part of the pain management plan, there was performed local intercostal block under ultrasound guidance from the 3rd to the 7th rib space at left, using Ropivacaine 1mg/kg. During the surgery, all parameters were normal HR 115-127bpm, oscillometric blood pressure MAP 60-80mmHg, strong and regular pulse, SpO2 96-98%, T 38.6. LRS infusion 2-5 ml/kg/h. Antibiotic prevention with ampicillin 20mg/ kg intravenous. During the thoracotomy, mechanical ventilation was used with parameters on Pressure Control Mode and SIMV, 10-12 RR, PEEP 3-4mmHg, Pinsp 7-10mmHg but not exceeding total pressure more than 10- 12mmHg and reached the goal for adequate minute volume without compromising the cardiovascular system and saturation above 97%. Unfortunately, arterial blood pressure was not successfully monitored due to technical reasons, but arterial samples were taken for blood gas analysis. Due to the surgery, it was decided to perform a pericardial window technique instead of subtotal pericardiectomy. A chest tube and nasal catheter were placed for postoperative continuation monitoring and oxygen therapy. The surgery was successful without anesthetic events.

Postoperative care

The post-operative period went well. After full awakening, Vigo received acepromazine 0.01mg/kg due to his temperament and overexcited behavior. As part of the analgesic plan, meloxicam was included in the pain management regimen. Fluid therapy was continued with maintenance 3ml/kg/h RLS. Oxygen therapy, via nasal catheter and saturation monitoring, oscillometric measurement of blood pressure, and monitoring of physiological parameters were continually performed. The prescribed therapy for the stay in the clinic remained Ampicillin 20mg/kg, Furosemide 2mg/kg, Vetmedin 5mg/kg, rescue analgesia with CRI ketamine 0.8mg/ kg/ h, lidocaine 1mg/ kg/ h, methadone. 0,05 mg/ kg/ h. The CRI was titrated till the desired effect and stopped the next morning. The chest tube was checked every 2- 4 hours for the first day and replaced on the third day. Because of the elevated liver enzymes hepatoprotection therapy was included. Broad-spectrum antibiotics, diuretics, and Pimobendan were continued at home. The follow-up from Vigo in the next control examinations is that he is feeling good.

Cutaneous neutrophilic panniculitis and vasculitis in a shar-pei associated with autoinflammatory disease

June 25, 2024

Dr. Okan Kahraman, DVM

İkon veterinary clinic

İstanbul/ turkey

CASE PRESENTATION

A 5-year-old neutered male Shar-Pei presented to the dermatology service with swelling and ulcerative crusted lesions on the flanks and chest.

The patient was clinically diagnosed with Shar-Pei Autoinflammatory Disease (SPAID), characterized by recurrent episodes of fever and lethargy occurring once or twice annually, resolving spontaneously or with the use of non-steroidal anti-inflammatory drugs (NSAIDs).

Cytological examination

Cytological examination of the skin lesion revealed a neutrophilic infiltrate with infectious agents (coc bacteri) , compatible with neutrophilic dermatitis-panniculitis.

Treatment and outcome:

Treatment was 1mg/kg prednisolon oral tablets (24h) 10 days than reduce dosis

Rilexine (virbac) 300 mg twice Daily 15 days

Antibacterial shampoo weekly

The neutrophilic panniculitis and vasculitis observed in this case responded well to anti-inflammatory corticosteroid therapy, implying

an underlying autoinflammatory condition as the etiology of the skin lesions.

1 weeks later

2 moths later

Enemy at the Gates: Hypothermia, the underestimated anesthesia complication

June 5, 2024

Dr Denica Djiodjeva

Central Vet Clinic

Sofia, Bulgaria

Hypothermia is one of the most frequent and major anesthetic complications, occurring in at least 40% of patients. Unfortunately, too little attention is paid to this condition, which is associated with many pathophysiological changes that affect the patient before, during and after surgery. In a dog, hypothermia is considered a temperature below 37° C. As with prolonged procedures and operations, the risk increases. These are operations in which the abdominal cavity is open for a long time, in small animals under 2 kg, weak, cachectic, pediatric and geriatric patients.

Thermoregulation is a process in which the body strives to maintain a constant body temperature, regardless of external conditions, which ensures normal functioning of enzymes, coagulation and immune response. The normal physiological limits for a dog and a cat are 37.5˚ C to 39.2˚ C for a dog and 37.8˚ C to 39.5˚ C for a cat. For mild hypothermia, 37.0˚ C to 37.7˚ C is accepted; moderate, 35.8˚ C to 37.0˚ C ; severe, 33.6˚ C to 35.8˚ C ; and critical, less than 33.6˚ C or less. The normal body temperature (head and body) is about 38° C, and that of the peripheral parts is 2-4° C lower. Animals and humans, in addition to maintaining their body temperature within certain limits, can also produce it. Their body is conditionally divided into two parts, central (core), which generates heat, and peripheral, which regulates. The body’s regulatory mechanisms work to keep heat within normal limits. Under normal conditions, the production of heat is the result of the metabolic processes of the internal organs. When the blood passes through them, it warms up and reaches the periphery of the body through the cardiovascular system. The main organ that plays the role of a thermostat is the hypothalamus. When the blood passes through it, its temperature depends on what the body’s response will be in order to maintain the balance between heat gain and loss. From the hypothalamus, through afferent and efferent nerve pathways, vasoconstriction is induced, which occurs before the activation of other energy-consuming reactions, such as shivering. It is important to mention that the efferent response includes both types of regulation – behavioral and autonomic. Behavioral is the strongest response to rewarming, but requires awareness, which is absent during anesthesia. For this reason, the patient must rely on autonomic defense mechanisms, such as maintaining normal blood pressure, vasoconstriction, etc. When local anesthesia is used, vasoconstriction is reduced in the area, where it is administered and this increases heat loss. In addition to central thermoreceptors for heat and cold (in the hypothalamus, spinal cord, abdominal organs, brain stem, muscles), there are also peripheral ones in the skin.

According to the second law of thermodynamics heat can only flow by temperature gradient from the body that is warmer towards the periphery or the environment that is colder, therefore, the body can never be heated from the periphery to the core which is usually warmer than the outside.

As already mentioned, when the animal is under anesthesia, the thermoregulatory mechanisms are blocked. Anesthesia slows down behavioral defense mechanisms, reduces metabolic needs, hypothalamic function and muscle tone. Heat loss begins within the first minutes of premedication because all sedatives and tranquilizers block the hypothalamus. The highest heat loss is during the first 20 minutes of induction, due to its distribution from the center to the periphery of the body. For this reason, it is very important to prevent heat loss at the beginning of the anesthesia, through various methods that will be mentiont later.

At first, the main mechanisms of heat loss are four.

Convection- This is one of the most common ways of losing heat, which occurs when body heat is dissipated into the surrounding space through the air. The larger the surface of the body, the greater the heat loss. In animals, hair greatly interferes with this mechanism and it is important, with a larger shaved area and an open abdominal cavity during prolonged surgery. Conduction – occurs in direct contact of surfaces with different temperatures. For example, when lying on a cold operating table. This mechanism is especially important, when the patient is lying on a wet and cold surface.

Radiation- The transfer of heat from one surface (e.g. the body) to another without direct physical contact. Radiation is received from the sun by any object exposed to sunlight. The heat load from solar radiation, can be significant in hot environments, where animals are exposed to sunlight for prolonged periods. When an animal is standing in bright sunlight, the amount of solar radiation absorbed may substantially exceed its own metabolic heat production.

Evaporation – evaporation of water at the surface of the body or respiratory tract results in heat loss and it’s approximately 22% of total body loss. 0.58 kilocalories of heat is lost for each gram of evaporated water. In human the evaporation is manifested like sweating but in animals due to the lack of sweat glands, it is expressed by panting. To prevent evaporation from the respiratory tract and a drop in body temperature during anesthesia, the oxygen flow can be reduced if this is compatible with the circuit used and the needs of the patient.

The main physiological disorders that occur with hypothermia are related to reduced liver metabolism, compromised cardiovascular system, reduced ventilation and oxygenation, compromised renal function, reduced cerebral flow. All these factors also influence the slower post-anesthesia recovery. In human medicine, there are many more studies on the subject and more specifically on the direct impact of hypothermia on the body. The most frequently observed are delayed pharmacokinetic and dynamics of anesthetics, impaired coagulation, a threefold increase in the risk of cardiac problems in high-risk patients, an increased likelihood of difficult wound healing and infection, leukocyte migration and suppression along with impaired phagocytosis and neutropenia.

When liver metabolism and enzyme systems are reduced, the metabolism of most anesthetics such as acepromazine, propofol is also impaired. As well as anesthetics can directly block the hypothalamus, such as acepromazine and morphine. Inhalational anesthetics are affected by hypothermia by increasing their solubility but not slowing their potency. They also reduce the intensity of shivering, as a mechanism to conserve heat. It has not been proven, whether that hypothermic patients may take longer to recover from anesthesia because of larger amounts of anesthetic that need to be exhaled. But it’s for sure known that propofol, as one of the most commonly used anesthetics, is also affected by body temperature, as for hypothermia with 3° C down, its plasma concentration increases by 30%. The only drug tested so far, which does not effect thermoregulatory responses, is midazolam. The vasodilator effect of most of the anesthetics surpasses physiological vasoconstriction, which supports thermoregulation. As with vasodilation, there is a large loss of heat that comes from the center of the body and is lost to the periphery.

The negative effect of hypothermia on coagulation and blood has three main factors. It affects – platelet function, coagulation enzyme function and fibrinolytic function. As a rule, hypothermia increases blood viscosity, which leads to deterioration of perfusion. For every 1° C decrease, the hematocrit rises by 2%. This accordingly leads to false results that can be interpreted as blood loss. Since the function of the enzyme systems is disturbed, this also affects blood clotting. PTT, PT increase significantly, there is temporary thrombocytopenia and reduced platelet function occur due to impaired synthesis of thromboxane B2. The morphology of the platelets also changes. There is a hypothesis according to which hypothermia results in coagulopathy by reducing the availability of platelet activators. This hypothesis is supported by the following observations: (a) The generation of thrombin, a potent platelet agonist, decreases under hypothermic conditions, and (b) hypothermia results in the release of a circulating anticoagulant with heparin-like effects. (1)

Due to the vasoconstriction that occurs, the oxygenation of the tissues is reduced and hence their slower healing. Direct suppression of neutrophil function is also a factor influencing healing in addition to the immunosuppressive effect, reducing leukocyte migration, neutrophil phagocytosis and production of ILF 1, 2, 6 and TNF.

In order to avoid all complications of hypothermia, different methods are used for pre-during and post-operative warming of patients. Typically, in the preparation of the animal for surgery, towels are used to cover the table or the animal is wrapped. A heating pad is often placed on the surgical table. The use of fluid-warming devices, which largely support normothermia, is also appropriate. Various methods can be used such as putting socks on the paws, wrapping in bubble rap, placing hot water bottles, red infrared lamps. After surgery, the animal can be wrapped with a blanket and any of the methods of warming can be used. But some of the most effective methods of maintaining a normal body temperature are warm air devices and warm water beds. According to a study comparing several methods of warming and prevention of heat loss, warm air is the most effective. (2) In addition to all the listed methods, it is important to reduce the time of the operation, especially in longer abdominal operations. Avoiding placing animals on cold metal tables, warm operating room.

It is advisable to warm up by 1-2° C per hour and under constant monitoring, because complications can occur from trivial burns to more serious systemic complications. Some of the underestimated ones are the so-called “afterdrop”, in which, despite the warming, the temperature of the animal continues to fall. This is caused by the return of cold blood from the peripheral limbs to the body, which makes it difficult to reach a normal temperature. It is important in such moments to warm up the body (chest, abdomen), and not the extremities. Afterdrop can cause deterioration of physiological parameters, cardiac arrhythmias and arrest.

Rewarming shock is very unknown and underestimated complicaton, which manifests itself in a sudden vasodilation with following drop in blood pressure and cardiac output. This results in increased metabolic demands and increased perfusion requirements. In this regard, there may also be areas of impaired perfusion that are hypoxic and lactate begins to form. During rewarming, these areas are reperfused and lactate re-enters normal oxidative pathways, consuming oxygen in the process. Because of the rewarming acidosis that has occurred, appropriate fluid therapy may be considered. Shivering is a normal response of the body, with which it tries to normalize its temperature, but on the other hand, it can also lead to additional complications, because additional oxygen consumption is needed and this can cause additional hemodynamic instability. The suppression of shivering by neuromuscular blockade is an effective method for decreasing O2 consumption. This method has been described in some human studies. (3) Monitoring during the warm-up should include as many indicators as possible, such as saturation, blood pressure, ECG, lactate, glucose.

WSAVA Offers Neurology CE to Balkan Member Associations

February 9, 2024

The World Small Animal Veterinary Association (WSAVA) is offering a series of one-day seminars on neurology to its member associations in the Balkan countries.

The sessions will be led by Dr Thomas Flegel, Head of Neurology and Neurosurgery at the Department for Small Animals, Leipzig University, Germany. He will show delegates how to use a neurological examination to determine a problem and the most likely causes. He will then use interactive case-based workups of common neurological presentations to discuss how to approach dogs suffering from seizures or the most common spinal diseases, as well as those with peripheral neuropathies. The sessions will take place as follows:

5 March	Banja Luka, Bosnia and Herzegovina	Contact bhuvmz@gmail.com
7 May	Skopje, North Macedonia
9 May	Priština, Kosovo
To be confirmed	Tirana, Albania
15 June	Venue, Podgorica, Montenegro

Dr Lea Kreszinger, a member of the WSAVA’s Continuing Education (CE) Committee and founder of a small animal clinic in Sesvete, Croatia, has organized this CE for WSAVA members in the Balkan region. She said: “Neurological cases can be daunting for general practitioners – a fact confirmed by a recent WSAVA learning needs survey, which highlighted neurology as a key topic on which our members wanted more education.

“We’re delighted respond by offering these free one-day sessions with Dr Flegel, a highly experienced practitioner and teacher. He will demonstrate that neurology doesn’t have to be complicated and show delegates how they can improve the quality of life of dogs with neurological problems.”

For further information and to register, veterinarians are asked to contact their country member association.

8 years Vets on The Balkans Conference- “Vets for Cats” 2024

December 3, 2023

We are delighted to announce that in 11-12^th May 2024 will hold our next conference at Ramada Parc Hotel in Bucharest, Romania.

We will enjoy the knowledge of Dr Luca Ferasin, DVM PhD CertVC PGCert(HE) DipECVIM-CA (Cardiology) GPCert(B&PS) FRCVS, European (EBVS) and RCVS Recognised Specialist in Veterinary Cardiology and Dr Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC, Assist. Prof., in Veterinary Dentistry.

We will have 2 more guests, local veterinarians, Dr Teodoru Soare,DVM,PhD Senior Profesor – Veterinary Pathology and Dr Elena Nenciulescu DVM, MRCVS – Veterinary Dentistry.

Scientific Program:

11^th May

8:00-9:00 Registration and welcome coffee

9:00- A fresh approach to heart murmurs in cats.

Dr Luca Ferasin

9:45- Oral Tumors- staging and treatment options

Dr Ana Nemec

10:30-11:00- Coffee Break

11:00 -Is classification of feline cardiomyopathy truly useful?

Dr Luca Ferasin

12:30-13:30 Lunch

13:30-The most common oral tumors in cats

Dr Ana Nemec

14:45- Dr Teodoru Soare- Pathology

15:30-16:00 Coffee Break

16:00 -Clinical cases- presentations of local vets

12^th May

9:00-A practical approach to the fainting cat.

Dr Luca Ferasin

9:45- Biopsy is always indicated: non-neoplastic oral lesions in cats

Dr Ana Nemec

10:30-11:00- Coffee Break

11:00-Beyond furosemide. Current therapeutic options in feline cardiology

Dr Luca Ferasin

12:30-13:30 Lunch

13:30- Two poorly understood clasics-feline chronic stomatitis and tooth resorption

14:45- Dr Elena Nenciulescu- veterinary dentistry

16:00-Clinical cases- presentations of local vets

17:00-TOMBOLA

Soon will be opened and the registration, the price for both days is 100 euro.

Thank you to our general sponsors:

Hills

Pamas Trading

Taste of The Wild

Vet Pharma Distribution

Veteco

Boehringer Ingelheim

Because of them we will enjoy our meeting full of knowledge.

Soon we will come with more information

Ear tip vasculitis in a Bull Terrier dog – case report

October 21, 2023

Dr Giulia Nadasan-Cozma

Giu The Vet- veterinary clinic

Arad, Romania

Pacient data and history:

Name: Connor

Breed: Bull Terrier

Age: 2 years

Patient presented for a dermatological consult after a few days of bleeding from the auricular pinnae.

The owner noted that the onset was acute, the lesions appeared “ overnight” and the animal was bothered by them, and started scratching and bleeding.

Dermatological findings:

Vasculitis lesions are noted bilaterally on the apex of the pinnae consisting of alopecia, ulceration, crusting in different stages and necrosis that led to loss of tissue and altered the shape of the pinnal apex.

The crust comes off very easily and hemorrhage starts.

Lesions begin at the apical margins of the pinnae and spread along the concave surface.

Diagnosis:

A sample was performed by the impression smear technique and sent to the lab for cytology. The result was consistent with neutrophilic acute inflammation. In correlation with the clinical aspect, we had a strong suspicion of vascular damage, which may be caused by inflammatory or noninflammatory diseases, and often are idiopathic. The diagnosis is normally confirmed by histopathology but unfortunately the owner did not agree with the medical procedure.

Diferential diagnosis:

Proliferative thrombovascular necrosis of the pinnae is the dermatological diagnosis but to confirm this diagnosis, a biopsy and a histopathology exam is needed.

Ear tip ulcerative dermatitis can be another dermatological diagnosis.

Vaccine associated vasculitis can be another cause.

Vasculitis can be associated with coexisting disease like hypersensitivity disorders, food allergies, insect bites and many drugs administration, even dexamethasone or prednisone.

Given the note that Connor is an atopic dog, atopy itself can be the reason these lesions appeared because he was treated with prednisolone over an year because of his atopic syndrome and owner’s budget restraints.

Treatment and outcome:

After a long talk the owner chose surgery but in the end we managed to convince him to try medication for at least 14 days.

The following treatment options were offered:

1: Oclacitinib

Dosage: 0.5-0.6 mg/kg/12 h

1 tablet of 16 mg to be given BID 30-90 days according to the studies

Local topical Tacrolimus 0,1%
Pentoxifylline tablets, dosage 15mg/kg BID
Doxicycline tablets, 5 mg/kg BID
Niacinamide tablets 500 mg/dog TID, for 30-90 days, may not work.

Treatment with oclacitinib (Apoquel 16 mg) was started despite budget restraints and Connor started to get better by day 7.

The treatment lasted 7 weeks ( 49 days) until complete remission of lesions.

He continued with Apoquel 16 mg 1×1/24 h to control his atopic syndrome.

Conclusion:

Oclacitinib it is not typically used to treat vasculitis in dogs but should be included

among the therapeutic options for ear tip vasculitis if there are no signs of infection. Oclacitinib has immune modulatory effects on numerous cytokine-mediated inflammatory, autoimmune or immune-mediated diseases in dogs. This type of vascular damage of the pinna is sometimes idiopathic and is hard to find a definitive diagnosis without a histopathology exam.

References:

Silvia Colombo, Luisa Cornegliani, Antonella Vercelli, Alessandra Fondati – Ear tip ulcerative dermatitis treated with oclacitinib in 25 dogs: a retrospective case series (2021) – Veterinary Dermatology
Thelma Lee Gross, P. J. Ihrke, E.J. Walder, V.K.Affolter – Skin diseases of the dog and cat, 2nd Edition, 2020, Blackwell
Rosanna Marsella, Katherine Doerr, Andrea Gonzales,Wayne Rosenkrantz – Oclacitinib 10 years later: lessons learned and directions for the future

(2023) – J Am Vet Med Assoc.

William H. Miller Jr., Craig E. Griffin, Karen L. Campbell – Muller and Kirk’s Small animal dermatology, 7nd Edition, 2012, Elsevier

OSTEOMIELITIS OF THE MANDIBLE IN A 7-YEAR-OLD CAT -case report

July 15, 2023

Michel (Mihai) GUZU, DVM, Dipl EVDC, ADVETIA Small Animal Hospital, Vélizy-Villacoublay, France
Dr Mihai Guzu

Dr Elena Nenciulescu

Elena Carmen NENCIULESCU, DVM, MRCVS, PET STUFF Small Animal Hospital, Bucharest, Romania

Address correspondence to Dr Guzu: guzu@advetia.fr

History and Clinical Examination Findings

A 7-year-old 5.350 kg neutered male Domestic Shorthair cat was referred for loss of appetite and generalized weakness lasting for 10 days. The owners reported a short episode of hemorrhagic ptyalism (for 24 hours), accompanied by moans and chewing efforts. Previous injection 0.1 mg/kg and prescription 0.05 mg/kg of meloxicam PO, q 24 h, for 2 days only permitted minor transitory food intake improvement. On physical examination, the patient appeared mildly dehydrated (5%) and hyperthermic (39.4°C ). Halitosis with concurrent rostral mandibular swelling were noticed. The swelling was fluctuating, with pain elicited by palpation. A seeping sore spot was observed on the ventral aspect of the mandible (Figure 1).

Figure 1: Initial clinical presentation, with appearance of the rostral intermandibular region before (a) and after shearing of the area of the swelling

Moderate bilateral mandibular lymph node enlargement was noted on palpation. Examination on the awake patient was very uncomfortable and the cat only allowed a brief evaluation of the oral cavity. An inflammation of the gingiva surrounding the right mandibular second incisor and the right mandibular canine teeth (402 and 404) was otherwise reported. The remaining physical examination was within normal limits. Biochemistry profile and ionogram results were unremarkable and the FIV/FeLV SNAP test was negative. Complete blood count and serum biochemistry were within normal limits.

A 22G intravenous catheter was placed on the right cephalic vein. The patient was premedicated with methadone hydrochloride 0.2 mg/kg IV and dexmedetomidine 5 µg/kg IV. The patient was induced with propofol 2 mg/kg IV, a 4.5 oral endotracheal tube was placed and then isoflurane 1.5% at a 2L/min rate of oxygen was used for maintenance. Intraoral examination under general anaesthesia and dental charting revealed severe focal periodontitis involving the right mandibular second incisor and the right mandibular canine teeth, with concurrent absence of several incisor teeth. Lateral and occlusal intraoral radiographs were obtained. Selected radiographic views are provided (Figure 2).

Diagnostic Imaging Findings

Radiographic study of the mandible highlighted stage 4c dental resorptive lesions of 402 and 404 (Figure 3). Three root fragments of incisor teeth were noticed (301, 302, 401). An ill-defined bone proliferation with osteolysis involving the surrounding bone was associated with extrusion of the right mandibular canine tooth (404) and concurrent enlarged periodontal space. Cytological examination under light microscope of a transcutaneous fine needle aspirate of the lesion showed degenerated neutrophils, bacteria and some phagocytic activity.

fig 3

Figure 3: Surgical debridement (a) and immediate postoperative aspect of the advancement flap with passive drain in place (b). Followed: Histological analysis reports ulcerative gingivitis with severe chronic suppurative osteomyelitis and inclusion of intralesional bacterial colonies. During the control on day 5 after surgery dehiscence of several skin points is noted after removal of the drain. Open wound management with iterative hydrocolloid dressings was undertaken for an additional 14 days. Skin point removal was performed 27 days after the initial presentation (Figure 4).

Treatment and Outcome

Within the same general anesthesia, bilateral inferior alveolar nerve blocks (intraoral approach) were performed using a mixture of 0.2 ml lidocaine 2% and 0.8 ml bupivacaine 0.5%. The surgical procedure had 2 parts – an intraoral procedure (dental extractions and biopsy of the diseased mandibular bone) and an extraoral procedure (debridement and reconstruction of the skin). For the first part, with the patient in lateral recumbency 10 mm mucosal incision was performed over the alveolar ridge on the distal aspect of the mandibular canine teeth and was prolonged mesially within the sulcus of the mandibular incisor teeth with a #15c scalpel blade. A mucogingival envelope flap was lifted using a Chompret stripper and a Molt periosteal elevator. Simple extraction of the incisor teeth was performed with a 1.5 mm dental luxator used in a circumferential motion. An external alveolar ostectomy was then performed mesially to the mandibular canine teeth (304 and 404) with a round tungsten carbide burr under irrigation over 50% of the height of the roots. 304 and 404 were extracted using a 3 mm luxator. Curettage of the alveolar sockets and of the remodeled bone was performed using a 3 mm Volkman curette for specimen submission to histology. A minimal alveolar osteoplasty (alveoloplasty) using a round diamond burr under irrigation was eventually performed before closure of the defect with a simple interrupted pattern suture with 5/0 polyglecaprone 25, by moving the flap in translation. For the second part of the procedure, the patient was placed in dorsal recumbency. Clipping and antisepsis (with iodine soap and iodine) of the mandibular and cervical cranial area were carried out before surgical draping. The cutaneous and subcutaneous tissues were debrided over a 3 x 3 cm area, then the site was thoroughly rinsed with a 0.9% NaCl solution (Figure 2). Reconstruction of the defect was undertaken using a submandibular skin flap advanced rostrally. A multi-fenestrated drain was inserted and secured ventrally. A first intent closure of the wound was considered using a simple interrupted pattern suture nylon (Figure 3). Perioperative amoxicillin-clavulanic acid 20 mg/kg was administered by slow IV injection, as well as a postoperative injection of buprenorphine 20 μg/kg IV and meloxicam 0,1 mg/kg SC. Amoxicillin-clavulanic acid 12,5 mg/kg BID for oral relay over a 10 days course and oral meloxicam SID for 5 days were prescribed postoperatively. Placement of a buster collar was recommended during the entire convalescence period.

The patient recovered uneventfully after surgery.

Figure 4: Clinical aspect of the operating site during the control at 3 months after the procedure.

Discussion

Mandibular swellings may be associated with a fluid collection, such as a cyst, inflammatory seroma, hematoma or, in some cases, a subcutaneous abscess. Development of subcutaneous abscesses may be related with penetrating or migrating foreign bodies, bites or scratches incidents, especially from other cats. A dental etiology (endodontic and/or periodontal disease) must be considered whenever the location involves the oromaxillofacial area. Some local or systemic conditions (neoplastic, inflammatory, infectious, metabolic or endocrine) may trigger the condition. The differential diagnosis summarizing the main causes responsible for mandibular swellings is shown in Table 1.Main DDx of orofacial swellings in cats

The radiographic findings in this case mainly support the hypothesis of a secondary osteomyelitis with regional subcutaneous abscess due to periodontal-endodontic complications of resorptive lesions. The prevalence of dental resorptive lesions varies between 25 and 40% in the general feline population. This rate is as high as 60 to 70% in purebred cats and/or presented within a dentistry department (Girard, 2008 et 2010; Van Wessum et al, 1992). The condition combines heterogeneous, destructive and progressive lesions of the tooth, resulting in ankylosis and replacement of dentoalveolar structures by bony tissue (ghost tooth). The resorption mostly initiates at the level of the radicular cementum and progresses towards the root and/or the dental crown. Involvement of the dental crown is usually associated by a characteristic crenate-looking patching gingiva filling the enamel-dentinal defect corresponding to the progression of a granulation tissue. Many local conditions (e.g. lack of oral hygiene and development of periodontitis, tooth fracture with pulpitis, chronic gingivostomatitis, occlusal trauma) have been documented in the literature, and some systemic causes (e.g. genetic, nutritional) have been suggested as possible triggering factors in the development of the disease in the feline patient. The resulting pulpal exposure (pulpitis) and/or progression towards periodontitis may then be associated with an endodontic-periodontal lesion, significantly decreasing the oral health status. In those cases, an acute pain may sometimes be elicited by finger percussion of the jaw. A characteristic, but not specific jaw trembling reflex may then be observed. The earliest affected teeth statistically reported in the literature are the mandibular third premolars (307 and 407). (Ingham, 2001) However, all teeth may be involved, with progression towards a generalized disease possible in some individuals. Typical but non-pathognomonic presentation is possible in canine teeth (dental extrusion or occult root destruction). Several clinical and radiological classifications have been proposed by the American Veterinary Dental College (AVDC) in regard to the location and severity of the lesions. (DuPont, 2002) A similar condition has also been described in humans and dogs, but is slightly different from the feline presentation. (Heithersay, 2007; Kim, 2013; Nemec, 2012; Peralta, 2010) Despite many evoked tracks (traumatic, metabolic, infectious, nutritional or genetic), the etiology of the feline tooth resorption remains rather vague and no prophylactic approach is available to date. (Okuda & Harvey, 1992; Reiter, 2005; Girard, 2008) It seems that metabolism of vitamin D may play a key role in the odontoclastic activation process. (Booij-Vrieling, 2009)

When facing an oromaxillofacial swelling, it is important to consider the specificity of the area, in particular the proximity of oral, nasal, orbital, nodal, vasculo-nervous or salivary structures. Reclining the lips and tongue, allowing a more detailed inspection of the gingiva, vestibule, floor of the mouth, as well as the ventral and lateral aspects of tongue is therefore essential. Fine needle aspiration should be performed whenever possible as cytological examination could bring additional information that could further guide diagnostic and therapeutic approach. Evidence shows a favorable predictive value of about 69% even in case of neoplastic conditions. (Ghisleni, 2006) The histopathological examination remains cornerstone, in order to confirm the diagnosis given the high rate of secondary infection in or near the oral cavity. According to the information gathered during the clinical examination and the localization of the lesion, different diagnostic imaging tools could be considered. The conventional extraoral radiography has two major disadvantages compared to the dental radiography: superimposed images and lack of sensitivity in the exploration of dental conditions (Chapnik, 1989). The CT scan provides good information in regard to the extension of any swelling condition. However, only 42 to 57% of the dental resorptive lesions are diagnosed on the CT scan when compared to the intraoral radiography (Lang et al, 2016) Therefore, dental radiographs still constitute the gold standard imaging method to diagnose tooth resorption. New diagnostic imaging devices such as the cone-beam computed tomography scan (CBCT) might be an interesting alternative in the exploration of these dento-alveolar conditions in the future. (Naitoh et al, 2010 ; Soukup, 2015 ; Creanga, 2015)

Extraction of the affected tooth by resorptive lesions remains the treatment of choice. (DuPont, 2005) According to the topography of the lesions, conservative techniques (glass ionomer restoration) have historically been described in early forms, localized to the collar and dental crown. However, the outcome for those teeth remained poor, with inevitable progression of the disease in the majority of the cases. In advanced forms, with associated root ankylosis, and for which tooth extraction would be an additional trauma for healthy tissue (e.g. high risk of mandibular fracture), crown-root amputation may constitute an acceptable alternative. The use of dental rotary instruments is mandatory. However, this option remains controversial for FIV or FeLV positive patients, as potentially at high risk of osteomyelitis, and systemic infectious spread. Specific cases affected by internal or localized forms to the root apex may be eligible to standard root canal treatment +/- apicoectomy as in other species, but fast progression of the disease known in the feline patient is a negative prognostic factor and therefore extraction is the only therapeutic option.

Figure 5: Stages of tooth resorption

When treating perioral wounds, choosing between first, second or even third intention healing strategies, the following must be taken into consideration: the size of the defect, the possible infection associated, the risk of tissue contraction, fibrosis and dehiscence, as well as more specific patient or systemic considerations. When infected, a surgical wound debridement with abundant sterile rinsing of the area should be considered first. It is generally accepted that leaving a wound heal by second intention is not recommended near a sphincter, or any orbicular muscle such as those constituting the lips due to the wound contraction associated, and possible restricted mobility. (Ishii & Byrne, 2009) Excessive tension should be avoided by proper use of reconstructive techniques and more specifically locoregional flaps described in the oromaxillofacial area. (Guzu et al, 2021) A random flap advanced rostrally using lateral releasing incisions and incremental subcutaneous dissection allows for simple reconstruction of the cutaneous defect in the intermandibular area. (Swaim in: Verstrate, 2012) Placement of walking sutures reduces the dead space between the flap and the underlying tissue while decreasing the tension on the wound. Depending on the different size and location of the defect, axial flaps (labial, angular oris), free cutaneous flaps, or even free vascularized flaps using microvascular anastomosis techniques are also appropriate surgical treatment options. (Tong & Simpson, 2012; Smith, 1991; Smeak, 1992; Bradford, 2011, Walsh & Gregory in: Verstraete, 2012) The survival of all those flaps does not rest on the presence of an underlying granulation tissue, but simply on the absence of major contamination. Drainage is generally recommended, in order to reduce the risk of fluid collection formation (hematoma, seroma, infection) which may compromise the vitality of the flap. (Wardlow & Lanz in: Tobias, 2012)

Conclusion:

Dental resorptive lesions constitute a potential source of discomfort, affecting approximately 30% of the cats in the general population. Early diagnosis and treatment remain particularly challenging for any practitioner. Despite many hypotheses regarding the initiating factors leading to its development, no preventive or conservative strategies are available to provide long-term control of the disease. Extraction of the affected teeth is the gold standard treatment, capable of slowing down the extension of the lesions to the adjacent teeth and preventing possible infectious complications. A better understanding of the mechanisms associated with the formation of dental resorptive lesions may improve its medical and surgical management in the future.

References

1. Verhaert L, Van Wetter C. Survey of oral diseases in cats in Flanders. Vlaams Diergeneeskd Tijdschr (2004) 73:331–40

2. Girard N, Servet E, Biourge V, Hennet P. Periodontal health status in a colony of 109 cats. J Vet Dent (2009) 26:147–55. doi:10.1177/089875640902600301

3. Girard N, Servet E, Biourge V, Hennet P. Feline tooth resorption in a colony of 109 cats. J Vet Dent. 2008 Sep;25(3):166-74.

4. Bilgic O, Duda L, Sánchez MD, Lewis JR.Feline Oral Squamous Cell Carcinoma: Clinical Manifestations and Literature Review. J Vet Dent. 2015 Spring;32(1):30-40.

5. Gracis M, Molinari E, Ferro S. Caudal mucogingival lesions secondary to traumatic dental occlusion in 27 cats: macroscopic and microscopic description, treatment and follow-up.J Feline Med Surg. 2015 Apr;17(4):318-28. doi: 10.1177/1098612X14541264. Epub 2014 Jul 7

Congenital pathology of duplicated ureter from left kidney with CKD in geriatric dog Chao – Chao

February 13, 2023

Dr Mila Kisyova

Dr. Mila Kisyova

veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

Introducion

Normal anatomy of the kidneys:

The kidneys are paired, bean-shaped structures located in the retroperitoneal space directly beneath the sublumbar muscles. The cranial pole of the right kidney lies in the renal fossa of the caudate liver lobe and is located more cranially than the left kidney. The cranial pole of the left kidney lies lateral to the ipsilateral adrenal gland, which is closely associated with the cranial aspect of the left renal vessels. The left kidney is generally more mobile than the right kidney. Each kidney has a cranial and caudal pole and a ventral and dorsal aspect .

The concave surface of the kidney is located along the medial aspect and is called the hilus. The hilus is the location where the renal artery enters the kidney and the renal vein and ureter exit. Nerves and lymphatic vessels enter at the hilus as well. Anatomically, the renal vein is located more ventrally, and the renal artery is more dorsally. In an animal of normal body condition, the kidney is typically surrounded by a substantial amount of fat; this fat is maintained even in lean animals. In obese animals, the surrounding adipose tissue can virtually hide the kidney from view, making gross evaluation difficult.

Patophysiology of duplicated ureters:

Duplicated Ureter or Duplex Collecting System is a congenital condition in which the ureteric bud, the embryological origin of the ureter, splits (or arises twice), resulting in two ureters draining a single kidney. In the case of a duplicated ureter, the ureteric bud either splits or arises twice. In most cases, the kidney is divided into two parts, an upper and lower lobe, with some overlap due to intermingling of collecting tubules. However, in some cases the division is so complete as to give rise to two separate parts, each with its own renal pelvis and ureter. Double ureters from each kidney are very rare condition in dogs. They are drain separate renal collection systems from the same kidney and open separately into the urinary or genital tract. Given the embryological migration pattern of ureters, their termination sites are often ectopic.

*) https://www.researchgate.net/figure/Classification-of-urethral-duplication-in-dogs-based-on-the-classification-in-human_fig3_250044546

Duplex kidney formation: developmental mechanisms and genetic predisposition
Vladimir M. Kozlov, Andreas Schedl, iBV, Institut de Biologie Valrose, Equipe Labellisée Ligue Contre le Cancer, Université Cote d’Azur, Centre de Biochimie, UFR Sciences, Parc Valrose, Nice Cedex 2, 06108, France

Duplex systems can have a variety of phenotypes, and multiple classification systems have been proposed to categorise this pathology. In incomplete duplication, the two poles of a duplex kidney share the same ureteral orifice of the bladder. Such duplex kidneys with a bifid pelvis or ureter arise when an initially single UB bifurcates before it reaches the ampulla. This is likely caused by a premature first branching event that occurred before the ureter has reached the metanephric mesenchyme (MM). Much more frequent are complete duplications, which occur when two UBs emerge from the nephric duct (ND). In most cases, the lower pole of the kidney is normal and the upper pole is abnormal an observation explained by the fact that the ectopic ureteric bud (UB) frequently emerges anteriorly to the position of the normal UB and drives the formation of the upper pole of a duplex kidney. Inverted Y-ureteral duplication is a rare condition in which two ureteral orifices drain from a single normal kidney. Inverted Y-ureteral duplication is believed to be caused by the merging of two independent UBs just before or as they reach the kidney anlagen. A very rare H-shaped ureter has also been reported. Although the vast majority of cases involve a simple duplication, multiplex ureters with up to six independent buds have also been described. In some cases, the additional ureter or ureters are ectopic and fail to connect to the bladder or the kidney (blind ending ureter).

Report and history of the patient

We saw Jonh (11 years old, non-castrated, cryptorchid, chao- chao) for first time in our clinic for second opinion related to chronic kidney disease (CKD). He was diagnosed with chronic renal failure by colleagues about 2 years ago. Prior to our examination, he had been taking only food supplements (Irc Vet) and Renal Food. He had polyuria and polydipsia (PU/PD). The owners said that the urine was very light in colour. Sometimes Jonny had episodes with vomiting and lose of appetite. There was data for periodic blood tests with a tendency to increase the basic renal parameters (urea and creatinine). There was no ultrasound or other type of imaging examination.

When we took Johnny’s case, we initially did a complete abdominal ultrasound and new blood tests:

1. Creatinine	456.20 mmol/L	44.30-138.40 mmol/L
2. Urea	26.32 mmol/L	3.00-8.00 mmol/L
3. ALP	272.59 U/L	10.60-109.00 U/L
4. Na	141.60 mmol/L	140.30-153.90 mmol/L
5. K	6.26 mmol/L	3.50-5.10 mmol/L
6. P	2.10 mmol/L	1.00-2.00 mmol/L
7. Albumin	31.37 g/L	25.80-39.70 g/L
8. Glucose	3.95 mmol/L	3.40-6.00 mmol/L
9. Bilirubin Total	5.07 mmol/L	0.00-5.10 mmol/L
10. Bilirubin Direct	3.05 mmol/L	0.00-3.60 mmol/L
11. ALT	31.33 U/L	8.50-109.00 U/L
12. AST	29.30 U/L	8.90-48.50 U/L

Abdominal Ultrasound:

We started a standard echo-screening and the prostatic gland was normal, the bladder too. And after that on the left abdomen near the left kidney we saw a big, elongated, strange formation with anechoic fluid with a diameter of about 3 cm. The left and right kidneys had a good ultrasound density. Three small cysts were found in the cortex of the left kidney. There was no evidence of pyeloectasis or hydronephrosis. The corticomedullary border was good. This finding may be a pathologically altered testis, cystic formation, or pathological /duplicate/ ureter. During the first ultrasound examination, the dog was fed, so we decided to repeat the examination on an empty stomach. For the next echo screening Jonny was on a 12- hour fasting diet but the ultrasound finding is the same as the previous examination – the strange formation after the left kidney was there with the same size and shape. After performing the second ultrasound examination, we had suspicion for duplicate ureter. In order to be definite in the diagnosis, it necessary to perform computed tomography (CT).

After the new blood tests we started a new supplements – Ipakitine/Rubenal 300/Renassense/IrcVet. But Jonny didn’t feel very well. After some days we made a new blood tests. Before that we had spoken with the owners about the ultrasound finding and we decided to do a CT and see what the exact cause of this strange ultrasound finding.

Rusults of the CT:

2-B

3-C

4-D

5-E

6-F

Images:

1-A – little arrows are the bought normal ureters (left and right), big arrow „А“ – duplicate/ectopic left ureter

2-B – big arrow „А“ – duplicate left ureter

3-C – little arrows are cranial and caudal renal medula, big arrow „А“ – duplicate/ectopic left ureter draining the cranial pole of the kidney

4-D – А“ – duplicate/ectopic left ureter, about 3 cm wide along entire length

5-Е – normal right kidney

6-F – Left kidney, big arrow „А“ – duplicate/ectopic left ureter

*) the photos are provided by colleagues from the CVK (Central Vet Clinic, Sofia)

Тhe conclusion of the computed tomography is the left kidney has a slightly enlarged pelvis. Two ureters originating from the left kidney are found. The ureter, originating from the left kidney, has greatly increased dimensions – a width of about 3 cm along its entire length. Before entering the bladder, it turns ventrally and then dorsally. The other ureter of the left kidney begins in the normal anatomical position and drains into the bladder in the area of the trigone. Both kidneys have no tomographic evidence of hydro/pyelonephrosis.

This kind of pathology of the urogenital system in dogs is very rare. In this case it was an incidental finding because for 11 years the patient had never previously undergone additional ultrasound examinations. Certainly, this rare pathology is directly related to the rapidly progressing renal failure.

Due to the rapidly progressing renal failure, deteriorated general condition and the age of the patient, surgical intervention could not be performed. Jonny’s prognosis is very poor.

Sourses:

„Urethral duplication in a dog: case report [Duplicação uretral em cão: relato de caso] R. Stedile, E.A. Contesini, S.T. Oliveira, C.A.C. Beck, E.C. Oliveira, M.M. Alievi, D. Driemeie, M.S. Muccillo Faculdade de Veterinária – UFRGS Av. Bento Gonçalves, 9090 91540-000 – Porto Alegre, RS „
„Duplex_kidney_formation_Developmental_mechanisms_a.pdf– in humans“
Atlas of Small Animal CT and MRI by Erik Wisner, Allison Zwingenberger ,

March 2015

Four-dimensional CT excretory urography is an accurate technique for diagnosis of canine ureteral ectopia (Tobias Schwarz, Nick Bommer, Maciej Parys, Florence Thierry, Jonathan Bouvard, Jorge Pérez-Accino, Jimmy Saunders, Maurizio Longo – onlinelibraly.wiley.com)

WSAVA Alerts to Emerging ‘Canine Welfare Crisis’ Caused by the Popularity of Short-Nosed Breeds

January 29, 2023

Veterinarians around the world are warning about an emerging canine welfare crisis caused by the rapidly increasing number of short-nosed (brachycephalic) dogs. These dogs can have exaggerated anatomical features that can seriously affect their health and well-being. The most concerning of the health issues they face is Brachycephalic Obstructive Airway Syndrome (BOAS).

The Hereditary Disease Committee (HDC) of the World Small Animal Veterinary Association (WSAVA) has produced an educational video highlighting the problems that BOAS can cause in brachycephalic breeds, including French bulldogs, English bulldogs, and pugs. During the video, members of the WSAVA HDC and other experts explain how the appearance of short-nosed breeds has been affected by breeding for extreme and exaggerated anatomical conformation. While dogs which snore or pant are considered cute by some, the experts point out that these traits are not normal and that the dogs are, in fact, struggling to breathe. Many short-nosed dogs require surgery to survive and have a significantly shorter lifespan than other dogs.

Speaking during the video, Dr Peter Sandøe, Director of the Centre for Companion Animal Welfare at the University of Copenhagen, says: “With French bulldogs now the most popular breed in many countries and with English bulldogs and pugs also very popular, the number of affected dogs is increasing dramatically. Selective breeding for an exaggerated short nose has created dogs whose health, in many cases, is compromised for the sake of perceived ‘cuteness’. It is simply unethical to breed dogs which struggle to breathe.”

The WSAVA Hereditary Disease Committee is calling on all stakeholders – breeders, owners, veterinarians, media, regulators, and others – to work together to improve the welfare of these breeds going forward, and change perceptions of what ‘healthy’ looks like in these dogs.

It urges them to work together on health-focused breeding initiatives to produce dogs with less exaggerated anatomical features so that BOAS and other related health issues are not passed on. The selective breeding which caused these problems in the first place, can return these breeds to better respiratory health by selecting for more moderate anatomical conformation and for normal breathing. Many kennel clubs have instituted Respiratory Function Grading (RFG) to screen prospective breeding dogs against BOAS. If RFG screening is not available, prospective breeding dogs should be able to go on a brisk three-minute walk without laboring to breathe. If they cannot do this, they should not be used for breeding.

The need for a united approach is reinforced by WSAVA HDC member Dr Monique Megens, who contributes to the video explaining that brachycephalic dogs are bred – legally and illegally – around the world and transported across borders so a global approach is the only way to make progress.

The 17-minute video, available in several languages, also features contributions from:

Dr Jerold Bell, Chair of the WSAVA HDC, Cummings School of Veterinary Medicine, Tufts University, USA
Dr Åke Hedhammar, WSAVA HDC member, Senior Professor in Internal Medicine at the University of Agricultural Sciences, Uppsala, Sweden
Dr Jane Ladlow, Clinical Lead of the BOAS Research Group, Cambridge University, UK

Dr Bell said: “Breeders did not purposefully select for dogs with impaired breathing but there is no doubt that breeding to create dogs with ever shorter muzzles has created serious health issues in these breeds.

“We hope our video will help educate breeders, owners, and all of those involved in or influencing the breeding and care of short-nosed dogs. We also hope it will give them useful advice on the steps they can take to help as we work together to resolve a serious welfare issue. All dogs deserve to live healthy lives. We must not let them down.”

The video can be seen here: https://bit.ly/3HmL5fk

The WSAVA represents more than 200,000 veterinarians worldwide through its 115 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, including pain management, nutrition and vaccination, together with lobbying on important issues affecting companion animal care worldwide.

The WSAVA Hereditary Disease Committee aims to facilitate clinician diagnoses, treatment and control of hereditary diseases and genetic predispositions in dogs and cats, thereby improving the health of patients now and in future generations.

Latest WSAVA Global Pain Management Guidelines Launched

November 7, 2022

Updated recommendations and resources for pain assessment and management to support veterinary teams now available

An updated set of Global Guidelines for the Recognition, Assessment and Treatment of Pain, which incorporate advances in knowledge and novel evidence, have been launched by the World Small Animal Veterinary Association’s (WSAVA’s) Global Pain Council (GPC) during its annual World Congress in Lima, Peru. WSAVA association member representatives gave enthusiastic support to the new Guidelines, with many signing up to support the GPC’s pledge to improve pain management in companion animals.

Following peer-review, the new Guidelines have been published by the Journal of Small Animal Practice (JSAP), the WSAVA’s official scientific journal, and are available for free download from the WSAVA website and from the JSAP website.

A key feature of the Guidelines is an emphasis on the use of pain scales for the assessment of acute and chronic pain in companion animals. They provide guidance, for instance, on selecting the most effective pain assessment tool based on the condition of the patient and scientific evidence, with links to relevant tools also provided.

In terms of pain management, the Guidelines take into account novel evidence regarding the efficacy and safety of both drug and non-drug therapies. For example, they evaluate the performance of new pharmaceuticals, including monoclonal antibodies, or those with new delivery systems, and evidence regarding the use of cannabinoids for chronic pain. They also discuss the use of non-drug therapies, including acupuncture – evidence of efficacy of which has increased in certain pain conditions. The Guidelines also stress that euthanasia should always be considered in cases where pain cannot be effectively managed and quality of life is poor.

Greater attention is paid to the role of emotions on the perception of pain in the Guidelines. It is now recognized that fear and stress can increase the perception of pain in animals so the document includes recommendations as to how to improve the experience of hospitalized patients, as well as giving advice to support the welfare of animals living with chronic pain and primarily managed by their caregivers at home.

The format of the Guidelines has been enhanced for this version to increase the accessibility of information with an increased use of visuals and graphics. Links to recommended tools are provided, as well as links to videos and additional resources for those wanting to further their knowledge.

A priority for the WSAVA is to provide Guidelines that are globally relevant. For the GPC, this means supporting veterinarians in regions with restricted access to analgesic drugs in working around the limitations they face. To help them, the Guidelines offer tiered protocols and highlight the role of local anesthetic techniques that don’t require additional training, together with the role of non-drug therapies to manage pain such as cold/ice therapy and the provision of a comfortable and safe environment to patients. They also discuss the importance of nursing and supportive care.

The Guidelines are currently available in English with translation into Spanish, Portuguese, Chinese and other languages underway.

Commenting on the launch of the updated Global Guidelines for the Recognition, Assessment and Treatment of Pain, Dr Bea Monteiro, GPC Chair, said: “Pain management is an area of veterinary medicine in which knowledge and understanding has expanded dramatically in recent years. Members of the GPC have worked tirelessly to pull together these latest WSAVA Guidelines, which now provide the most comprehensive and state-of-the-art resource available to support veterinary professionals, wherever in the world they are in practice.

“With animal sentience now legally recognized in many countries and jurisdictions, veterinary health professionals have a medical and ethical duty to mitigate suffering to the best of our ability. Despite the advances in pain management, pain still occurs more commonly than it is treated. We hope that these Guidelines will help colleagues understand the importance of pain management for patient health and welfare and that they will commit to:

Frequently assess pain in every patient
Taking measures to prevent pain and other negative emotions (such as fear and anxiety)
Treat pain using drug or non-drug therapies.”

The work of the GPC is generously supported by Zoetis.

“At Zoetis, we are committed to ongoing innovation, and we have long history of providing medications, tools/resources and educational initiatives to help veterinarians diagnose and manage pain in pets more effectively,” said Dr Mike McFarland, chief medical officer at Zoetis. “Pain has broad negative impacts on an animal’s health, causes suffering and lowers quality of life. Because we know that pain can lower quality of life and disrupt the important human-animal bond which benefits people and the pets they love, it’s important to ensure veterinarians around the world have access to solutions that can help better diagnose and alleviate pain in animals.”

The goal of the WSAVA Global Pain Council, comprising a team of global experts, is to create a global environment for companion animals in which pain is considered as the fourth vital sign and addressed appropriately. Its first Global Guidelines were published in JSAP in 2014 and have been downloaded from its website 53,000 times.