the canadian veterinary journal la revue vétérinaire ... · new six-month clinical results...

Visual inspection of stored canine blood for hemolysis compared with measured plasma-free hemoglobin to assess suitability for transfusion

Vasopressor use in 41 critically ill cats (2007–2016)

Many Canadian dog and cat foods fail to comply with the guaranteed analyses reported on packages

Sartorius muscle flap for body wall reconstruction: Surgical technique description and retrospective case series

Antimicrobial resistance of bovine Salmonella enterica ssp. enterica isolates from the Alberta Agriculture and Forestry Disease Investigation Program (2006–2014)

A longitudinal investigation of an outbreak of toe tip necrosis syndrome in western Canadian feedlot cattle

Piecemeal endoscopic polypoidectomy for the management of a canine pharyngeal hemangiosarcoma

Successful control of disseminated follicular cysts in a dog with low dose isotretinoin

Propofol infusion-like syndrome in a dog

The Canadian Veterinary Journal La Revue vétérinaire canadienne

November/Novembre 2018 Volume 59, No. 11

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1Hill’s® Prescription Diet® k/d® feline with chicken dry food. 2Data on file. Hill’s Pet Nutrition, Inc. 2018. Results are average values with statistical significance (p value less than or equal to 0.05). 3Royal Canin® Veterinary Diet Renal Support A Feline, dry formula. ©2018 Hill’s Pet Nutrition Canada, Inc. ®/™ Hill’s, Prescription Diet, k/d and E.A.T. Technology are trademarks owned by Hill’s Pet Nutrition, Inc. Royal Canin is a registered trademark owned by ROYAL CANIN SAS.

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CVJ / VOL 59 / NOVEMBER 2018 1139

SCIENTIFIC RUBRIQUE SCIENTIFIQUE

ARTICLES

1171 Visual inspection of stored canine blood for hemolysis compared with measured plasma-free hemoglobin to assess suitability for transfusionBrittany Jaeger, Miryam Reems

1175 Vasopressor use in 41 critically ill cats (2007–2016)Nikki Licht, Elizabeth A. Rozanski, John E. Rush

1181 Many Canadian dog and cat foods fail to comply with the guaranteed analyses reported on packagesStuart W. Burdett, Wilfredo D. Mansilla, Anna K. Shoveller

1187 Sartorius muscle flap for body wall reconstruction: Surgical technique description and retrospective case seriesSebastian Mejia, Sarah E. Boston, Owen T. Skinner

1195 Antimicrobial resistance of bovine Salmonella enterica ssp. enterica isolates from the Alberta Agriculture and Forestry Disease Investigation Program (2006–2014)Simon J.G. Otto, Katrina L. Ponich, Rashed Cassis, Carol Goertz, Delores Peters, Sylvia L. Checkley

1202 A longitudinal investigation of an outbreak of toe tip necrosis syndrome in western Canadian feedlot cattleMurray Jelinski, Sonia Marti, Eugene Janzen, Karen Schwartzkopf-Genswein

CASE REPORTS RAPPORTS DE CAS

1209 Piecemeal endoscopic polypoidectomy for the management of a canine pharyngeal hemangiosarcomaJoseph Cyrus Parambeth, Jessica M. Vallone, John F. Griffin IV, Audrey K. Cook

1213 Successful control of disseminated follicular cysts in a dog with low dose isotretinoinMarcin Szczepanik, Piotr Wilkołek, Łukasz Adamek, Anna Smiech, Iwona Taszkun, Grzegorz Kalisz

1216 Propofol infusion-like syndrome in a dogJohn M. Mallard, Teresa M. Rieser, Nathan W. Peterson

1153 QUIZ CORNER TEST ÉCLAIR

Contents Table des matières

NOVEMBER/NOVEMBRE 2018


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Contents Table des matièresFEATURES RUBRIQUES SPÉCIALES

NOVEMBER/NOVEMBRE 2018

PRESIDENT’S MESSAGE LE MOT DE LA PRÉSIDENTE

1145 Our unsung heroesTerri Chotowetz

1149 VETERINARY MEDICAL ETHICS DÉONTOLOGIE VÉTÉRINAIRE

VETERINARY PRACTICE MANAGEMENT GESTION D’UNE CLINIQUE VÉTÉRINAIRE

1223 Companion animal practices versus mixed and large: A 10-year comparison Cliniques pour animaux de compagnie et cliniques mixtes et pour grands animaux : comparaison sur une période de 10 ansDarren Osborne

1227 DIAGNOSTIC OPHTHALMOLOGY OPHTALMOLOGIE DIAGNOSTIQUEMarina L. Leis, Lynne S. Sandmeyer

WHAT CAN’T BE TAUGHT CE QUI NE S’ENSEIGNE PAS

1229 Stay positive and set boundariesAlexandra Schlesiger

VETERINARY DERMATOLOGY DERMATOLOGIE VÉTÉRINAIRE

1231 Pseudomonas otitis externa in dogsCharlie Pye

Contributors

“Instructions for authors” are available online (www.canadianveterinarians.net).

Les «Directives à l’intention des auteurs» sont disponibles en ligne (www.veterinairesaucanada.net).

1201 Correction

1212 Industry News Nouvelles de l’industrie

1234 Index of Advertisers Index des annonceurs

1235 Classifieds Petites annonces

NOTICES ANNONCES

1155 NEWS NOUVELLESHeather Broughton, Isabelle Vallières

N E W S | N O U V E L L E S


1142 CVJ / VOL 59 / NOVEMBER 2018

The Canadian Veterinary Journal La Revue vétérinaire canadienne

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www.veterinairesaucanada.net

© Canadian Veterinary Medical Association 2018 L’Association canadienne des médecins vétérinaires 2018

The Canadian Veterinary Journal is indexed or abstracted in:La Revue vétérinaire canadienne est indexée ou ses articles sont résumés dans :AGRICOL, Biological Abstracts, Capsule Report, Current Contents — Agriculture, Derwent Veterinary Drug File, EMBASE/Excerpta Medica, Index Veterinarius, Index Medicus, Quarterly Index, Science Citation Index, Small Animal Practice, Veterinary Bulletin, Veterinary Reference Service, Veterinary Update.

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Return undeliverable Canadian addresses to: 339 rue Booth Street Ottawa, Ontario K1R 7K1 e-mail: [email protected]

Subscriptions (2018). Annual: Canada $210 + applicable GST or HST; foreign $225 US; institutional $280. Express subscriptions available. Single issue/back issue: $25 each, institutional single issue = $50.00 + GST or HST, if applic able. (All prices subject to change.) Missing issues will be replaced if the Subscriptions Office is notified within 6 months (for requests within Canada) and 1 year (for requests from abroad) of the issue date. The pub lisher expects to supply missing issues only when losses have been sustained in transit and when the reserve stock will permit. Telephone (613-236-1162) or (1-800-567-2862) and fax (613-236-9681) orders accepted with a valid Visa or MasterCard number. Please advise the publisher of address changes promptly.Abonnements (2018). Annuel : Canada 210 $ + TPS ou TVH en vigueur; pays étranger 225 $ É-U; prix d’une institution 280 $. Abonnement express disponible. Anciens numéros (chacun) : 25 $, ancien numéro d’institution 50 $ + TPS ou TVH en vigueur. Les prix sont sujets à changement sans préavis. Les numéros qui ne sont pas reçus seront remplacés si l’éditeur en est informée dans les 6 mois (pour les demandes venant du Canada) et 1 an (pour les demandes venant de l’étranger) suivant la date de parution. L’éditeur s’engage à remplacer les numéros manquants seule ment lorsque les pertes ont été subies en transit et lorsque ses réserves le permettent. On peut payer son abonnement par téléphone (613-236-1162) ou (1-800-567-2862), par télé copieur (613-236-9681) ou par carte de crédit (Visa ou MasterCard). Veuillez aviser le bureau de l’éditeur de tout changement d’adresse.

Editorial policy: All published articles including editorials and letters reflect the opinions of the authors and do not necessarily reflect the opinion of the publisher.Publication of an advertisement does not necessarily imply that the publisher agrees with or supports the claims therein.The Canadian Veterinary Medical Association holds complete copyright of all articles within this issue.Politique de la Rédaction : Tous les articles publiés, y compris les éditoriaux et les lettres, représentent l’opinion de l’auteur et non pas nécessairement la position de l’éditeur.La publication d’une annonce ne signifie pas nécessairement que l’éditeur est d’accord avec son contenu ou qu’il l’appuie.L’Association canadienne des médecins vétérinaires détient le droit d’auteur complet sur tous les articles contenus dans le présent numéro.

Editor-in-Chief/Rédacteur en chef Carlton Gyles, Guelph, OntarioAssociate Editors/Rédacteurs associés Bruce Grahn, Saskatoon, Saskatchewan Wayne McDonell, Guelph, OntarioFeature Editors/Rédacteurs des chroniques Jangi Bajwa, Burnaby, British ColumbiaBruce Grahn, Saskatoon, SaskatchewanMyrna Milani, Charlestown, New HampshireDebbie Stoewen, Ayr, OntarioTim Blackwell, Fergus, OntarioAssistant Editors/Rédacteurs adjoints Robert Friendship, Guelph, Ontario Greg Harasen, Regina, Saskatchewan Jacob Thundathil, Calgary, Alberta Ron Johnson, Guelph, Ontario Richard Kennedy, Pincher Creek, Alberta Shawn McKenna, Charlottetown, P.E.I. Luis Gaitero, Guelph, OntarioManaging Editor/Directrice de la rédaction Heather Broughton, Ottawa, OntarioAssistant Managing Editor/Directrice adjointe de la rédaction Stella Wheatley, Ottawa, OntarioEditorial Coordinator/Coordonnatrice de la rédaction Avery Broughton, Ottawa, OntarioAdvertising and Sponsorship Consultant/Consultante, publicité et commandites Laima Laffitte, Wendover, Ontario

Published monthly by/ Publication mensuelle deCanadian Veterinary Medical Association

The editors and staff of The Canadian Veterinary Journal are pleased to have as readers student veterinarians at Canadian veterinary colleges! The production and distribution of student

subscriptions is made possible through the generous sponsorship of Scotiabank

Les rédacteurs et le personnel de La Revue vétérinaire canadienne sont heureux de compter les étudiants en médecine vétérinaire des collèges vétérinaires au Canada au nombre de leurs lecteurs. La production et

la distribution des abonnements des étudiants ont été rendues possible grâce au généreux soutien de Banque Scotia

STUDENT SUBSCRIPTIONS/ABONNEMENTS DES ÉTUDIANTS


ADVANCING YOUR ISSUES, YOUR CONCERNS AND YOUR PROFESSIONAL INTERESTS.

INFLUENCE

As a CVMA member you benefit from…

• Engagement with Government and key stakeholders to influence policy decisions

• International relations to provide the Canadian veterinary perspective• Media and public relations to provide balanced and trustworthy information

and to promote veterinary professionals• Position statements on animal welfare and national veterinary issues• Codes of practice for Canadian kennel and cattery operations,

and for the care and handling of farm animals• Member consultations and online discussions on key veterinary issues• Pan-Canadian Framework for Professional Standards in Veterinary

Oversight of Antimicrobial Use.

KNOWLEDGEKEEPING YOU CURRENT ON VETERINARY SCIENCE AND PRACTICE, RESEARCH, INNOVATION AND TRENDS TO ENHANCE YOUR LIFELONG LEARNING.


• The Canadian Veterinary Journal• Canadian Journal of Veterinary Research• Clinician’s Brief™ (free global digital edition)• CVMA national convention• CVMA Veterinary Summit• CVMA National Issues Forum• CVMA Emerging Leaders Program• CVMA Canadian Veterinary Reserve• Member e-newsletter ‘Online from 339’ • CVMA online continuing education portal• VetFolio® online educational resources (subscription discount)

SUPPORTING YOU THROUGH EVERY STAGE OF YOUR CAREER WITH ACCESS TO EXCLUSIVE PRACTICE TOOLS AND RESOURCES.

RESOURCES


• NEW! CVMA PetcardTM Program - financing options for your clients• NEW! MonerisTM preferred payment processing rates for CVMA members• MyVetStore.ca™ - CVMA web store solution for clinics• Practice owner’s economic survey• Individual practice diagnostic and valuation report• Provincial suggested fee guide• Associate compensation and benefits report• Compensation report for non-DVM staff• Compensation report for DVMs outside private practice• Practice management articles and resources• CVMA group insurance program• CVMA mentoring program• VetLaw Online™ legal advice column• CVMA Green Veterinary Practice and self-audit tool• Antimicrobial SmartVet mobile app• Veterinarian health and wellness resources• Early career DVM web resource hub• Guidelines for the successful employment of new veterinary graduates• Sedative, anaesthetic and pain management protocols posters• Guidelines for the legitimate use of compounded drugs in veterinary

practice• Antimicrobial prudent use guidelines for beef cattle, dairy cattle, poultry

and swine• Therapeutic decision cascade poster• Animal abuse resources for practitioners faced with this issue• Preventive healthcare, nutritional assessment and client education tools

and resources• Animal health week annual public awareness campaign

SAVINGSPUTTING MONEY IN YOUR POCKET AND DELIVERING MORE VALUE TO INCREASE YOUR PROFITABILITY.


• NEW! Mont Tremblant SkiMax (discount on lift tickets)• NEW! GoodLife Fitness Corporate Discount• NEW! HRdownloads™ discounts• Hotel discounts worldwide• National and Enterprise Rent-a-Car discounts• The Personal Insurance home and auto group savings• Scotiabank® business banking and lending solutions• The CVJ classified ads discount• Staples Advantage™ business products• Adtel® telephone hold service and digital signage• Petro-Canada SuperPass™ fuel/diesel/car wash discount• WSAVA World Congress (registration discount)• WVA Congress (registration discount)• Plumb’s Veterinary Drugs™ (subscription discount)

Your CVMA membership means MORE...

CANADIAN VETERINARY MEDICAL ASSOCIATION339 Booth Street, Ottawa (Ontario) K1R 7K1T • (800) 567-2862 • (613) 236-1162F • (613) [email protected]

For information about the many benefits and privileges of membership.

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President’s Message Le mot de la présidente

S i vous aviez fait naufrage sur une île déserte et que vous pouviez choisir seulement un compagnon, qui serait cette

personne? S’agirait-il de quelqu’un qui s’occuperait de vous, de quelqu’un dont vous aimez la compagnie ou de quelqu’un qui vous aiderait à quitter l’île? Si vous avez de la chance, peut-être que cette personne pourrait remplir ces trois rôles, et si vous avez beaucoup de chance, cette personne serait un technicien vétérinaire agréé (TVA). Y a-t-il un autre groupe de personnes dans notre profession qui est aussi attentionné, capable et résilient? Ces personnes très compétentes et engagées sont le ciment qui assure la cohésion de la médecine vétérinaire.

Lorsque j’ai terminé mon cours il y a 28 ans, la plupart des techniciens passaient leurs journées à nettoyer la clinique et à retenir les animaux. De nos jours, ils mettent en œuvre des protocoles d’anesthésie complexes, réalisent des interventions dentaires, placent des cathéters, opèrent les analyseurs sanguins, prennent des radiographies, remplissent des ordonnances et accomplissent des prouesses extraordinaires pour servir la clientèle. La plupart des vétérinaires savent que, avec un technicien compétent, ils peuvent effectuer le travail de deux vétérinaires et que, sans un technicien, nous peinons à réaliser le travail d’un vétérinaire. Les techniciens rehaussent la qualité des soins que nous fournissons à nos patients et à nos clients et ils atténuent quotidiennement notre charge de travail.

Presque toutes les provinces du Canada sont confrontées à une pénurie de techniciens vétérinaires. Le nombre de finissants dans les collèges est-il insuffisant pour répondre à la demande? Les salaires sont-ils trop bas pour offrir aux techniciens un niveau de vie acceptable? Pourquoi sommes-nous incapables de conserver les techniciens d’expérience à long terme en milieu de travail? Est-ce que les longues heures et le manque de personnel causent du stress et de l’épuisement professionnel? Avons-nous aidé les techniciens à fixer des objectifs et à avancer leur carrière afin qu’ils puissent tirer une plus grande satisfaction au travail? Comment pouvons-nous atteindre les personnes qui ont quitté le milieu et les encourager à revenir?

If you were stranded on a deserted island and could pick only one companion, who would it be? Would it be someone to

take care of you, someone whose company you enjoy or some-one to get you off of the island? If you’re lucky maybe one per-son would be all 3, and if you’re really lucky that person would be a registered veterinary technician (RVT). Is there any one group in our profession that is more kind, capable and resilient? These very skilled and committed individuals are the glue that holds veterinary medicine together.

When I graduated 28 years ago most technicians spent their day cleaning clinics and restraining animals. Today, they are implementing complicated anesthetic protocols, performing dentals, placing catheters, running blood analyzers, taking X-rays, filling prescriptions and performing amazing feats of customer service. Most veterinarians know that with a compe-tent technician we can do the work of 2 vets and without a tech we struggle to do the work of one. They increase the quality of care we provide our patients and clients and ease our workload day after day.

Almost every province in Canada faces a shortage of vet-erinary technicians. Are the numbers graduating from colleges inadequate to fill the demand? Are the wages too low to provide technicians with an acceptable standard of living? Why are we unable to retain experienced technicians long term in the work-place? Are long hours and understaffed clinics leading to stress and burnout? Have we helped technicians set goals and advance their careers so they can experience greater job satisfaction? How do we reach the individuals who have left the workforce and encourage them to return?

The average career for a technician is 5 years. The average wage for RVTs across Canada varies but most will earn between $20 and $25 per hour in a clinic setting. Many technicians face tough decisions after maternity leaves when it no longer makes financial sense to return to work and pay for childcare. When experienced technicians leave the workforce, planning to replace them with new graduates is no longer possible. There are simply

Our unsung heroes

Des héros méconnus

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.



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La durée moyenne d’une carrière de technicien est de cinq ans. Le salaire moyen des TVA varie au Canada, mais, pour la plupart des techniciens, il se situe entre 20 $ et 25 $ l’heure dans une clinique. Beaucoup de techniciens doivent faire des choix difficiles après les congés de maternité, lorsque la situation monétaire ne justifie pas le retour au travail en raison des coûts de la garde d’enfants. Lorsque des techniciens d’expérience quittent la profession, il n’est plus possible de planifier leur remplacement par des finissants. Il n’y a simplement pas assez de diplômés et il est impossible de remplacer les années d’expérience. Nous devons trouver une façon de rémunérer les techniciens pour leur travail et la valeur financière qu’ils représentent pour nos entreprises afin qu’ils puissent envisager l’avenir au-delà de cinq ans. Il doit y avoir des façons de reconnaître et de récompenser le rendement exceptionnel. On mentionne souvent que le modèle financier de la médecine vétérinaire empêche les employeurs de rémunérer les TVA à leur juste valeur. Si tel est le cas, alors nous devons trouver des méthodes de remplacement pour les rémunérer, notamment le partage des profits, des régimes de retraite, des programmes de bonis ou peut-être l’accès à des services de garderie abordables. Il doit y avoir une façon d’aider les techniciens à gagner leur vie tout en permettant aux cliniques vétérinaires de croître.

En 2017, 692 techniciens ont obtenu leur diplôme à l’un des 19 collèges agréés du Canada. En 2014, La RVC publiait mensuellement une moyenne de 35 postes de TVA et, jusqu’à ce jour en 2018, la moyenne s’établit à 106 postes. Le nombre de diplômés n’a certainement pas triplé au cours des quatre dernières années. Comment pouvons-nous donc aborder ce problème? Un financement inadéquat des collèges et de l’infrastructure empêche une hausse du nombre de finissants qui permettrait de répondre aux besoins de main-d’œuvre. Tous les 15 mois, Olds College produira une nouvelle promotion de finissants, mais la plupart des techniciens souhaiteraient que la durée du programme passe de deux à trois années. Le curriculum suffit déjà à peine à enseigner les compétences techniques requises en milieu clinique. La plupart des collèges ont des programmes de communication et il serait souhaitable de les élargir et d’intégrer des scénarios et de la formation sur la gestion des situations difficiles en milieu de travail. Par ailleurs, il a été démontré que les étudiants réussiront mieux en milieu clinique s’ils ont accès à des animaux au début de leur formation scolaire. Est-ce que tous les programmes offrent un tel accès? Acceptons-nous les bons candidats? Certains programmes adoptent toujours une approche de premiers arrivés, premiers servis pour les admissions une fois que les exigences scolaires ont été satisfaites. Cette approche permet-elle d’admettre les meilleurs candidats au programme? Est-il temps d’envisager un processus d’entrevues durant la sélection des étudiants, même si cela engendrerait un coût important au niveau des ressources humaines?

Nous savons que nous devons attirer des personnes exceptionnelles dans les programmes techniques et les rémunérer de manière adéquate pour leur travail et la valeur qu’il contribue. Alors, que pouvons-nous faire pour empêcher l’exode des techniciens de la profession? Les penseurs critiques et les résolveurs de problèmes doivent se sentir impliqués dans leur travail et être actifs au sein de leur profession pour éprouver une satisfaction au travail. L’inclusion des techniciens au sein de nos

not enough graduates and there is no way to replace the years of experience. We must find a way to compensate technicians for the work they do and the economic value they add to our busi-nesses so they can see a future past 5 years. There must be ways of recognizing and then rewarding exceptional performance. It is often mentioned that the financial model of veterinary medicine prevents employers from paying RVTs their true worth. If this is the case then we need to find alternate methods of compensation like profit sharing, pension plans, bonus programs or perhaps access to affordable daycare. There has to be a way to help tech-nicians earn a living while allowing veterinary clinics to grow.

In 2017, 692 technicians graduated from Canada’s 19 accred-ited colleges. In 2014, The CVJ had a monthly average of 35 job postings for RVTs compared with an average of 106 postings so far in 2018. The number of graduates has certainly not tripled in the past 4 years so how do we address this problem? Funding for colleges and infrastructure concerns prevent graduate numbers from increasing quickly enough to meet workforce demands. Olds College will be graduating a class every 15 months yet most technicians would like to see the program expanded from a 2- to a 3-year program. The curriculum is already struggling to keep up with the technical skills that are required clinically. Most colleges have a communications program yet it would be nice to see these expanded to incorporate mock scenarios and instruction on handling difficult workplace scenarios. It has been shown that students will be more successful in a clinical setting when they have early access to animals while in school. Do all programs have such access? Are we accepting the right candi-dates? Some programs still have a first-come first-serve approach to admissions once minimum academic requirements are met. Does this let the best applicants into the program? Is it time to look at an interview process during the selection of students even though there would be a significant human resource cost?

We know we need to attract great people to the technical programs and then pay them appropriately for their work and the value they bring. So how then do we keep technicians in the workforce? Critical thinkers and problem solvers need to be engaged and active in their profession to experience job satis-faction. Having technicians be part of provincial and national veterinary associations has been a great start. Let’s get better at letting them know about certification programs and specialties in which they can become involved. We need to have defined avenues for advancement and long-term, career-sustaining goals so technicians can see beyond 5 years. Professional growth is an intrinsic reward. So let’s help the heroes of veterinary medi-cine — the unrecognized mentors to so many veterinarians, the grief counsellors to so many clients and those who offer so much kind advice behind the scenes. For so many years technicians have had veterinarians’ backs, it’s time now to have theirs. ■

Terri Chotowetz



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associations provinciales et nationales de médecins vétérinaires représente un excellent point de départ. Mais, nous devons aussi nous améliorer afin de les renseigner à propos des programmes de certification et des spécialités qu’ils peuvent suivre. Nous devons avoir des avenues définies pour l’avancement et des objectifs de carrière à long terme afin que les techniciens puissent penser au-delà de cinq ans. La croissance professionnelle est une récompense intrinsèque. Nous devons aider les héroïnes et

héros de la médecine vétérinaire — les mentors méconnus de tant de vétérinaires, les conseillères et conseillers en deuil de tant de clients et celles et ceux qui offrent des conseils attentionnés dans les coulisses. Pendant tant d’années, les techniciens nous ont appuyés et il est maintenant temps pour nous de leur rendre la pareille. ■

Terri Chotowetz

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Veterinary Medical Ethics Déontologie vétérinaire

Ethical question of the month — November 2018Your beef cattle clients know from experience that foot-rot responds well to antibiotic treatment. Recently, your clients have begun to treat their cattle with foot-rot using a dart gun. Producers find this approach time efficient compared with moving affected animals into a chute or treatment pen. You are aware of published research demonstrating that dart guns are not as effective as the standard syringe injection procedure when dose and injection site are compared (1,2). You prescribe and dispense medication with clear instructions regarding dose and injection technique while aware that your clients are using dart guns to treat their animals. New antibiotic prescription rules in Canada place a greater responsibility on you than previously to ensure appropriate antibiotic use in livestock. Should you continue to dispense antibiotics to your beef cattle clients, fully aware that these drugs will be used in an extra-label manner that you do not recommend?

References1. Coetzee JF, Kleinhenz MD, Magstadt DR, et al. Pneumatic dart delivery of tulathromycin in calves results in lower antimicro-

bial concentrations and increased biomarkers of stress and injection site inflammation compared with subcutaneous injection. J Anim Sci 2018;96:3089–3101.

2. Hairgrove T, Gill R, Waters C, et al. Does dart gun delivery of antibiotics cause changes in drug disposition or meat quality? Proceedings of the American Association of Bovine Practitioners, Charlotte, North Carolina, 2016:167–168.

Question de déontologie du mois — Novembre 2018Vos clients éleveurs de bovins de boucherie savent d’expérience que la fièvre aphteuse répond bien au traitement antibiotique. Récemment, vos clients ont commencé à traiter leurs bovins atteints de piétin à l’aide d’un fusil à injection. Les éleveurs trouvent que cette approche est rapide et ils la préfèrent au déplacement des animaux affectés dans un couloir de contention ou un enclos de traitement. Vous êtes au courant que des études de recherche ont démontré que les fusils à injection ne sont pas aussi efficaces que les injections de seringue lorsque l’on compare la dose et le site d’injection (1, 2). Vous prescrivez et distribuez des médicaments en donnant des directives claires concernant la dose et la technique d’injection, tout en sachant que vos clients utilisent des fusils à injection pour traiter leurs animaux. Les nouvelles règles de prescription des antibiotiques au Canada vous imposent maintenant une responsabilité accrue afin d’assurer une utilisation appropriée des antibiotiques chez le bétail. Devriez-vous continuer à distribuer des antibiotiques à vos clients qui sont éleveurs de bovins de boucherie en sachant que ces médicaments seront utilisés d’une manière en dérogation des directives de l’étiquette que vous ne recommandez pas?

Renvois1. COETZEE, J.F., M.D. KLEINHENZ, D.R. MAGSTADT et al. «Pneumatic dart delivery of tulathromycin in calves results

in lower antimicrobial concentrations and increased biomarkers of stress and injection site inflammation compared with subcutaneous injection», J Anim Sci, 2018, vol. 96, p. 3089–3101.

2. HAIRGROVE, T., R. GILL, C. WATERS et al. «Does dart gun delivery of antibiotics cause changes in drug disposition or meat quality?», Proceedings of the American Association of Bovine Practitioners, Charlotte, Caroline du Nord, 2016, p. 167–168.

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

L’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.



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Ethical question of the month — August 2018Emergency on-farm slaughter is meant to provide a practical solution to situations in which an animal cannot be humanely transported to a slaughter facility but is fit for human consumption. Emergency slaughter involves killing and bleeding the animal on-farm before transporting the carcass to a meat plant for processing. This practice allows the farmer to recover some of the animal’s value and removes the incentive to “hang on” to a compromised animal hoping it improves so it can be transported alive to a slaughter facility. Emergency slaughter provisions therefore, can reduce the risk of unnecessary suffering in livestock. For example, if a feedlot steer seriously injures a limb on a weekday morning, under ideal conditions, the steer can be isolated and slaughtered on-farm within hours of the incident. However the possibility to recover some value from an injured animal means that the same injury on a Friday evening may cause the animal to be held over the weekend without treatment until an abattoir is available to handle the carcass. In such cases the emergency slaughter option could be seen as contributing to animal suffering. How should one balance the benefits of emergency slaughter with the increase in suffering it may create in other situations?

Question de déontologie du mois — Août 2018Un abattage d’urgence à la ferme sert de solution pratique dans les situations où un animal ne peut pas être transporté sans cruauté vers un abattoir mais est toujours propre à la consommation humaine. L’abattage d’urgence consiste à tuer et à saigner l’animal à la ferme avant le transport de la carcasse à l’établissement de traitement des viandes. Cette pratique permet à l’agriculteur de récupérer une partie de la valeur de l’animal et supprime l’incitatif de conserver un animal fragilisé dans l’espoir que son état s’améliore afin qu’il puisse être transporté vivant à un abattoir. Par conséquent, le protocole d’abattage d’urgence peut réduire le risque de souffrances inutiles chez le bétail. Par exemple, si un bouvillon du parc d’engraissement se blesse gravement à un membre un jour de semaine, dans des conditions idéales, le bouvillon pourra être isolé et abattu à la ferme quelques heures après l’incident. Cependant, la possibilité de récupérer une partie de la valeur d’un animal blessé signifie que, si la même blessure se produit un vendredi soir, il faudra peut-être garder l’animal sans traitement pendant la fin de semaine jusqu’à ce qu’un abattoir soit disponible pour traiter la carcasse. Dans de tels cas, l’option d’abattage d’urgence pourrait être considérée comme un élément contribuant aux souffrances de l’animal. Comment devrait-on équilibrer les avantages de l’abattage d’urgence avec les souffrances accrues qu’il peut occasionner dans d’autres situations?

Responses to the case presented are welcome. Please limit your reply to approximately 50 words and forward along with your name and address to: Ethical Choices, c/o Dr. Tim Blackwell, 6486 E. Garafraxa, Townline, Belwood, Ontario N0B 1J0; telephone: (519) 846-3413; fax: (519) 846-8178; e-mail: [email protected] ethical questions of the month are also welcome! All ethical questions or scenarios in the ethics column are based on actual events, which are changed, including names, loca-tions, species, etc., to protect the confidentiality of the parties involved.

Les réponses au cas présenté sont les bienvenues. Veuillez limiter votre réponse à environ 50 mots et nous la faire parvenir par la poste avec vos nom et adresse à l’adresse suivante : Choix déontologiques, a/s du Dr Tim Blackwell, 6486, E. Garafraxa, Townline, Belwood (Ontario) N0B 1J0; téléphone : (519) 846-3413; télécopieur : (519) 846-8178; courriel : [email protected] propositions de questions déontologiques sont toujours bienvenues! Toutes les questions et situations présentées dans cette chronique s’inspirent d’événements réels dont nous modifions certains éléments, comme les noms, les endroits ou les espèces, pour protéger l’anonymat des personnes en cause.

Comments/Commentaires :

Name/Nom :

Address/Adresse :



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An ethicist’s commentary on emergency on-farm slaughterThere is nothing inherently problematic about on-farm slaugh-ter. In fact, it has sometimes been argued that the most humane meat possible is derived from large game ranches. For example, in Africa, these ranches are essentially huge tracts of land representing natural habitat for the animals in question, and separated from wilderness only by sturdy fences. Expert hunters are dispatched to kill the animal with minimal chase and the attendant stress. Few people would argue that a food animal, particularly one that lives under extensive situations, is not better off when slaughter takes place in its familiar habitat. Transport of long duration, with its attendant discomfort as a result of crowding, extremes in temperature, problematic ventila-tion, and fear is a main stressor in a farm animal’s life.

Few people would argue with the claim that the fundamental obligations to an animal used for human purposes are a decent life, and a quick, decent, painless death accompanied by mini-mal, and ideally no, suffering. Indeed, much has been done to change slaughterhouses from the horrific places described so vividly by Upton Sinclair, particularly in the cattle business. (On the other hand, as we discussed in a recent column, much remains to be done particularly with regard to the stunning of poultry prior to slaughter.)

I learned firsthand about rancher commitment to a good death during a cattlemen’s meeting in the 90s discussing the shipping of “downer” animals, i.e., animals which were shipped while sick or severely injured, leading to great suffering. During a gap in the discussion, one rancher got everyone’s attention when he said, “we should eat our mistakes, not ship them!” This turned the tide of the discussion, and the ranchers agreed

to support what became the strongest downer bill in the United States. Understanding full well the mercenary motivations of someone who would ship a downer animal, the bill stipulated that if someone does ship a sick or injured animal, the slaugh-terhouse veterinarian will immediately euthanize the animal and the animal will be shipped back to the owner along with the bill for the euthanasia and the shipping! Predictably, the law has worked well.

The current case has no conceptual or deeply ethical issues. Everyone has agreed that on-farm euthanasia is the proper solu-tion. The only problem is a technical and financial one — the slaughterers do not work on weekends. The point, therefore, is to pay them enough to overcome their reluctance for week-end work. That tactic has worked with plumbers, mechanics, electricians, and innumerable other skilled workers. Alleviating the animal suffering is at least as important as getting a toilet to flush properly. One approach would be for all the farmers in the area served to chip in, collectively negotiate with the slaughterers, and make occasional weekend work in the case of emergency a condition of non-weekend employment. There are innumerable ways to do this; the key point is it can be done and should be done. Given the societal ethic regarding animal treatment, the extra cost must be seen as the price of doing busi-ness in today’s world. The public perception price of leaving the animal to suffer over a weekend far outweighs that cost, and that cost can in any case be passed on to consumers.

Bernard E. Rollin, PhD

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ONLINE: Go to canadianveterinarians.net and click My Portal (email address and password required). You’ll find your information under My Account > My Profile.

EMAIL: Send us your updated information at [email protected].

CALL US: 1-800-567-2862 between 8AM – 5PM (ET). We’ll update your information for you.

New address? New job? Haven’t heard from the CVMA lately?


The quest for an intellectual challenge after moving to Singapore led veterinarian Anna Kokosinska to further study.

Wanting to explore her new home base and the surrounds of Asia rather than having to work weekends and being on call led Anna sought to spend her time more wisely with distance learning, leading her to Massey University’s Master of Veterinary Medicine (MVM).

“Furthering my veterinary career while still having the flexibility to travel and spend evenings with my husband and two rescue dogs, I chose to start the MVM programme,” she says.

At a crossroads in her career, Anna was also deciding if she wanted to pursue further training as an Anatomic Pathologist or continue as a veterinarian in local practice.

“I felt the MVM training would give me the edge required for selection into the highly competitive residency training, and I was right!

“The MVM programme not only got me noticed and selected into an Anatomic Pathology residency, but also opened the door to some of the best connections not only at Massey, but also globally with the Pathology world,” she says.

Completing the course from Singapore, Anna valued the flexibility of the distance learning with Massey.

“It allowed me to manage my own work hours in and around other commitments. The programme is extremely flexible and the online resources such as recorded lectures were very useful, so there were very few schedule commitments.

“There’s a wide range of units on offer with flexibility in timeline and required contact hours. I really felt like I was able to choose units that suited my intended specialisation and areas of interest,” she says.

Another stand out for Anna were Massey’s educators, particularly for her Cardiorespiratory and Endocrinology units.

“Both are world experts in their fields and make these subjects far easier to tackle. By the end of these courses, I could confidently interpret an ECG and an echo, and those complicated Addison’s and Cushing’s cases no longer scared me!”

Anna feels the MVM has made a significant impact on her veterinary career and says, “Electing to complete the research component of the Masters was instrumental in broadening my professional network, not only throughout New Zealand but also globally given Massey’s breadth of contacts and partnerships.”

Through introductions and recommendations from the Massey University faculty, Anna is about to commence the final year of her Anatomic Pathology residency at the University of Georgia.

“I feel without the contacts that I made during the MVM course, this would not have been possible,” she says.

Find out more about Massey University’s Master of Veterinary Medicine at massey.ac.nz/mvm.

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1. Cats require which of the following nutrients that are found naturally in meat sources but NOT in plant sources?A. Taurine, arachidonic acid, vitamin AB. Taurine, arachidonic acid, biotinC. Arachidonic acid, vitamin A, vitamin ED. Taurine, vitamin E, folic acidE. Arachidonic acid, vitamin E, folic acid

2. All EXCEPT which of the following are potential presenting complaints by the owner of a dog with laryngeal paralysis? A. Inspiratory dyspneaB. Swelling under tongueC. CoughingD. Change in barkE. Collapse

3. Which of the following is the usual first line of treatment for TCC of the bladder located in the trigone?A. Surgical excision of the tumorB. Cystectomy and creation of an external bag for urine

collectionC. Radiation therapyD. Piroxicam or another NSAIDE. Chemotherapy with platinum compounds

4. A 7-year-old Clydesdale stallion is being evaluated for moderate-to-intense pruritus of the legs. Examination reveals crusted, ulcerated lesions on the fetlocks and pas-terns. Skin scrapings reveal large mites with 4 pairs of legs and short pedicles ending in suckers. Which of the following is the most appropriate recommendation for control of the infestation?A. Treat all contact animals.B. Quarantine the barn.C. Improve nutrition.D. Improve hygiene.E. Treat the affected animals.

1. De quels éléments suivants retrouvés naturellement dans les viandes et NON dans les plantes les chats ont-ils besoin?A. taurine, acide arachidonique, vitamine A;B. taurine, acide arachidonique, biotine;C. acide arachidonique, vitamine A, vitamine E;D. taurine, vitamine E, acide folique;E. acide arachidonique, vitamine E, acide folique.

2. Laquelle des manifestations suivantes NE représente PAS un problème potentiel mentionné par le propriétaire d’un chien souffrant de paralysie laryngée?A. dyspnée inspiratoire;B. enflure sous la langue;C. toux;D. changement de l’aboiement du chien;E. collapsus.

3. Lequel des traitements suivants constitue le traitement de première ligne du carcinome des cellules de transition localisé dans le trigone de la vessie?A. excision chirurgicale de la tumeur;B. cystectomie et pose d’un sac externe de récupération de

l’urine;C. radiothérapie;D. piroxicam ou un autre anti-inflammatoire non stéroïdien;E. chimiothérapie à l’aide de composés de platine.

4. On fait l’examen d’un étalon de race Clydesdale âgé de 7 ans à cause de prurit modéré à intense aux membres. L’examen révèle des lésions croûteuses et ulcérées sur les boulets et les paturons. Les raclages de la peau démontrent de gros acariens avec 4 paires de pattes et de courts pédicules se terminant par des ventouses. Laquelle des recommandations suivantes est la plus appropriée pour prendre l’infestation en charge?A. traiter tous les animaux qui sont en contact;B. placer la ferme en quarantaine;C. améliorer la nutrition;D. améliorer l’hygiène;E. traiter tous les animaux malades.

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5. Which of the following diseases are associated with Mycoplasma spp. and are common on a dairy farm?A. Otitis interna, pneumoniaB. Polyarthritis, pneumoniaC. Otitis interna, polyarthritisD. Puerperal metritis, pneumonia

5. Lesquelles des maladies suivantes sont associées à Mycoplasma sp. et sont communes sur une ferme laitière?A. otite interne et pneumonie;B. polyarthrite et pneumonie;C. otite interne et polyarthrite;D. métrite puerpérale et pneumonie.

Questions and answers were derived from Review Questions and Answers for Veterinary Boards 2nd ed., a 5-volume series including Basic Sciences, Clinical Sciences, Small Animal Medicine and Surgery, Large Animal Medicine and Surgery, and Ancillary Topics, by kind permission of the publisher, Mosby–Year Book, Inc., St. Louis, Missouri.

Les questions et les réponses sont extraites de Review Questions and Answers for Veterinary Boards 2nd ed., une série de cinq volu mes qui comprend Basic Sciences, Clinical Sciences, Small Animal Medicine and Surgery, Large Animal Medicine and Surgery, et Ancillary Topics, avec l’aimable permission de l’éditeur, Mosby–Year Book, Inc. de St. Louis (Missouri).

(See p. 1180 for answers./Voir les réponses à la page 1180.)

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N E W S | N O U V E L L E S

Bienvenue et bonne rentrée aux étudiants en médecine vétérinaire!

Je souhaite une bonne rentrée à tous les étudiants en médecine vétérinaire ainsi que de chaleureuses félicitations aux nouveaux

étudiants de première année! Bienvenue au monde de la médecine vétérinaire, nous sommes excités de vous compter parmi nous!

J’espère que vous avez tous passé un été agréable et que vous êtes excités par les possibilités offertes par l’année universitaire. Nous sommes tellement fortunés au sein de notre profession d’avoir accès à un vaste éventail de comités, de clubs et d’activités afin de donner libre cours à nos passions individuelles. Cette année, je vous encourage à participer aux activités organisées à votre école, car la période des études s’écoulera rapidement et il faut donc vous s’assurer d’en tirer le maximum à votre façon!

À titre d’étudiants de médecine vétérinaire, nous sommes tous des membres à part entière de l’Association canadienne des médecins vétérinaires (ACMV) et nous avons droit à tous les avantages et à toutes les possibilités de l’ACMV. Je fais partie du Comité des Étudiants de l’ACMV (ÉACMV) à titre de représentante de l’Ontario Veterinary College. Le Comité des ÉACMV se compose de deux représentants étudiants de chaque école de médecine vétérinaire qui aident à organiser et à gérer les activités étudiantes comme les présentations d’assurance, la présentation Une Voix, l’Atelier de leadership étudiant des ÉACMV, le Symposium des ÉACMV et plus encore! Voici une récapitulation rapide de certaines activités récentes et prochaines des ÉACMV cette année.

En septembre, chaque école a organisé la Cérémonie d’accueil à la profession pour la nouvelle promotion. Les nouveaux étudiants ont été accueillis à la profession et ont reçu leur propre sarrau brodé de l’ACMV et leur insigne d’identité personnalisé. N’oubliez pas de regarder les photos des promotions dans la section des nouvelles Web de l’ACMV!

Le Western College of Veterinary Medicine a déjà été occupé pendant cette année universitaire car il a organisé l’Atelier de leadership étudiant (ALE) annuel en octobre. L’ALE, qui a été fondé par des représentants du Comité des ÉACMV et est présenté par le Dr Rick DeBowes, constitue un événement annuel qui se déroule selon une rotation entre les cinq écoles de médecine vétérinaire et enseigne aux étudiants l’importance du leadership et du travail en équipe en médecine vétérinaire. Cet atelier est l’équivalent du Programme des futurs leaders, un atelier interactif pour les vétérinaires praticiens qui vise à favoriser des liens plus étroits entre les collègues par diverses activités de communication et de leadership.

N’oubliez pas d’inscrire les dates des 18 et 19 janvier à votre calendrier, car le Symposium 2019 des ÉACMV aura lieu à la Faculté de médecine vétérinaire à Saint-Hyacinthe, au Québec. Le Symposium des ÉACMV est un événement annuel qui se déroule

Welcome (Back) Student Veterinarians!

I am extending a warm welcome back to all of the returning student veterinarians, and big congratulations to all of the new

first-year students! Welcome to the world of veterinary medicine; we are so excited to have you!

I hope each of you had an enjoyable summer and are excited about this academic year and all of the opportunities it will pres-ent. Within this profession we are so fortunate to be offered a wide variety of committees, clubs, and events to enhance each of our own passions. This year, I encourage you to become involved with your school; our time as students quickly flies by, so be sure to make the most of it — in whatever way that appeals to you!

As veterinary students, we are all full Canadian Veterinary Medical Association (CVMA) members, and entitled to all the CVMA benefits and opportunities. I am a part of the Students of the CVMA (SCVMA) Committee as the Ontario Veterinary College representative. The SCVMA Committee consists of 2 student representatives from each veterinary college who help organize and run student-focussed events such as insurance lunch-and-learns, the One Voice presentations, the SCVMA Student Leadership Workshop, the SCVMA Symposium, and more! Here is a quick recap of some recent and upcoming events happening with the SCVMA this year.

Brittany O’Brien



N à tour de rôle à chacune des écoles de médecine vétérinaire canadienne et tous les étudiants en médecine vétérinaire du pays sont invités à participer à des conférences, à des laboratoires de travaux pratiques et à des excursions en lien avec la médecine vétérinaire. L’an dernier, le Symposium s’est tenu à l’Atlantic Veterinary College et a connu un immense succès! Nous avons eu l’occasion de réseauter avec des étudiants de toutes les régions du Canada et de participer à une foule d’activités excitantes (comme la nécropsie d’un dauphin en gestation). Les écoles organisent des activités uniques chaque année et il y aura donc des activités excitantes qui répondront à tous les goûts!

Si vous avez des questions à propos de l’ACMV, des ÉACMV ou des autres activités prochaines, veuillez ne pas hésiter à contacter le représentant du Comité des ÉACMV de votre école. De plus, veuillez vous joindre à la page Facebook des ÉACMV, suivez les ÉACMV sur Instagram (@scvma.eacmv) et lisez le bulletin semestriel des ÉACMV «En direct du 339 — édition étudiante» pour garder le contact et demeurer au courant des enjeux vétérinaires nationaux. Grâce à votre adhésion à l’ACMV, vous pourrez aussi avoir accès à des rabais hôteliers, à une réduction sur un abonnement à GoodLife Mise en forme et à un abonnement gratuit à La Revue vétérinaire canadienne. Consultez le site Web de l’ACMV pour trouver une liste complète des initiatives étudiantes et assurez-vous de profiter de vos avantages en tant qu’étudiant de l’ACMV!

Je vous offre mes meilleurs vœux de succès pour l’année universitaire. Continuez à poursuivre vos rêves, travaillez fort et saisissez les occasions qui se présentent — mais, surtout, rappelez-vous de bien profiter de votre passage à l’école de médecine vétérinaire!

(par Brittany O’Brien, représentante des ÉACMV, Ontario Veterinary College)

This past September, each College hosted their Professional Welcoming Ceremony for the incoming class. Each new student was welcomed into the profession and presented with their own embroidered CVMA lab coat and personalized name tag — be sure to check out each of the class photos in the CVMA web news section!

The Western College of Veterinary Medicine has already been busy this school year, hosting the annual Student Leadership Workshop (SLW) this past October. The SLW, founded by past SCVMA Committee representatives and presented by Dr. Rick DeBowes, is an annual event that rotates through the 5 veteri-nary colleges and teaches students the importance of leadership and teamwork in veterinary medicine. This workshop mirrors the Emerging Leaders Program, an interactive workshop for prac-ticing veterinarians that helps bring colleagues closer together through different communication and leadership activities.

Be sure to mark your calendars because on January 18 and 19, the 2019 SCVMA Symposium will be held at the Faculté de médecine vétérinaire in Saint-Hyacinthe, Québec. The SCVMA Symposium is an annual event that rotates through each of the Canadian veterinary colleges, and invites veterinary students from across the country to take part in lectures, wet labs, and excursions pertaining to veterinary medicine. Last year, the Symposium was held at the Atlantic Veterinary College and was a huge success! We had the opportunity to network with students from across Canada and participate in countless exciting activities (such as a pregnant dolphin necropsy). Each school organizes unique events every year, so there is sure to be something exciting for everyone!

If you have any questions about the CVMA, SCVMA, or any upcoming events, please do not hesitate to reach out to your college’s SCVMA Committee representative. Also, join the SCVMA Facebook page, follow the SCVMA on Instagram (@scvma.eacmv), and read the bi-annual SCVMA eNewsletter “Online from 339 — Student Edition” to stay connected and informed on national veterinary issues. With your CVMA membership, you also get access to hotel discounts, a GoodLife Fitness membership discount, and a free subscription to The Canadian Veterinary Journal. Check out the CVMA website to find a full list of all student initiatives, and make sure to take advantage of your benefits as a Student of the CVMA!

I wish you the best of luck with this academic year. Continue to chase your dreams, work hard and seize every opportunity — but most importantly remember to enjoy your journey throughout vet school!

(by Brittany O’Brien, SCVMA Representative, Ontario Veterinary College)



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L’Association canadienne des médecins vétérinaires (ACMV) appuie vivement la participation des vétérinaires à l’approche

Une seule santé car ils jouent un rôle clé dans l’amélioration de la santé et du bien-être des animaux qu’ils traitent d’une manière qui protège et appuie aussi la santé humaine et un environnement sain.

L’approche Une seule santé est particulièrement pertinente pour l’élaboration de stratégies de collaboration pour l’utilisation responsable des antimicrobiens, ce qui soutient ainsi le contrôle de l’antibiorésistance.

«L’antibiorésistance est reconnue comme une menace grandissante partout dans le monde. Le gouvernement fédéral a notamment répondu à cette menace à l’échelle nationale en mettant en œuvre des modifications aux politiques et aux règlements qui affecteront l’utilisation des antimicrobiens importants sur le plan médical chez les animaux» dit la présidente de l’ACMV, la Dre Terri Chotowetz. «L’Association canadienne des médecins vétérinaires a participé activement aux activités visant à appuyer une nouvelle approche pour la surveillance vétérinaire de l’utilisation des antimicrobiens.»

En février 2018, l’ACMV a entrepris la deuxième phase de deux initiatives qui appuient la stratégie mondiale et nationale de réduction de l’utilisation des antimicrobiens pour aborder, respectivement, l’antibiogouvernance et la surveillance de l’utilisation des antimicrobiens chez les animaux.

Les activités du projet se sont concentrées sur la conception d’outils pratiques prêts à livrer afin d’appuyer les vétérinaires dans l’utilisation prudente des antimicrobiens pour les six groupes d’espèces définis — porcs, volaille, bovins de boucherie, bovins laitiers, petits ruminants et animaux de compagnie — ainsi que sur la conceptualisation, la conception et la proposition d’une initiative de surveillance vétérinaire de l’utilisation des antimicrobiens qui portera d’abord sur les aliments du bétail.

Les deux initiatives ont été intégrées dans un atelier visant à identifier des occasions où l’antibiogouvernance peut aider à cibler les activités de surveillance et, à l’inverse, où les données de surveillance peuvent aider à appuyer les activités d’antibiogouvernance. Les participants à l’atelier incluaient des praticiens vétérinaires, des organismes de réglementation de la médecine vétérinaire, des représentants des gouvernements fédéral et provinciaux, des représentants de l’industrie (producteurs et industries des aliments du bétail et de la santé animale) et des universitaires.

Pendant l’été 2018, un projet pilote de l’outil d’antibiogouvernance en ligne a été mis à l’essai dans des régions et des secteurs agricoles ciblés du Canada.

Ces deux initiatives ont commencé au début de 2017, grâce au soutien financier de l’Agence canadienne d’inspection des aliments et d’Agriculture et Agroalimentaire Canada. L’ACMV sollicitera des fonds additionnels afin de pleinement développer et mettre en œuvre les résultats découlant de ces projets.

The Canadian Veterinary Medical Association (CVMA) strongly supports the involvement of veterinarians in One

Health as they play a key role in improving the health and wel-fare of the animals they treat in a manner that also protects and supports human health and a healthy environment.

The One Health approach is particularly relevant to the development of collaborative strategies for responsible antimicro-bial use (AMU), thereby supporting the control of antimicrobial resistance (AMR).

“Antimicrobial resistance is recognized as a growing threat around the world. One response to this on a national level has been the upcoming federal government policy and regulatory changes affecting the use of medically important antimicrobials in animals,” says CVMA president, Dr. Terri Chotowetz. “The Canadian Veterinary Medical Association has been actively engaged in activities intended to support a new approach towards veterinary oversight of antimicrobial use.”

In February 2018, the CVMA undertook the 2nd phase of 2 initiatives that support the global and national strategy to reduce AMR and to address, respectively, antimicrobial steward-ship and antimicrobial use surveillance in animals.

Project activities focused on developing ready-for-delivery, practical tools to assist veterinarians in the prudent use of antimicrobials for 6 defined species groups — swine, poultry, beef, dairy, small ruminants and companion animals, as well as conceptualizing, designing and proposing a pilot veterinary AMU surveillance initiative focusing initially on animal feed.

The 2 initiatives were integrated in a workshop aimed at identifying opportunities where AMU stewardship can help target surveillance activities and, vice versa, where surveillance data can support stewardship activities. Workshop participants included veterinary practitioners, veterinary regulatory bodies, federal and provincial government representatives, industry officials (producers, feed and animal health industries) and academics.

A pilot of the online stewardship tool was tested throughout the summer of 2018 in targeted regions and agricultural sectors in Canada.

Both initiatives began in early 2017, with financial support from the Canadian Food Inspection Agency and Agriculture and Agri-Food Canada. The CVMA will seek additional funding to fully develop and implement the outputs developed under these projects

The CVMA actively participates on the sub-committee of the Canadian Animal Health Products Regulatory Advisory Committee (CAHPRAC) and continues to discuss the imple-mentation and impact of Health Canada’s moving all medi-cally important antimicrobials to the Prescription Drug List (by December 2018). The sub-committee members include, in addition to the CVMA, participants from the drug industry,

One Health Day and World Antibiotic Awareness Week Raise the Importance of a One Health Approach to Address Antimicrobial ResistanceLa Journée Une seule santé et la Semaine mondiale pour un bon usage des antibiotiques soulignent l’importance de l’approche Une seule santé afin d’aborder la résistance aux antimicrobiens



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Encan en ligne de Vétérinaires sans frontières

Vétérinaires sans frontières (VSF) offre de nouveau l’occasion à la collectivité

vétérinaire de soutenir la collectivité et de se procurer des articles intéressants! L’encan silencieux annuel de VSF commencera le 15 novembre et, une fois de plus, il y aura une foule d’articles intéressants offerts. Au cours des années antérieures, il y a eu des safaris photos en Afrique, des montres iWatches, l’inscription à des conférences vétérinaires et des vols dans des avions d’époque. Comme

d’habitude, les fonds recueillis aideront VSF à améliorer la vie des exploitants de petites fermes en Afrique et en Asie et assureront des soins vétérinaires présents aux collectivités éloignées dans le Grand nord canadien. Le 15 novembre, n’oubliez pas de visiter notre site (https://www.32auctions.com/VWB-VSF2018).

Veterinarians without Borders OnLine Auction

Ve te r inar i ans wi thout Border s /Vétérinaires sans frontières (VWB/VSF)

is once again offering the veterinary com-munity a chance to help others and get great stuff! VWB/VSF’s annual silent auction will start November 15 and once again there will be a whole range of excellent items to bid on. In previous years there have been African photo safaris, iWatches, registrations for veterinary conferences, and flights in vintage aircraft. As usual, the money will go to help VWB/VSF improve the lives of smallholder farmers in Africa and Asia, and bring consistent veterinary care to isolated communities in Northern Canada. On November 15 be sure to check in (https://www.32auctions.com/VWB-VSF2018).

L’ACMV participe activement au sous-comité du Comité consultatif canadien sur la réglementation des produits de santé animale (CCCRPSA) et continue de discuter de la mise en œuvre et de l’impact du transfert, par Santé Canada, de tous les antimicrobiens importants sur le plan médical à la Liste des drogues sur ordonnance (d’ici décembre 2018). Les membres du sous-comité incluent, en plus de l’ACMV, des participants de l’industrie pharmaceutique, des producteurs d’aliments, des producteurs d’aliments du bétail, Santé Canada et l’Agence canadienne d’inspection des aliments. Ce sous-comité reconnaît l’importance de la collaboration et du soutien de l’élaboration de plans pour une communication cohérente concernant la transition, l’engagement des intervenants et la mise en œuvre des principaux échéanciers. Visitez la section de la Surveillance vétérinaire de l’utilisation des antimicrobiens au Canada du site Web de l’ACMV (www.veterinairesaucanada.net), sous l’onglet Politiques et défense des intérêts, pour en apprendre davantage.

Le travail de l’ACMV appuiera l’engagement du Canada en vue de préserver l’efficacité des antimicrobiens maintenant et dans l’avenir, chez les animaux et les humains, comme le décrit le document Lutter contre la résistance aux antimicrobiens et optimiser leur utilisation : un cadre d’action pancanadien qui se trouve sur le site Web Canada.ca.

La Journée Une seule santé aura lieu le 3 novembre 2018. Le but consiste à rehausser la sensibilisation à l’égard de l’approche Une seule santé pour la gestion des problèmes de santé complexes touchant les humains, les animaux et l’environnement. Pour en savoir davantage, visitez le site Web de la One Health Commission (www.onehealthcommission.org).

La Semaine mondiale pour un bon usage des antibiotiques se déroulera du 12 au 18 novembre 2018. Elle vise à rehausser la sensibilisation à l’égard de la résistance mondiale aux antibiotiques et à encourager des meilleures pratiques parmi le grand public, les travailleurs de la santé et les décideurs politiques afin de freiner l’émergence et la propagation de l’antibiorésistance. Visitez le site Web de l’Organisation mondiale de la santé pour en savoir davantage.

food producers, feed producers, Health Canada, and the Canadian Food Inspection Agency. It recognizes the impor-tance of collaboration and helping to develop plans around consistent communication regarding the transition, engagement of stakeholders, and implementation of key timelines. Visit the Veterinary Oversight of Antimicrobial Use in Animals in Canada section of the CVMA website (www.canadianveterinarians.net), under the Policy & Advocacy tab, to find out more.

The work by the CVMA will help Canada’s commitment to conserve the effectiveness of antimicrobials now and into the future, in animals and humans, as described in the Tackling Antimicrobial Resistance and Antimicrobial Use: A Pan-Canadian Framework for Action that can be found on the Canada.ca website.

One Health Day takes place on November 3, 2018. The goal is to raise awareness of the One Health approach for managing complex health problems involving people, animals and the envi-ronment. For more information, visit the One Health Commission’s website (www.onehealthcommission.org).

World Antibiotic Awareness Week runs from November 12 to 18, 2018. It aims to increase awareness of global antibiotic resistance and to encourage best practices among the general public, health workers and policy makers to avoid the further emergence and spread of antibiotic resistance. Visit the World Health Organization website for more information.



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Chaque année, dans le cadre de son programme de prix, l’Association canadienne des médecins vétérinaires (ACMV)

reconnaît fièrement des personnes qui ont accompli des réalisations exceptionnelles et ont fait preuve d’un leadership exemplaire ainsi que d’un dévouement infatigable envers la collectivité vétérinaire du Canada. Les mises en candidature pour les Prix de l’ACMV 2019 seront acceptées jusqu’au 31 janvier 2019.

«Nous vous encourageons à mettre en candidature un collègue méritant à l’un des prix prestigieux de l’ACMV», dit la Dre Terri Chotowetz, présidente de l’ACMV 2018-2019. «Nous comptons sur les personnes sur le terrain, qui travaillent aux côtés de vétérinaires exceptionnels, pour nous aider à reconnaître ceux qui font une différence tous les jours. Veuillez nous aider à honorer ces vétérinaires exceptionnels qui œuvrent au pays.»

ADMISSIBILITÉ AUX PRIXLes personnes mises en candidature (sauf celles mises en candidature pour le titre de membre honoraire) doivent être membres en règle de l’ACMV pour être admissibles à la mise en candidature. Cependant, elles peuvent être mises en candidature par des non-membres de l’ACMV. Nous vous invitons à considérer la mise en candidature d’un collègue méritant à l’un des prestigieux prix de l’ACMV suivants :

Prix humanitaire de l’ACMVCréé par l’ACMV en 1986 et commandité par Merck Santé animale, ce prix reconnaît le leadership à l’égard du soin et du bien-être des animaux. Le prix, qui comporte une bourse de 1000 $ et une plaque, est décerné à un membre de l’ACMV dont le travail représente une contribution importante au bien-être des animaux.

Prix de l’industrie de l’ACMVCréé en 1996, le Prix de l’industrie de l’ACMV reconnaît et souligne publiquement le rôle de l’industrie en médecine vétérinaire. Ce prix reconnaît officiellement la contribution d’un membre de l’ACMV à l’avancement de la médecine vétérinaire.

Prix vétérinaire MerckÉtabli en 1985 et commandité par Merck Santé animale, ce prix est décerné à un membre de l’ACMV dont le travail en pratique de la production des animaux destinés à l’alimentation, en recherche clinique ou en sciences fondamentales représente une contribution importante pour l’avancement de la médecine et de la chirurgie des animaux destinés à l’alimentation, y compris la gestion de la santé du troupeau. Le prix comporte une bourse de 1000 $ et une plaque.

Prix du praticien des petits animauxCommandité par Petsecure assurance maladie pour animaux, ce prix est décerné à un membre de l’ACMV dont le travail en pratique des petits animaux, en recherche clinique ou en sciences fondamentales représente une contribution importante à l’avancement de la médecine ou de la chirurgie des petits

Each year, through its awards program, the Canadian Veterinary Medical Association (CVMA) proudly recognizes

individuals who have demonstrated significant accomplishments, exemplary leadership, and tireless commitment to Canada’s vet-erinary community. Nominations for the 2019 CVMA Awards are being accepted from now until January 31, 2019.

“We encourage you to nominate a deserving colleague for one of CVMA’s prestigious awards,” says Dr. Terri Chotowetz, 2018–19 CVMA president. “We depend on those in the field, working alongside outstanding veterinarians to help us acknowl-edge those who are making a difference every day. Please help us recognize exceptional veterinarians across our country.”

AWARD ELIGIBILITYAward nominees (excluding those nominated for Honorary Membership) must be current CVMA members to be eligible for nomination; however, they can be nominated by non-CVMA members. We invite you to consider nominating a deserving colleague for one of the following CVMA’s prestigious awards:

CVMA Humane AwardEstablished by the CVMA in 1986, and sponsored by Merck Animal Health, this award recognizes leadership in the care and well-being of animals. The award, consisting of $1000 and a plaque, is presented to a CVMA member whose work is judged to have contributed significantly to the welfare and well-being of animals.

CVMA Industry AwardInstituted in 1996, the CVMA Industry Award publicly acknowledges and celebrates the role of industry in veterinary medicine. The award formally recognizes a CVMA member for their contributions to the advancement of veterinary medicine.

Merck Veterinary AwardEstablished in 1985, and sponsored by Merck Animal Health, this award is presented to a CVMA member whose work in food animal production practice, clinical research, or basic sciences is judged to have contributed significantly to the advancement of food animal medicine and surgery, including heard health management. The award consists of $1000 and a plaque.

Small Animal Practitioner AwardSponsored by Petsecure Pet Health Insurance, this award is pre-sented to a CVMA member whose work in small animal practice, clinical research or basic sciences is judged to have contributed significantly to the advancement of small animal medicine, sur-gery, or the management of a small animal practice. The award consists of $1000 and a plaque.

CVMA Practice of the Year AwardEstablished in 2013, the Practice of the Year Award consists of $1000 and a plaque and is sponsored by Scotiabank, a leader in banking services for professionals. The award recognizes a

2019 CVMA Awards Nominations Are Open!Prix de l’ACMV 2019 Ouverture des mises en candidature!



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Prix de la pratique de l’année de l’ACMVInstauré en 2013, le Prix de la pratique de l’année comporte une bourse de 1000 $ et une plaque. Ce prix est commandité par la Banque Scotia, un leader au chapitre des services bancaires pour les professionnels. Le prix reconnaît l’équipe d’une pratique vétérinaire pour des réalisations exceptionnelles dans sa collectivité locale. Ces réalisations peuvent inclure l’innovation dans la prestation de services vétérinaires, l’engagement envers l’équilibre travail-vie, une participation communautaire ou du travail de bienfaisance ou encore la mise en œuvre de protocoles écoresponsables pour la pratique.

Membre à vie de l’ACMVLe titre de membre à vie est conféré à un membre de l’ACMV pour un service exceptionnel et de longue date au sein du Conseil, de l’exécutif, des bureaux et des comités de l’ACMV ou pour des contributions exceptionnelles à la profession vétérinaire. Le membre à vie reçoit un certificat encadré et il est invité à assister aux réunions de l’association. Il ne doit pas verser de cotisation mais jouit de tous les droits et privilèges conférés par l’adhésion.

Membre honoraire de l’ACMVLe titre de membre honoraire est conféré à un membre de l’ACMV qui a rendu des services distingués à la profession et réside au Canada ou ailleurs. Le membre honoraire ne doit pas verser de cotisation, mais il ne peut pas voter lors des réunions ni occuper un poste élu au sein de l’ACMV.

TROUSSE DE MISE EN CANDIDATURELe choix des récipiendaires de prix se fonde uniquement sur les renseignements fournis dans la trousse de mise en candidature. Veuillez suivre les étapes suivantes afin de garantir l’inclusion des documents requis dans la trousse de mise en candidature :1. Il faut soumettre un formulaire de mise en candidature

rempli. Un exemplaire de ce formulaire est inclus dans le présent numéro de La RVC. Le formulaire peut aussi être téléchargé dans la section des Prix de l’ACMV de notre site Web (www.veterinairesaucanada.net).

2. Inclure les documents à l’appui suivants dans la trousse de mise en candidature :• Décrire les principales réalisations professionnelles du

candidat (maximum de 1000 mots)• Lettres d’appui (maximum de 5 lettres; chaque lettre compte

500 mots ou moins)• Coupures de journaux (le cas échéant; maximum de

2 articles écrits au cours des deux dernières années)• Articles rédigés par le candidat (maximum de 3 liens Web

vers les articles).Les trousses de mise en candidature doivent être soumises

d’ici le 31 janvier 2019, par courriel ([email protected]), par télécopieur 613-236-9681 ou par la poste au bureau de l’ACMV au 339 rue Booth, Ottawa (Ontario) K1R 7K1.

Veuillez visiter la section des Prix de l’ACMV du site Web ou contactez le Service des communications au 1-800-567-2862, poste 125, pour en savoir davantage.

veterinary practice team for outstanding achievement within their local community. Such achievements may include innova-tions in provision of veterinary services, commitment to work-life balance, meaningful community or charitable involvement, or implementation of “green” practice procedures.

CVMA Life MembershipLife Membership is presented to a CVMA member for long and outstanding service on CVMA Council, Executive, Boards, and Committees or for outstanding contributions to the veterinary profession. The Life Member is presented with a framed certifi-cate and shall be invited to attend meetings of the Association, and shall not be liable to pay dues, but shall enjoy all the rights and privileges of membership.

CVMA Honorary MembershipHonorary membership is presented to an individual who has rendered distinguished service to the profession, whether resid-ing in Canada or elsewhere. The Honorary Member does not pay fees and cannot vote at meetings, or hold any elected office in the CVMA.

NOMINATION PACKAGESelection of award recipients is based solely on the informa-tion provided in the nomination package. Please follow these steps to ensure all required documents are included with your nomination package:1. Submit a completed nomination form. A copy of this form

is included in this issue of The CVJ. The form is also available for download under the CVMA Awards section of the website (www.canadianveterinarians.net).

2. Include the following supporting documents as part of the nomination package:• Outline of nominee’s key professional accomplishments

(maximum of 1000 words)• Letters of support (maximum of 5 letters; each letter

500 words or less)• Newspaper articles (if applicable; maximum of 2 articles

written within the last 2 years)• Articles written by nominee (maximum of 3 web links

to articles).Nomination packages are due by January 31, 2019,

via e-mail ([email protected]), by fax to 613-236-9681, or by mail to the CVMA office at 339 Booth Street, Ottawa, ON K1R 7K1.

Please visit the CVMA Awards section of (www.canadianveterinarians.net) or contact Communications at 1-800-567-2862, ext. 125 for further information.



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L’ACMV a pour mission d’être la voix nationale et internationale des vétérinaires du Canada en assurant le leadership et la

défense des intérêts pour la médecine vétérinaire. C’est pourquoi le leadership à l’égard des enjeux nationaux et la défense du bien-être animal sont deux des grandes priorités stratégiques de l’ACMV. Nous présentons ci-dessous quelques-unes de ces initiatives de l’ACMV qui ancrent ces priorités stratégiques et appuient la profession vétérinaire dans son ensemble.

Sommet de l’ACMVLe Sommet annuel de l’ACMV est un forum où les leaders vétérinaires canadiens et internationaux partagent des renseignements sur les principaux enjeux en médecine vétérinaire. Les discussions du Sommet se sont avérées précieuses pour l’exploration et l’adoption d’approches communes afin de répondre aux défis de notre profession. Tous les délégués au congrès de l’ACMV peuvent assister à cet événement qui est organisé annuellement pendant le congrès de l’ACMV.

Le Sommet 2018 de l’ACMV a porté sur La dynamique changeante de la pratique privée. La pratique vétérinaire privée évolue rapidement. L’acquisition des établissements par de grandes entreprises est la nouvelle réalité à laquelle sont confrontés les diplômés tandis qu’ils entrent sur le marché du travail et pour les vétérinaires qui planifient leur stratégie de retraite. Les attentes des clients et les niveaux de soins fournis par les équipes vétérinaires continuent de s’améliorer, ce qui accentue le stress des praticiens qui travaillent en vue de satisfaire à ces exigences. En juillet dernier, lors du congrès 2018 de l’ACMV qui s’est tenu à Vancouver, en Colombie-Britannique, la profession vétérinaire s’est penchée sur ces défis et a fourni des stratégies afin d’aborder ces préoccupations.

Forum sur les enjeux nationauxL’édition annuelle du Forum sur les enjeux nationaux de l’ACMV offre aux membres l’occasion d’exprimer leurs vues sur un sujet d’intérêt national dans la collectivité vétérinaire. Les discussions du forum se sont avérées extrêmement utiles pour l’exploration et la formulation de positions sur des enjeux vétérinaires importants. Tous les délégués au congrès de l’ACMV peuvent assister à cet événement qui se tient durant le congrès de l’ACMV.

L’édition 2018 du Forum sur les enjeux nationaux de l’ACMV a discuté et exploré les enjeux et les défis en lien avec l’Usage thérapeutique des cannabinoïdes en médecine vétérinaire.

Relations gouvernementalesL’ACMV défend les intérêts des vétérinaires canadiens afin d’influencer les enjeux législatifs et politiques pertinents qui peuvent menacer la portée de l’exercice de la médecine vétérinaire et la santé des humains et des animaux. L’ACMV a participé à la mise à l’annexe et à l’inscription des produits pharmaceutiques, à l’accès aux médicaments, aux privilèges de prescription, à la capacité d’utiliser les médicaments en dérogation des directives de l’étiquette, à l’usage des antimicrobiens et à l’antibiorésistance, aux lois en matière de protection et de bien-être des animaux et à la mobilité de la main-d’œuvre et plus encore.

The CVMA’s mission is to be the national and international voice for Canada’s veterinarians, providing leadership and

advocacy for veterinary medicine. That’s why leadership on national veterinary issues and animal welfare advocacy are 2 of the CVMA’s key strategic priorities. Below are some of the CVMA’s initiatives that underpin these strategic priorities and in turn, support the entire veterinary profession.

CVMA SummitThe Annual CVMA Summit is a forum where Canadian and international veterinary leaders share information on key issues in veterinary medicine. These Summit discussions have proven invaluable in exploring and adopting common approaches to challenges in our profession. All CVMA Convention delegates can attend this event, hosted annually during the CVMA Convention.

The 2018 CVMA Summit was on The Changing Dynamics of Private Practice. Veterinary private practice is rapidly changing. Corporate practice ownership is the new reality facing graduates as they enter the workforce and for veterinarians planning an exit strategy. As client expectations and the level of care veterinary teams provide their patients continue to rise, so does practitio-ners’ stress trying to meet these demands. This past July, at the 2018 CVMA Convention in Vancouver, British Columbia the veterinary profession addressed these challenges and provided strategies for dealing with these concerns.

National Issues ForumThe Annual CVMA National Issues Forum allows CVMA mem-bers an opportunity to express their views on a topic of national interest in the veterinary community. Forum discussions have proven invaluable in exploring and formulating positions on important veterinary issues. All CVMA Convention delegates can attend this event, hosted during the CVMA Convention.

The 2018 CVMA National Issues Forum discussed and explored issues and challenges pertaining to the Therapeutic Use of Cannabinoids in Veterinary Medicine.

How Does the CVMA Support the Veterinary Profession as a Whole?Comment l’ACMV appuie-t-elle la profession vétérinaire dans son ensemble?



N Un autre domaine d’intérêt pour l’ACMV est maintenant le cannabis, plus particulièrement l’usage du cannabis médicinal pour les animaux de compagnie. Avec la légalisation du cannabis au Canada, la profession désire maintenant savoir comment elle pourra potentiellement prescrire cette substance aux animaux de compagnie. L’ACMV a exercé des pressions auprès du gouvernement fédéral afin d’assurer l’inclusion des vétérinaires dans la définition de «praticien de la santé» en vertu du Règlement sur l’accès au cannabis à des fins médicales. L’ACMV a aussi demandé que les produits pour humains soient bien étiquetés afin de protéger les animaux et d’inclure certains produits de cannabis dans la catégorie des produits de santé animale à faible risque.

Par ailleurs, le Canada est aussi confronté à une crise de santé nationale en raison du nombre grandissant de surdoses et de morts causées par les opioïdes. L’exposition de la profession vétérinaire dans ce domaine concerne les clients qui visitent plusieurs médecins à la recherche d’opioïdes sur ordonnance pour leurs animaux auprès de plusieurs vétérinaires dans le but d’utiliser eux-mêmes ces médicaments. La Direction des médicaments vétérinaires de Santé Canada a contacté l’ACMV afin d’aborder cette situation dans les établissements vétérinaires. De plus, l’ACMV a produit un document intitulé «Opioïdes : Évaluation des risques et stratégies d’atténuation en médecine vétérinaire». Ce document comprend des renseignements sur l’évaluation des risques et la gestion stratégique des opioïdes, l’orientation et la formation des employés, l’assurance de la qualité à l’interne et l’éducation des clients.

Relations internationalesL’ACMV veille à ce que la voix des vétérinaires canadiens soit entendue de par le monde. La salubrité des aliments, l’approvisionnement en médicaments, la mobilité de la main-d’œuvre, l’éducation, les normes et le commerce mondial figurent parmi les enjeux transfrontaliers qui peuvent avoir un impact sur la profession, la portée d’exercice ou les normes de pratique. L’ACMV assure la participation des vétérinaires canadiens à ces questions et elle assume un leadership national et international lors des discussions internationales. L’ACMV fait d’ailleurs partie de la délégation canadienne auprès de l’Organisation mondiale de la santé animale (OIE) et elle représente les vétérinaires canadiens auprès de l’Association mondiale vétérinaire, du North American Veterinary Medical Education Consortium, des North American Veterinary Leaders, de la Commonwealth Veterinary Association, de PANVET, de la World Small Animal Veterinary Association, de la Pet Nutrition Alliance, de Partners for Healthy Pets et de l’International Veterinary Officers Council.

Amélioration de l’antibiogouvernance au CanadaLa surveillance vétérinaire de l’utilisation des antimicrobiens fait l’objet d’un resserrement au Canada dans le cadre de la lutte contre l’antibiorésistance, ce qui occasionnera des changements importants pour les praticiens des animaux de compagnie et des animaux destinés à l’alimentation. Par exemple, d’ici la fin de l’année, tous les antimicrobiens ajoutés aux aliments et à l’eau seront disponibles uniquement sur ordonnance vétérinaire. L’ACMV travaille depuis plus de deux décennies en vue d’apporter ce changement important et son Groupe consultatif sur la gouvernance des produits pharmaceutiques vétérinaires, en collaboration avec les organismes de réglementation de la médecine vétérinaire, a élaboré un Cadre de travail pancanadien pour les normes professionnelles régissant

Government relationsThe CVMA advocates for Canadian veterinarians to influence relevant legislative and policy issues that may threaten the vet-erinary scope of practice and the health of humans and animals. The CVMA has been involved in the scheduling and registration of pharmaceuticals, drug access, prescribing privileges, the ability to use drugs extra-label, the use of antimicrobial drugs and anti-microbial resistance, animal protection and welfare legislation, and labor mobility and more.

Another area of focus for the CVMA now is cannabis; more specifically the use of medicinal cannabis for companion animals. With the legalization of cannabis in Canada, the profession is eager to know how they fit into potentially prescribing it to pets. The CVMA has lobbied the federal government to ensure veterinarians are included under the definition of “medical practitioner” under the Access to Cannabis for Medical Purposes Regulations. The CVMA also requested properly labelled human products to protect animals, and to have certain cannabis prod-ucts included under the low risk Veterinary Health Products category.

Canada is also facing a national health crisis with a grow-ing number of overdoses and deaths caused by opioids. The veterinary profession’s exposure in this area pertains to clients engaging in “doctor” shopping, seeking opioid prescriptions for their pets from several veterinarians with the intent to use the drugs themselves. Health Canada’s Veterinary Drug Directorate reached out to the CVMA to help address this issue in veterinary practices. The CVMA produced a document titled “Opioids: Risk Evaluation/Mitigation Strategies in Veterinary Medicine.” The document includes information on risk assessment and stra-tegic management of opioid class medications, staff orientation and training, internal quality assurance, and client education.

International relationsThe CVMA ensures the voice of Canadian veterinarians circle the globe. Food safety, drug supply, labor mobility, education, standards, and global trade are some of the issues crossing bor-ders and that may impact the profession, the scope of practice, or practice standards. The CVMA ensures Canadian veterinarians’ involvement in these matters and provides national and inter-national leadership in global discussions. The CVMA is part of the Canadian delegation to the World Organisation for Animal Health (OIE), and represents Canadian veterinarians with the World Veterinary Association, North American Veterinary Medical Education Consortium, North American Veterinary Leaders, Commonwealth Veterinary Association, PANVET, World Small Animal Veterinary Association, Pet Nutrition Alliance, Partners for Healthy Pets, and the International Veterinary Officers Council.

Improving antimicrobial stewardship in CanadaVeterinary oversight of antimicrobial use is being strengthened in Canada as part of the fight against antimicrobial resistance. This means important changes for companion and food-producing animal practitioners. For example, by year’s end, all feed and water antimicrobials will be available upon veterinary prescrip-tion only. The CVMA lobbied for this significant change for over 2 decades and its Veterinary Pharmaceutical Stewardship Advisory Group, in collaboration with the veterinary regulatory



Nles médecins vétérinaires qui a été communiqué aux vétérinaires canadiens. L’ACMV a fourni régulièrement des renseignements et des mises à jour à tous les vétérinaires canadiens sur les nouvelles exigences réglementaires.

Médias et relations publiquesL’ACMV est la voix nationale de la profession vétérinaire et elle fournit des renseignements crédibles aux médias et au public. L’ACMV surveille et identifie les enjeux qui vous touchent.

Pour la troisième année d’affilée, l’ACMV a déclaré le mois de mars le Mois national de la sensibilisation aux tiques. En collaboration avec son partenaire de l’industrie, Merck Santé animale, l’Association a produit plusieurs outils de communication dont une série de vidéos intitulée «Que savez-vous vraiment au sujet des tiques?» afin de fournir des réponses aux questions fréquemment posées par les propriétaires d’animaux. Ces vidéos sont une ressource éducative que les cliniques peuvent utiliser en tout temps.

La Semaine de la vie animale (SVA) est une campagne annuelle de sensibilisation nationale du public et elle représente l’occasion pour l’équipe de soins vétérinaires de célébrer la santé animale au sein de votre collectivité. Chaque année, sous la bannière du thème choisi pour la SVA, la collectivité vétérinaire attire l’attention sur un message important lié à la santé. Les membres de l’ACMV reçoivent des réductions de prix sur la marchandise de la SVA et des outils de marketing en ligne sont offerts.

Santeanimale.ca est un site Web, qui a été créé par l’ACMV et est administré par l’Association, qui fournit aux propriétaires d’animaux des renseignements généraux sur les problèmes et les affections fréquemment observés en santé animale ainsi que des ressources utiles. Tous les articles sont rédigés par des vétérinaires canadiens et font la promotion des soins vétérinaires préventifs. Vous pouvez recommander cette ressource en ligne fiable à vos clients en toute confiance. On peut aussi accéder au site Web public dans la section des propriétaires d’animaux du site Web de l’ACMV.

Énoncés de positionLe Comité sur les enjeux nationaux (CEN) et le Comité sur le bien-être animal (CBA) examinent et surveillent constamment les enjeux vétérinaires et les questions liées au bien-être animal. Les comités effectuent de la recherche et élaborent des énoncés de position sur des questions qui sont jugées d’intérêt pour les membres. Le CEN et le CBA de l’ACMV considèrent attentivement la rétroaction des membres et des associations provinciales de médecins vétérinaires, des organismes de réglementation et des groupes d’intervenants et ils en tiennent compte lors de la préparation de la version finale du document. Les données scientifiques et/ou éthiques servent de base aux énoncés de position. Une fois que les énoncés sont finalisés par les comités, ils sont présentés au Conseil de l’ACMV aux fins d’approbation et d’adoption.

Les énoncés de position de l’ACMV ont pour but de servir de lignes directrices et de principes pour aborder les enjeux vétérinaires ainsi que la protection et le bien-être des animaux. Ils visent à guider la profession et à éduquer le public à l’égard du point de vue vétérinaire sur des enjeux particuliers. Les positions fournissent un point de vue «avant-gardiste» sur les enjeux en fonction de la conjoncture, non seulement au sein de la société et de la profession au Canada mais aussi à l’échelle internationale.

bodies, developed a Pan-Canadian Framework of Professional Standards for Veterinarians, which has been communicated to Canadian veterinarians. The CVMA has been delivering regular information and updates to all Canadian veterinarians on the new regulatory requirements.

Media and public relationsThe CVMA is the veterinary profession’s national voice and pro-vides credible, expert information to the media and public. The CVMA carefully monitors and identifies issues that affect you.

For the 3rd year, the CVMA declared March as National Tick Awareness Month. In collaboration with its industry partner, Merck Animal Health, the Association produced numerous communication tools including a video series called “What do you really know about ticks?” providing answers to pet owners’ frequently asked questions. These videos have educational lasting power for clinics to use anytime.

Animal Health Week (AHW) is an annual national public awareness campaign and an opportunity for your health care team to celebrate your community’s animal health. Each year, through the AHW chosen theme, the veterinary community draws attention to an important health-related message. CVMA members receive discounted prices on AHW merchandise and online promotional marketing tools are available.

AnimalHealthCare.ca is a website, created and administered by the CVMA, to provide animal owners with general infor-mation on common animal health issues and conditions, as well as helpful resources. All articles are provided by Canadian veterinarians and promote preventive veterinary care. You can recommend this reliable online resource to your clients with total confidence. The public website can also be accessed through the CVMA Website’s Animal Owners section.

Position statementsThe CVMA’s National Issues Committee (NIC) and Animal Welfare Committee (AWC) review and monitor veterinary and animal welfare issues on an ongoing basis. The Committees research and develop position statements on issues or matters judged to be of member concern. The CVMA’s NIC and AWC carefully consider member feedback and feedback from the pro-vincial veterinary associations, regulatory bodies and stakeholder groups, and take these into account as a final draft document is prepared. Scientific evidence and/or ethics form the basis of the position statements. Once final draft statements are finalized by the Committees, they are presented to CVMA Council for approval and adoption.

The purpose of CVMA position statements is to serve as guidelines and principles addressing veterinary issues and the stewardship and welfare of animals. They are meant to guide the profession, and educate the public on the veterinary viewpoint on select issues. Positions provide a “forward-thinking” view-point on issues based on what is happening, not just in Canadian society and the veterinary profession, but internationally.

Research & knowledgeThe CVMA responds to demands for research and knowl-edge in various fields of veterinary medicine through offering continuing education opportunities and the publication of The Canadian Veterinary Journal and the Canadian Journal of Veterinary Research.



N Recherche et connaissancesL’ACMV répond aux demandes de recherche et de connaissances dans les divers domaines de la médecine vétérinaire en offrant des occasions de formation continue et en publiant La Revue vétérinaire canadienne et la Revue canadienne de recherche vétérinaire.

Réserve vétérinaire canadienneL’ACMV administre la Réserve vétérinaire canadienne (RVC), un organisme doté d’un effectif volontaire national de vétérinaires canadiens prêt à porter assistance rapidement aux gouvernements en cas d’éclosions de maladies animales exotiques et d’autres situations d’urgence et catastrophes à grande échelle touchant les animaux.

Bureau national des examinateurs (BNE)L’ACMV administre les examens pour les vétérinaires canadiens et ceux formés à l’international et elle émet le Certificat de compétence qui rend les candidats admissibles à la présentation d’une demande de permis dans tous les territoires au Canada. Le BNE participe aussi au Council on Education de l’American Veterinary Medical Association dans le cadre d’un programme d’agrément des collèges de médecine vétérinaire afin d’assurer le respect des normes minimales.

Agrément des programmes pour les techniciens et technologues en santé animaleL’ACMV offre l’agrément des programmes de techniques vétérinaires à l’échelle du Canada dans le but d’établir des normes qui répondent le mieux aux besoins des équipes de soins vétérinaires.

Si vous avez des questions ou si vous aimeriez en savoir davantage à propos des initiatives de l’ACMV mentionnées dans le présent article, vous pouvez visiter le site Web de l’ACMV (www.veterinairesaucanada.net) ou contacter l’ACMV ([email protected]).

Alerte sanitaire de l’ACIA : un cas d’anémie infectieuse des équidés est confirmé en Saskatchewan

Un résultat positif d’anémie infectieuse des équidés a été confirmé le 20 juillet 2018 par le laboratoire national de

référence de l’Agence canadienne d’inspection des aliments (ACIA) pour un cheval dans une municipalité rurale de Great Bend, en Saskatchewan. Un prélèvement avait été effectué pour un cheval par un vétérinaire autorisé afin de satisfaire à une exigence préalable à l’entrée dans des installations particulières. Les premiers rapports indiquent que ce cheval avait effectué de nombreux déplacements dans la province pour le travail et les concours.

Aucun signe clinique n’a été observé au moment du prélèvement. Une enquête de l’ACIA est en cours et, conformément aux politiques du programme, l’animal infecté et les animaux qui sont entrés en contact avec lui sur les lieux ont été mis en quarantaine. La quarantaine demeurera en vigueur jusqu’à toutes les activités d’intervention pour la maladie aient été achevées, y compris des tests de suivi et l’ordre de destruction des cas positifs.

On peut obtenir de plus amples renseignements sur l’anémie infectieuse des équidés sur le site Web de l’ACIA.

Canadian Veterinary ReserveThe CVMA operates the Canadian Veterinary Reserve (CVR), which has a national, volunteer membership of qualified Canadian veterinarians who are available to rapidly assist gov-ernments in responding to outbreaks of foreign animal disease and other large-scale emergencies and disasters affecting animals.

National Examining Board (NEB)The CVMA administers the exams for Canadian and inter-nationally trained veterinarians and issues the Certificate of Qualification, which makes candidates eligible to apply for licensure in any jurisdiction in Canada. The NEB also partici-pates with the Council on Education of the American Veterinary Medical Association in an accreditation program for colleges of veterinary medicine to ensure that minimum standards are met.

Animal Health Technicians and Technologists Program AccreditationThe CVMA provides for the Canada-wide veterinary technician program accreditation, with the goal of setting standards that best meet the needs of the veterinary healthcare teams.

If you have questions or would like more information about any of the CVMA initiatives mentioned in this article, you can visit the CVMA website (www.canadianveterinarians.net) or contact the CVMA ([email protected]).

CFIA Health Alert: Case of Equine Infectious Anemia Confirmed in Saskatchewan

A positive Equine Infectious Anemia (EIA) result was con-firmed by the Canadian Food Inspection Agency’s (CFIA’s)

national reference laboratory for a horse in the rural municipality of Great Bend, Saskatchewan on July 20, 2018. The horse had been sampled by an accredited veterinarian to satisfy a pre-entry requirement for a particular premises. Initial reports indicate that this horse has travelled extensively within the province for both work and competition.

No clinical signs of disease were noted at the time of sam-pling. A CFIA investigation is underway and as per program policy, a quarantine has been placed on the infected animal and its on-premises contact animals. The quarantine will remain until all disease response activities have been completed, including follow-up testing and ordering the destruction of positive cases.

More details on EIA may be found on the CFIA website.



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Chaque année, Vétérinaires sans frontières (VSF) Canada envoie de jeunes bénévoles dans les pays en développement

pour un stage d’été de trois mois. Cet été, une équipe de jeunes a de nouveau été envoyée au Kenya, l’un des cinq pays participant au Programme de jeunes bénévoles en 2018. L’équipe comprenait deux étudiantes de l’OVC, Aiyanna Hoogsteen et Alexandra Lundhild, ainsi qu’Elle Côté, une étudiante en journalisme de Humber College. Deux vétérinaires canadiens, Dr Gerald Dykstra et Dre Kelsey Goodick, étaient aussi présents à titre de superviseurs au pays et nous avions une équipe incroyable de Kényans qui traduisaient et fournissaient de l’assistance lors de notre travail sur le terrain.

L’équipe a formé un partenariat avec Mukurwe-ini Wakulima Dairy (MWD) pour travailler surtout avec de jeunes exploitants de petites fermes laitières de la région afin de leur donner une formation sur les façons d’améliorer la santé et la nutrition des vaches. Les bénévoles de VSF visitent cette entreprise laitière pour ce projet de formation jeunesse depuis 2016. Les exploitants de petites fermes laitières au Kenya possèdent habituellement une ou deux vaches laitières et éprouvent souvent des problèmes de faible production de lait en raison du manque de ressources et de connaissances sur les meilleures pratiques de gestion. La vente de lait fournit une excellente source de revenu quotidien et sert à faire vivre les femmes dans les collectivités rurales qui effectuent la grande partie du travail dans les fermes.

Cet été, nous avons présenté 45 ateliers aux membres de MWD et travaillé directement auprès de 510 fermiers qui étaient âgés d’entre 18 et 86 ans. Les ateliers portaient cette année sur la nutrition appropriée des vaches (eau, ensilage, minéraux et coproduits), la reproduction et le moment approprié pour l’insémination artificielle, la prévention de la mammite par des techniques de traite hygiéniques ainsi que le confort des vaches

Every year, Veterinarians without Borders-Canada (VWB) sends youth volunteers to developing countries for a

3-month summer placement. This summer, a youth team was again sent to Kenya, one of the 5 countries participating in the Youth Volunteer Program in 2018. The team included 2 OVC students, Aiyanna Hoogsteen and Alexandra Lundhild, and Elle Côté, a journalism student from Humber College. Two Canadian veterinarians, Dr. Gerald Dykstra and Dr. Kelsey Goodick, went as in-country supervisors, and we had an incred-ible team of Kenyans, who translated and provided assistance with our field work.

The team partnered with the Mukurwe-ini Wakulima Dairy (MWD) to work with primarily young local smallholder dairy farmers to train them on ways to improve cow health and nutrition. Volunteers from VWB have been visiting this dairy company for this youth training project since 2016. Smallholder dairy farms in Kenya typically have 1 or 2 milking cows and often struggle with low milk production due to lack of resources and knowledge on best management practices. Dairy farming can be an excellent source of daily income from milk sales and provide livelihoods for women in rural communities who do most of the work on the farms.

This past summer, we presented 45 seminars to members of the MWD, working directly with 510 farmers ranging in age from 18 to 86. This year, the seminars focused on proper cow nutrition (water, forages, mineral, and dairy meal), reproduction and proper timing of AI, mastitis prevention through hygienic milking techniques, and cow comfort and stall design, with the goal of helping to improve milk production and income for the farmers. The farmers were always eager to learn and were also not afraid to ask questions, which showed how interested they were in improving! One of our goals this summer was to continue to

Aiyanna Hoogsteen (left) and Alexandra Lundhild on a smallholder dairy farm in Kenya.

Aiyanna Hoogsteen (à gauche) et Alexandra Lundhild dans une petite exploitation laitière au Kenya.

Aiyanna Hoogsteen discusses the results of a California Mastitis Test with a Kenyan farmer.

Aiyanna Hoogsteen discute des résultats de l’épreuve au teepol avec un fermier kényan.

Veterinarians without BordersYouth Volunteer Program — Kenya 2018

Vétérinaires sans frontièresProgramme de jeunes bénévoles — Kenya 2018



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et la conception des stalles dans le but de favoriser la production de lait et d’améliorer le revenu des fermiers. Les fermiers étaient toujours motivés à apprendre et prêts à poser des questions, ce qui illustrait bien leur désir d’amélioration! Cet été, l’un de nos objectifs était de continuer à se concentrer sur l’enseignement et le travail auprès des femmes afin d’améliorer leur niveau de vie et leur rôle au sein de la famille. Nous étions très heureuses de constater que 58 % des participants aux ateliers étaient des femmes!

Après les ateliers, nous avons visité les fermes de divers participants pour répondre à leurs questions concernant leurs vaches et leurs fermes. Nous avons discuté les programmes d’alimentation individuels, réglé les problèmes de santé des vaches et porté assistance avec l’ajustement des stalles afin d’améliorer leur conception. Parmi les fermiers à qui nous avons parlé cet été, beaucoup ont dit que leur production de lait avait doublé, triplé ou même, dans certains cas, quadruplé depuis leur collaboration avec VSF.

En plus des ateliers avec les fermiers, la visite dans huit écoles de la région de Mukurwe-ini, où nous avons enseigné à 602 étudiants de 6, 7 et 8 années, a été un autre fait saillant de notre été. Nous avons parlé aux étudiants à propos des zoonoses, de la prévention de la rage, du comportement animal, du lavage des mains approprié et des mesures de sécurité à prendre près des chiens et du bétail. Nous avons adoré visiter les étudiants parce qu’ils sont toujours curieux à notre égard et, surtout, parce qu’ils sont motivés à participer et à apprendre! Ils apprécient l’éducation d’une manière qui est moins souvent observée au Canada parmi les étudiants de cet âge.

Cette année, le projet était doté d’un volet supplémentaire car Elle s’est jointe à nous et son rôle consistait à documenter le travail des étudiants en médecine vétérinaire, à réaliser des entrevues avec les participants au projet et à travailler avec MWD afin d’améliorer le marketing et les communications de l’entreprise. Elle a réalisé des entrevues avec 41 fermiers, 15 étudiants, 6 enseignants et 7 employés de MWD ainsi que, bien entendu, avec nous, les deux étudiantes bénévoles! Elle a aussi réuni des

focus on teaching and working with women to help improve their livelihoods and their role in the family. We were very happy to see that 58% of the seminar participants were women!

After the seminars, we visited various participants’ farms, to give them one-on-one feedback about any concerns they had regarding their cows and farm. We discussed individual feeding programs, troubleshot any health concerns the farmer had about their cow, and assisted with adjusting the stalls to improve their design. Of the farmers we spoke with this past summer, many said their milk production has doubled, tripled, or, in some cases, even quadrupled since becoming involved with VWB.

In addition to seminars with farmers, another highlight of our summer was visiting 8 schools in the Mukurwe-ini area and teaching 602 students in Grades 6, 7 and 8. We taught the stu-dents about zoonotic diseases, rabies prevention, animal behav-ior, proper hand washing, and safety around dogs and cattle. We loved visiting the students because they were always curious about us — and more importantly, they were eager to partici-pate and learn! They had an appreciation for education that is less commonly seen in Canada among student in those grades.

This year, the project had an added feature, as we were joined by Elle, whose role was to document the work of the vet stu-dents, interview project participants, and work with the MWD to enhance the company’s marketing and communications. She interviewed 41 farmers, 15 students, 6 teachers, and 7 MWD staff, and us 2 vet student volunteers naturally! She also gathered thousands of photos, hundreds of videos and worked with the MWD’s communications department to assist in developing their online presence. Look out for her social media posts, pho-tos and more on VWB’s online platforms.

We want to thank everyone who made this project possible — our Kenyan team members, who did so much this summer to ensure the project ran smoothly, the MWD for their partnership, and the farmers and community who welcomed us and made us feel right at home. We want to thank our in-country super-visors, Drs. Dykstra and Goodick for their guidance to ensure

Alexandra Lundhild teaching Grades 7 and 8 students about safety around cattle.

Alexandra Lundhild enseigne les mesures de sécurité autour du bétail aux étudiants de 7e et de 8e années.

Elle Côté (right) interviews a Kenyan smallholder dairy farmer with a translator.

Elle Côté (à droite) réalise une entrevue auprès d’un fermier kényan par l’entremise d’un interprète.



Nmilliers de photos, des centaines de vidéos et travaillé avec le service des communications de MWD pour l’aider à améliorer sa présence en ligne. Recherchez ses messages et ses photos dans les médias sociaux ainsi que d’autres informations dans les plates-formes en ligne de VSF.

Nous désirons remercier toutes les personnes qui ont permis la réalisation de ce projet : les membres de notre équipe kényane, qui ont déployé des efforts importants cet été afin d’assurer le bon fonctionnement du projet, MWD pour son partenariat ainsi que les fermiers et la collectivité qui nous ont bien accueillies et nous ont mises à l’aise. Nous désirons aussi remercier nos superviseurs sur place, les Drs Dykstra et Goodick de leurs conseils afin de nous préparer aux ateliers ainsi que les Drs John VanLeeuwen et Shauna Richards qui ont coordonné le projet et étaient toujours disponibles pour communiquer des conseils. Leurs efforts antérieurs, de concert avec les autres Canadiens et Kényans qui ont participé au projet avec MWD au cours des 15 dernières années, ont été cruciaux pour le succès du projet. Nous désirons aussi remercier VSF de son soutien logistique et financier ainsi qu’Affaires mondiales Canada, Farmers Helping Farmers et le Sir James Dunn Animal Welfare Centre de leurs contributions respectives ainsi que toutes les personnes qui ont donné de leur temps, ont fait des dons et nous ont appuyées. Le projet a été un succès grâce au solide soutien des vétérinaires canadiens et de leur collectivité!

(par Aiyanna Hoogsteen et Alexandra Lundhild, avec Elle Côté)

we were prepared to take on the seminars, as well as Drs. John VanLeeuwen and Shauna Richards who coordinated the project and were always available to share advice. Their previous efforts, among other Canadians and Kenyans involved with the MWD over the last 15 years, were integral to the project success. We also want to thank VWB for their logistical support and fund-ing from Global Affairs Canada, Farmers Helping Farmers, and the Sir James Dunn Animal Welfare Centre for their respective contributions, as well as everyone else who gave their time, donations, and support to us. The project was successful because of such strong support by Canadian veterinarians and their community!

(by Aiyanna Hoogsteen and Alexandra Lundhild, and Elle Côté)



N NécrologieDr Russell WilloughbyC’est avec tristesse que nous annonçons le décès du Dr Russell Willoughby, OVC 1957, le 17 avril 2018. Le Dr Willoughby était un ancien professeur de l’Ontario Veterinary College et ancien directeur du Département des sciences cliniques.

Le Dr Willoughby est né le 7 juillet 1933 à Tilston, au Manitoba, enfant des défunts J.T. Wilfred et M. Christina (Young) Willoughby. Il a grandi à la ferme familiale à Alameda, en Saskatchewan. À l’âge de 11 ans, il conduisait le grain au village. Sa passion pour l’agriculture et les véhicules motorisés n’a par la suite jamais diminué.

Le Dr Willoughby a obtenu son doctorat de médecine vétérinaire à l’Université de Toronto (Guelph) en 1957. Il a fondé une clinique pour grands animaux à Grenfell, en Saskatchewan, et a obtenu un Ph.D. de l’Université Cornell en 1965, avant de retourner à l’Ontario Veterinary College où il a été professeur, chef de médecine dans le Département des études cliniques (1965–1978); doyen associé, Recherche et développement (1978–1983); et directeur, Études cliniques (1983–1986). Il a fondé et a été le premier directeur de l’Equine Research Centre de 1986 à 1990.

Pendant qu’il occupait le poste de doyen associé, Recherche et développement, il a joué un rôle crucial en vue solliciter et d’obtenir l’approbation du sénat pour les fonds de financement du Programme d’études supérieures de D.Sc.Vet. à l’Ontario Veterinary College (OVC). Il a négocié le transfert des fonds et du fonctionnement de la Station de recherche sur le terrain de l’OVC au contrat de recherche de l’Université de Guelph et du ministère de l’Agriculture de l’Ontario. Il a coordonné la planification et la construction d’un agrandissement de 22 millions $ de l’aile de l’hôpital pour grands animaux ainsi que de nouveaux locaux d’anesthésie, de chirurgie, de diagnostic et de tapis roulants, de bureaux et d’autres installations dans l’aile clinique.

Il était membre fondateur de l’American College of Veterinary Internal Medicine, membre des Associations canadiennes et américaines de médecins vétérinaires, président du Club Rotary de Guelph, d’Hospice Wellington, de Guelph Probus et membre de la Wellington County Lung Association et du Guelph Wellington Men’s Club.

Dr Willoughby est survécu par sa femme dévouée, Peggy, son fils Doug (Connalyn), ses filles Joanne (Jonathan McSherry) et Sandra (Steve Waters), ses petits-enfants Corene, Lauren, Adrienne et Rowan. Il a été précédé dans la mort par son frère Gerald.

ObituariesDr. Russell WilloughbyWe’re sad to announce the passing of Dr. Russell Willoughby, OVC’57, on April 17, 2018. Dr. Willoughby was a former Ontario Veterinary College faculty member and former chair, Department of Clinical Studies.

Dr. Willoughby was born July 7, 1933 in Tilston, Manitoba, to the late J.T. Wilfred and M. Christina (Young) Willoughby. He was raised on the family farm in Alameda, Saskatchewan. By age 11, he was driving grain into town. His passion for farming and driving never faded.

Dr. Willoughby obtained a Doctor of Veterinary Medicine, University of Toronto (Guelph) in 1957. He established a large animal veterinary practice in Grenfell, Saskatchewan, obtained a PhD from Cornell University in 1965, before returning to the Ontario Veterinary College where he was a professor, Head of Medicine in the Clinical Studies Department (1965–1978); associate dean, Research and Development (1978–1983); and chair, Clinical Studies (1983–1986). He established and was the first director of the Equine Research Centre from 1986 to 1990.

While serving as associate dean, Research and Development, he was instrumental in initiating, gaining senate approval and receiving funding for the DVSc Graduate Program at the Ontario Veterinary College (OVC). He negotiated transferring the funding and operation of the OVC Field Research Station to the University of Guelph/Ontario Ministry of Agriculture Research Contract. He coordinated the planning and building of a $22-million expansion of the Large Animal Hospital area, new anesthetic, surgery, diagnostic and treadmill areas, offices and other facilities in the clinical area.

He was a charter member of the American College of Veterinary Internal Medicine, member of the Canadian and American Veterinary Medical Associations, president of the Guelph Rotary Club, Hospice Wellington, Guelph Probus and a member of Wellington County Lung Association and Guelph Wellington Men’s Club.

Dr. Willoughby is survived by his devoted wife, Peggy, son Doug (Connalyn), daughters Joanne (Jonathan McSherry) and Sandra (Steve Waters), grandchildren Corene, Lauren, Adrienne and Rowan. He is predeceased by his brother Gerald.

Dr./Dr Russell Willoughby



NDre Hélène Van DoninckC’est avec une grande tristesse que nous partageons la nouvelle du décès de la Dre Hélène Van Doninck à la suite d’un cancer ovarien un mois après avoir reçu le Prix humanitaire 2018 de l’Association canadienne des médecins vétérinaires (ACMV). En raison de sa maladie, elle n’avait pas pu assister à la cérémonie de remise des prix qui s’était déroulée en juillet durant le congrès national qui s’est tenu à Vancouver, en Colombie-Britannique.

La Dre Van Doninck a consacré sa vie au traitement de la faune et, avec son mari, elle a fondé le Cobequid Wildlife Rehabilitation Centre en 2001, qui est situé à Brookfield, en Nouvelle-Écosse. On lui a décerné le Prix humanitaire de l’ACMV, qui est commandité par Merck Santé animale, pour ses soins vétérinaires et sa réadaptation bénévoles de plus de 400 animaux sauvages blessés et orphelins chaque année.

«Hélène était une personne très dévouée et une véritable championne de la faune, particulièrement les rapaces», dit la Dre Troye McPherson, la présidente sortante de l’ACMV et une vétérinaire praticienne en Nouvelle-Écosse. «Les collègues d’Hélène sentaient qu’une chaleur spéciale l’entourait. Elle était douce, généreuse et possédait un excellent sens de l’humour et un grand amour de la vie. J’espère qu’elle savait à quel point la profession vétérinaire la tenait en haute estime.»

En 2014, grâce à des activités de financement organisées et gérées par Hélène, le Centre de réadaptation a assisté à l’ouverture d’un Bald Eagle Flight Centre, qui fournissait l’espace nécessaire pour renforcer les muscles de vol et accroître les chances de succès de la mise en liberté. Le Flight Centre est la seule installation en son genre au Canada.

Diplômée de l’Atlantic Veterinary College, la Dre Van Doninck s’intéressait particulièrement aux rapaces, à la contamination des oiseaux par le pétrole et à l’empoisonnement par le plomb des pygargues à têtes blanches et elle avait travaillé avec les chasseurs et les pêcheurs au cours des dix dernières années afin d’encourager l’abandon volontaire des munitions et des plombs de pêche au plomb et de protéger la santé des humains et de la faune. Elle croyait fermement en l’importance de la faune et elle encourageait activement les autres vétérinaires à élaborer des pratiques conviviales pour la faune.

Afin d’honorer la passion et l’héritage d’Hélène, des dons à sa mémoire peuvent être faits au Cobequid Wildlife Rehabilitation Centre.

Dr. Helene Van DoninckIt is with great sadness that we share the news of Dr. Helene Van Doninck’s passing due to ovarian cancer a month after receiving the 2018 Canadian Veterinary Medical Association’s (CVMA) Humane Award. Due to her illness, she was unable to attend the awards ceremony that took place in July during the CVMA Convention in Vancouver, British Columbia.

Dr. Van Doninck dedicated her life to the treatment of wildlife and, with her husband, established the Cobequid Wildlife Rehabilitation Centre in 2001, located in Brookfield, Nova Scotia. She was honored with the Merck Animal Health sponsored CVMA Humane Award for her volunteer veterinary care and rehabilitation of over 400 injured and orphaned wildlife each year.

“Helene was very dedicated and a true champion for wildlife, especially the raptors,” says Dr. Troye McPherson, immediate past-president of the CVMA and a practicing veterinarian in Nova Scotia. “To her colleagues, there was a special warmth that surrounded Helene. She was gentle, kind, with a great sense of humor and a love for life. I hope she knew just how much esteem the veterinary profession holds for her.”

In 2014, through fundraising activities she organized and managed, the Rehabilitation Centre saw the opening of a Bald Eagle Flight Centre, which provides space to strengthen flight muscles and increase the odds of successful release into the wild. The Flight Centre is the only structure of its kind in Canada.

A graduate of the Atlantic Veterinary College, Dr. Van Doninck was particularly interested in birds of prey, oil contami-nation of birds, and lead poisoning in bald eagles and she had been working with hunters and anglers for the past 10 years to encourage voluntary transition away from lead-based ammuni-tion and fishing tackle, for the health of both humans and wild-life. She firmly believed wildlife matters and actively encouraged other veterinarians to develop wildlife-friendly practices.

To honor Helene’s passion and legacy, donations in her mem-ory can be made to the Cobequid Wildlife Rehabilitation Centre.

Dr./Dre Helene Van Doninck


February 17-20, 2019 | Las Vegas, NV

As a veterinary professional, you’re not caring for a pet—you’re caring for a best friend, a non-judgmental exercise companion, a cuddle buddy, a source of happiness and unconditional love. That’s why your professional development matters, and why WVC is committed to supplying you with the education and resources you need to provide exceptional care.

REGISTER TODAY wvc.org/conference

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Article

Visual inspection of stored canine blood for hemolysis compared with measured plasma-free hemoglobin to assess suitability for transfusion

Brittany Jaeger, Miryam Reems

Abstract — Canine blood was visually inspected for hemolysis and compared with the Food and Drug Administration’s standard of less than 1% hemolysis as measured by plasma-free hemoglobin. This was the basis for deciding to transfuse or dispose of stored canine blood. Free hemoglobin was measured in stored red blood cell units and compared to a calculated 1% hemolysis. Veterinarians and technicians determined if they would transfuse units based on visual inspection for hemolysis. Their evaluation was compared to the calculated hemolysis cutoff. The evaluations of veterinarians and technicians were significantly different from the mathematically derived cutoff. The technicians’ visual assessments of the usability of samples were significantly different from those of the veterinarians: technicians more frequently judged the sample as unusable. Experienced veterinary personnel both over- and under-estimate the degree of hemolysis in stored canine RBCs. We recommend objective analysis of the amount of free hemoglobin in stored blood prior to transfusion.

Résumé — Inspection visuelle du sang canin entreposé pour l’hémolyse comparativement à la mesure de l’hémoglobine libre pour évaluer sa qualité pour la transfusion. Du sang canin a été inspecté visuellement pour l’hémolyse et comparé à la norme de la Food and Drug Administration de moins de 1 % d’hémolyse mesurée par l’hémoglobine libre dans le plasma. Ce paramètre a été utilisé pour décider soit de faire la transfusion ou de jeter le sang canin entreposé. L’hémoglobine libre a été mesurée dans les unités de globules rouges entreposées et comparée à une hémolyse calculée à 1 %. Les vétérinaires et les techniciens ont déterminé s’ils effectueraient une transfusion des unités en se basant sur une inspection visuelle pour l’hémolyse. Leur évaluation a été comparée au seuil de coupure calculé pour l’hémolyse. Les évaluations des vétérinaires et des techniciens étaient significativement différentes du seuil dérivé des calculs mathématiques. Les évaluations visuelles des techniciens pour déterminer l’utilisabilité des échantillons étaient significativement différentes de celles des vétérinaires : les techniciens jugeaient plus fréquemment que les échantillons étaient inutilisables. Le personnel vétérinaire d’expérience surestime et sous-estime le degré d’hémolyse dans les globules rouges canins entreposés. Nous recommandons une analyse objective de la quantité d’hémoglobine libre dans le sang entreposé avant la transfusion.

(Traduit par Isabelle Vallières)

Can Vet J 2018;59:1171–1174

Introduction

T he use of stored canine red blood cell (RBC) products in anemic dogs is routine practice. As hemolysis occurs,

free hemoglobin (fHgb) accumulates in stored RBC units and contributes to the biochemical storage lesion (1). The RBC storage lesion refers to any biochemical, biomechanical, and immunologic event which affects RBC survival, function, and recipient response to transfusion (1).

Methods to identify hemolysis are crucial to ensure quality control of RBC products (2). Measurement of fHgb has proven to be superior to visual inspection methods in human medicine (3–5) and is advocated in veterinary medicine (3,4). An effective quantitative method of evaluating hemolysis in stored canine blood products has not been determined.

The Food and Drug Administration’s (FDA’s) standard for transfusion of human blood products requires that hemolysis affect 1% of stored RBCs (6). There are no comparable guidelines regarding the degree of hemolysis or fHgb permissible in stored canine RBC units. Subjective visual inspection of the supernatant of RBCs is used clinically to determine if a unit is acceptable for transfusion (7).

The aim of this study was to compare subjective visual assess-ment of hemolysis to objectively measured fHgb as the basis for determining the suitability of blood products for transfu-sion. The FDA’s human standard of 1% hemolysis was used as the cutoff point of suitability. We hypothesized that visual

BluePearl Veterinary Partners, 3000 Busch Lake Blvd, Tampa, Florida 33614, USA.Address all correspondence to Dr. Brittany Jaeger; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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assessment would overestimate the amount of hemolysis in stored blood.

Materials and methodsBlood donors were adult (age range: 1 to 7 y) large breed (weight range: 20.4 to 63 kg) overtly healthy dogs which had undergone routine screening. Blood was collected from the jugular vein of 51 dogs. Four large dogs donated 2 units of blood at one time, giving a total of 55 units. Total Hgb levels of the donor dogs were measured using a hemoglobinometer (HemoCue 201; HemoCue AB; Ängelholm, Sweden).

Each dog underwent standard blood donation procedures. The venipuncture site was cleaned, a 16-gauge needle was inserted into the jugular vein, and 450 mL of blood was collected aseptically into a standard triple blood banking bag (Teruflex blood bag system; Terumo, Tokyo, Japan) containing anticoagulant citrate phosphate dextrose solution. Blood was processed into packed RBC (pRBC) units using standard proto-col with storage bags containing Optisol (Terumo). The tubing between the bags contained pRBCs, CPD (citrate phosphate dextrose), and optisol, the same contents and pRBC units as in the bag. The tubing was then sealed (Teruflex Tube Sealer ACS-152; Terumo) to separate it into 7 segments per unit. In 7 cases only 6 segments were produced. Segments were stored in a dedicated and locked blood product storage refrigerator (Jewett Surveillance model T100-1; Thermo Scientific Jewett Blood Bank Refrigerators, Thermo Fisher, Asheville, North Carolina, USA) at 2C and inverted daily.

Segments were analyzed at 7 time points, 1 wk apart. Seventy-five samples were not analyzed due to conflicting schedules of the sample analyzer and the inspectors. The contents of the seg-ment were emptied into a plain tube (BD Microtainer Z — no additive tube; Becton, Dickinson and Company, Franklin, New Jersey, USA). The tubes were placed on a tube rocker (Blood

rocker MXL-BLf7-16T1; LW Scientific, Lawrenceville, Georgia, USA) for a minimum of 60 s. Two microhematocrit tubes were filled using the mixed sample and centrifuged (IDEXX StatspinVT #V901-22, microhematocrit setting: rpm 15 800, rcf 13 700, 120 s, rotor RM02, IDEXX, Westbrook, Maine, USA). After mixing, the plain tube was centrifuged [IDEXX StatspinVT #V901-22, normal setting: rpm 15 800, rcf 12 000, 90 s, rotor RT12, IDEXX].

Samples were then processed using the Plasma/Low Hb Photometer (HemoCue AB, Ängelholm, Sweden) and fHgb was measured according to the manufacturer’s instructions, with 1 exception: plasma was carefully pipetted from the plain tube using a 40-L microhematocrit tube and tested unfiltered. This was done to conserve the small test sample available.

After centrifugation, the microhematocrit tubes were shown to 1 veterinarian and 1 technician, chosen based on availability. Investigators 1 and 2 were diplomates of the American College of Veterinary Emergency and Critical Care (DACVECC); investigator 3 was a diplomate of the American College of Veterinary Internal Medicine (DACVIM); investigator 4 was a certified veterinary technician with 10 y of experience in critical care and the intensive care unit (ICU); and investigator 5 was a certified veterinary technician with a combined 15 y experience in emergency, ICU, and critical care. Investigators were blinded to the other investigators’ decisions and the measured fHgb level, but not the purpose of the study. They could visualize the microhematocrit tubes against a white paper background in fluorescent light and were permitted to have knowledge of the age of the stored RBCs. They were required to make a decision to transfuse (usable unit), or to not transfuse (nonusable unit).

The percentage hemolysis in a RBC unit was estimated from the following calculation (8):

[100hematocrit (unit)] fHgb (g/L)/total Hgb (g/L)

Figure 1. Supernatants of packed red blood cells showing various levels of measured free hemoglobin. The percent hemolysis is dependent on the total hemoglobin. The free hemoglobin which is equivalent to 1% hemolysis varies with the hemoconcentration of the unit.

Measured free Hgb (g/L)

Percent hemolysis

[100 HCT(unit)] free plasma Hgb (g/L)/total Hgb (g/L) = % hemolysis Red = above 1% hemolysis cutoff Green = below 1% hemolysis cutoff

total Hgb (g/L)/HCT of unit/1% free Hgb cutoff (g/L)

130/39%/2.1

170/51%/3.5

220/66%/6.5

0%

0%

0%

1.03%

0.60%

0.34%

1.60%

0.98%

0.53%

2.11%

1.30%

0.70%

3.14%

1.93%

1.04%

3.75%

2.31%

1.24%

9.10%

5.60%

3.00%

0 2.2 3.4 4.5 6.7 8.0 19.4



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The total Hgb was measured using the patient’s whole blood. The total Hgb was multiplied by 3 to estimate the hematocrit (HCT) of the unit (9–11).

Inspectors’ assessments were compared against 3 other 1% hemolysis fHgb cutoffs, representing various units encoun-tered in practice. This was done to assess the investigators’ visual inspection ability at a variety of hemoconcentrations. The total Hgb values of these units were chosen to represent various typical whole blood and pRBC units. Figure 1 shows a variety of samples with various free hemoglobin concentrations, as well as the degree of hemolysis this represents in units with varying hemoconcentration.

Statistical analysesA McNemar’s test was conducted to examine the accuracy of the veterinarians’ and technicians’ assessments (12). Since multiple tests were calculated, a Bonferroni-corrected P-value (0.00625) was used to control for type 1 error inflation (13). All statistical tests were conducted using SPSS version 22 for windows (IBM, Armonk, New York, USA) and R: A Language Environment for Statistical Computing (2013).

ResultsA series of McNemar’s tests was conducted to test the dif-ference between the inspectors’ judgments and the four 1% hemolysis cutoff values. Table 1 shows the frequencies of the veterinarian’s judgments. The proportion of usable and unusable samples as determined by the veterinarians’ visual inspection was not significantly different from the proportion as determined by the calculated 1% hemolysis cutoff value of the sample, 2 = 3.790, df = 1, P = 0.052. However, the proportion of usable and unusable samples as determined by the veterinarians’ visual inspection was significantly different from the propor-tion as determined by the 2.10 g/L cutoff (2 = 99.150, df = 1, P 0.00001), the 3.50 g/L cutoff (2 = 16.03, df = 1, P = 0.00006), and the 6.50 g/L cutoff (2 = 55.00, df = 1, P 0.000001). For each unit (2.10, 3.50, and 6.50 g/L, respectively), the judgment of the veterinarians was significantly different from the mathematically derived sample cutoff.

For the technicians, there was a significant difference in the judgment of usability versus non-usability, compared to usability as determined by each 1% hemolysis cutoff. This was true for the sample (2 = 39.41, df = 1, P 0.00001), the 2.10 g/L unit (2 = 44.83, df = 1, P 0.00001), the 3.50 g/L unit (2 = 59.51, df = 1, P 0.00001), and the 6.50 g/L (2 = 97.00, df = 1, P 0.00001). Table 2 shows the frequencies related to the technicians’ judgments.

DiscussionThe data herein support the hypothesis that visual assessment of hemolysis when compared with measurement of fHgb results in blood being rejected that would meet FDA standards, as well as blood being deemed acceptable, which would not meet the FDA standard of 1% hemolysis. These quantitative data highlight the subjective nature of visual assessment and speak to the benefits of an objective measure, such as fHgb, to quantify hemolysis in stored blood.

Veterinarians deemed 10% of usable blood units as non-usable based on visual assessment, whereas technicians deemed 25% of usable blood units as non-usable. Both veterinarians and technicians consented to use of blood that would have exceeded the 1% hemolysis cutoff value. This occurred 25% of the time when the blood was assessed by veterinarians and 20% of the time when assessed by technicians. Despite the experience of the technicians and the level of training of the veterinarians in this study, visual assessment was not a reliable way to identify hemolysis exceeding the 1% hemolysis standard.

Inspectors’ assessments were compared, based on their visual assessment of the supernatant of our samples, to 3 additional fHgb cutoffs. These cutoffs were calculated based on units of blood representing typical units encountered in practice. Cutoffs for one unit with a HCT of 39%, a second unit with a HCT of 51%, and a third unit with a HCT of 66% were calculated. This analysis was done to assess visual inspection at various degrees of hemoconcentration. These cutoffs were compared to the known fHgb concentration of each sample and the investigators’ deci-sion to deem a unit usable or not usable at that fHgb concentra-tion. This could be done as inspectors did not actually assess for

Table 1. Frequency statistics for veterinarians’ judgments and 1% hemolysis cutoff values.

1% hemolysis cutoff values

Sample 2.10 g/L 3.50 g/L 6.50 g/L

Judgment No Yes Total No Yes Total No Yes Total No Yes Total

No 38 25 63 61 2 63 35 28 63 8 55 63Yes 13 226 239 105 134 239 5 234 239 0 239 239Total 51 251 302 166 136 302 40 262 302 8 294 302

Table 2. Frequency statistics for technicians’ judgments and 1% hemolysis cutoff values.

1% hemolysis cutoff values

Sample 2.10 g/L 3.50 g/L 6.50 g/L

Judgment No Yes Total No Yes Total No Yes Total No Yes Total

No 41 64 105 94 11 105 37 68 105 8 97 105Yes 10 187 197 72 125 197 3 194 197 0 197 197Total 51 251 302 166 136 302 40 262 302 8 297 302



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1% hemolysis, but rather made an assessment to transfuse or not based on the degree of redness of the supernatant, which is dependent only on the concentration of fHgb.

Technicians and doctors universally rejected non-transfusable blood in the most hemoconcentrated unit, the unit with the highest cutoff. However, technicians would have rejected 33% of transfusable units and veterinarians would have rejected 19% of transfusable units based on their visual assessment. We suspect that this is because the cutoff value of fHgb in the most concentrated calculation was relatively high at 6.50 g/L and easily recognizable as reddened. FHgb as low as 0.40 g/L has been shown to cause a grossly reddened appearance of plasma (5). Hemolysis is therefore more recognizable when the unit is more hemoconcentrated.

For the least concentrated unit, which had the lowest cutoff at 2.10 g/L, technicians and veterinarians would have inap-propriately accepted 43% and 63% of units, respectively. Technicians would have rejected 8% and veterinarians 1.5% of transfusable units. The lower the starting HCT of the blood, the lower the fHgb cutoff, and the less grossly reddened was the supernantant. This led to underestimation of the degree of hemolysis and inappropriate acceptance of a unit. It is not surprising that the accuracy of the inspectors’ decision varied at different cutoffs. The fHgb level which equals 1% hemolysis varies based on the starting RBC concentration in the sample, but the visual inspection method used in practice is simply a subjective assessment of redness. This further highlights the benefits of an objective measure of fHgb rather than subjective visual assessment of hemolysis.

This study had limitations. The number of total investigators and the number in each group was small. The technicians ability to judge blood for transfusion, compared with that of the veteri-narians, cannot be generalized to other veterinary professionals.

The formula used to calculate the 1% hemolysis of units was modified as the total Hgb or HCT of the processed units was not recorded. At our institution, only the total Hgb of the donor’s whole blood is routinely measured at the time of dona-tion. Therefore, the total Hgb of the donor’s whole blood was used in the equation and an HCT was extrapolated from this number and used to calculate a 1% hemolysis cutoff value. This was remedied by the comparison of differences in visual assess-ment at various levels of hemoconcentration.

The fHgb was calculated from blood stored in segments rather than from the blood stored in the parent bag. The seg-ments were made from the same material as the blood storage bag and had the same contents after stripping the lines and mixing the units. While it is possible that a segment may not be representative of the parent bag, this would not affect our results. This does not change the calculated 1% hemolysis cutoff

values, the measured value of fHgb, nor the inspector’s ability to make an assessment to transfuse or not transfuse. We believe that for the purposes of our investigation the segments were acceptable storage media.

Inspectors were not able to analyze the packed cell volume (PCV) of the sample, and access to this may have altered their decision to transfuse or not. While the PCV decreases only fractionally with 1% hemolysis, the PCV of the sample affects the amount of fHgb that constitutes 1% hemolysis. This was not discussed with the inspectors. As the 1% hemolysis cutoff is not a standard currently used in veterinary medicine, we do not believe our investigators are likely to have considered this.

In conclusion, this study shows that experienced veterinar-ians and veterinary technicians both over- and underestimate the degree of hemolysis in stored canine RBCs when relying on visual inspection. Visual inspection does not allow reliable differentiation of samples which do and do not exceed the FDA standard of 1% hemolysis in stored blood units. The clinical relevance of transfusing a unit with 1% hemolysis to dogs is unknown and further studies are required to determine if the FDA standard is relevant for dogs. CVJ

References 1. Obrador R, Musulin S, Hansen B. Red blood cell storage lesion. J Vet

Emerg Crit Care 2014;25:187–199. 2. Patterson J, Rousseau A, Kessler RJ, Giger U. In vitro lysis and acute

transfusion reactions with hemolysis caused by inappropriate storage of canine red blood cell products. J Vet Intern Med 2011;25:927–933.

3. Tocci JL, Ewing PJ. Increasing patient safety in veterinary transfusion medicine: An overview of pretransfusion testing. J Vet Emerg Crit Care 2009;19:66–73.

4. Maglaras CH, Koenig A, Bedard DL, Brainard BM. Retrospective evalu-ation of the effect of red blood cell product age on occurrence of acute transfusion-related complications in dogs: 210 cases (2010–2012). J Vet Emerg Crit Care 2017;27:108–120.

5. Janatpour KA, Paglieroni TG, Crocker VL, DuBois DJ, Holland PV. Visual assessment of hemolysis in red blood cell units and segments can be deceptive. Transfusion 2004;44:284–289.

6. AABB. Standards for Blood Banks and Transfusion Services. 29th ed. Bethesda, Maryland: AABB, 2014:120.

7. Prittie JE. Controversies related to red blood cell transfusion in critically ill patients. J Vet Emerg Crit Care 2010;20:167–176.

8. Sowemimo-Coker SO. Red blood cell hemolysis during processing. Transfusion Med Rev 2002;16:46–60.

9. Turkson PK, Ganyo EY. Relationship between haemoglobin concentra-tion and packed cell volume in cattle blood samples. Onderstepoort J Vet Res 2015;82:1–5.

10. Bain BJ, Bates I. Basic haematological techniques. In: Lewis SM, Bain BJ, Bates I, eds. Practical Haematology. 9th ed. Edinburgh, UK: Churchill Livingstone, 2001:19–46.

11. Stockham SL, Scott MA. Erythrocytes. In: Stockham SL, Scott MA, eds. Fundamentals of Veterinary Clinical Pathology. 2nd ed. Ames, Iowa: Blackwell, 2008:107–221.

12. McNemar Q. Note on the sampling error of the difference between correlated proportions or percentages. Psychometrika 1947;12:153–157.

13. Bonferroni CE. Teoria statistica delle classi e calcolo delle probabil-ità, Pubblicazioni del R Istituto Superiore di Scienze Economiche e Commerciali di Firenze. 1936;8:3–62.



Article

Vasopressor use in 41 critically ill cats (2007–2016)

Nikki Licht, Elizabeth A. Rozanski, John E. Rush

Abstract — This study describes the use of vasopressors in critically ill cats. Records of 41 cats hospitalized in the ICU were evaluated. Signalment, blood pressure, underlying conditions, evidence of sepsis, type of treatment (surgical versus non-surgical), vasopressor type and duration, adverse events attributed to vasopressors, and survival were recorded. Twenty-one cats (51%) had an underlying disease considered amenable to surgical treatment while 20 (49%) cats did not. Evidence of sepsis was present in 24 (59%) cats. Thirty-four cats developed a Doppler blood pressure (DBP) 80 mmHg during therapy, and 29 cats became normotensive (DBP 90 mmHg). Seven cats did not increase their DBP to 80 mmHg. All cats received dopamine and/or norepinephrine and 6 cats also received other vasopressors. Sixteen cats survived (39%). Surgical intervention was associated with a higher survival (P = 0.004). Critically ill hypotensive cats may benefit from administration of vasopressors.

Résumé — Utilisation de vasopressine chez 41 chats en état critique (2007–2016). Cette étude décrit l’utilisation de vasopresseurs chez les chats en condition critique. Les dossiers médicaux de 41 chats hospitalisés ont été évalués. Le signalement, pression sanguine, conditions sous-jacentes, évidence de sepsis, type de traitement (chirurgical contre médical), type de vasopresseurs et durée, effets adverses reliés à l’utilisation des vasopresseurs et survie ont été comptabilisés. Vingt et un chats (51 %) avaient une condition sous-jacente susceptible au traitement chirurgical contrairement aux 20 autres chats (49 %). L’évidence de sepsis était présente dans 24 (59 %) chats. Trente-quatre chats ont développé une pression sanguine au Doppler (DBP) 80 mmHg durant le traitement et 29 chats sont devenus normotensifs (DBP 90 mmHg). Sept chats n’ont pas eu d’augmentation de leur DBP 80 mmHg. Tous les chats ont reçu de la dopamine et/ou de la norépinéphrine et 6 chats ont reçus d’autres vasopresseurs. Seize chats ont survécu (39 %). Une intervention chirurgicale est associée à un plus grand taux de survie (P = 0,004). Les chats hypotensifs en condition critique peuvent bénéficier de l’utilisation de vasopresseurs.

(Traduit par les auteurs)

Can Vet J 2018;59:1175–1180

Introduction

H ypotension is a common occurrence in animals admitted to the ICU, and a subset of this population is refractory to

fluid resuscitation (1). Hypotension in critically ill cats has been associated with a poor prognosis, particularly when coupled with increases in lactate (1,2). In humans, unresolved hypotension and inadequate tissue perfusion are recognized as precursors to multi-organ dysfunction and death, and are important and tangible targets for intervention (2,3). Evidence-based guidelines advocate the use of vasopressors in hypotensive humans who are adequately volume resuscitated and are therefore considered to have refractory hypotension (4), but evidence-based guidelines

do not exist in cats surrounding the optimal use of vasopressors. However, based on expert opinion, the use of vasoactive drugs such as dopamine, dobutamine, norepinephrine, phenylephrine, vasopressin, or epinephrine has been recommended to improve blood pressure and subsequently restore organ perfusion (5–9). Potential concerns surrounding the use of vasopressors in humans include hypertension, arrhythmias, acute kidney injury (AKI), splanchnic and/or peripheral ischemia, and medication errors (10,11).

The purpose of this study was to describe the use and out-comes in cats treated with vasopressors in the ICU for hypoten-sion associated with critical illness.

Materials and methodsThe medical record database between January 1, 2007 and May 31, 2016 was searched, using the keywords “feline,” and “norepinephrine,” “phenylephrine,” “epinephrine,” “dopamine,” “dobutamine,” and “vasopressin.” Cats receiving vasopressors for less than 1 h and cats that received vasopressors only during anesthesia were excluded.

The following data were collected from the medical record: signalment, blood pressure measurements, underlying disease

Cummings School of Veterinary Medicine at Tufts University, 55 Willard Street, North Grafton, Massachusetts 01536, USA.Address all correspondence to Dr. Elizabeth Rozanski; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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conditions, including presence or suspicion of sepsis, and whether surgery was performed for the underlying condition, type, and duration of vasopressor therapy, and documented adverse events (arrhythmias, acute kidney injury, new onset of vomiting, or bloody diarrhea) attributed to vasopressor use. Additionally, blood component transfusions and glucocorticoid use were recorded. Finally, survival at 24, 48, and 72 h, weaning from vasopressors, duration of hospitalization and whether mor-tality occurred due to euthanasia or natural death were recorded.

Hypotension was defined as a Doppler blood pressure 90 mmHg, while normotension was defined as 90 to 150 mmHg. Doppler blood pressure determinations were made using a cuff size that was 30% to 40% of the limb circumfer-ence, the same size cuff was used for repeated measurements, and usually the same limb, unless catheter location affected use of a specific limb. Volume status was evaluated by physical examination, vital signs, and in some cases measurement of central venous pressure (CVP) or point-of-care ultrasound to subjectively assess left ventricular size. Acute kidney injury (AKI) was defined as an increase in creatinine of 26.6 mol/L (12). Critical illness in a cat was defined as having clinical signs of systemic disease, and inability to maintain homeostasis without aggressive supportive measures.

Descriptive statistics were used and the Fisher’s exact test was used to compare groups, with a P-value of 0.05 considered to be statistically significant. Correlation was evaluated using the Pearson correlation coefficient.

ResultsSignalmentForty-one cats fulfilled the inclusion criteria. Breeds identified included 23 domestic shorthairs, 6 domestic longhairs, 3 Maine coons, 3 Siamese cats, and 1 each of the following breeds: Norwegian forest cat, Persian, Himalayan, Bombay, ragdoll, and Turkish van. There were 24 castrated males, 15 spayed females, and 2 intact females. The median age was 10 y (range: 1 to 19 y).

Blood pressureBlood pressure measurements were performed using Doppler ultrasonography in all cats. Initially all cats had a Doppler blood pressure (DBP) 80 mmHg or a non-detectable blood pres-sure before vasopressor therapy was initiated. Blood pressures could not be measured in 14 cats. In the cats with detectable blood pressure the median DBP was 56 mmHg (range: 40 to 70 mmHg). Median temperature on initiation of vasopressor therapy was 36.9°C (range: 32.5°C to 40.0°C), but any hypo-thermic cats were actively rewarmed before vasopressor therapy was intitated. Median heart rate at initiation was 160 beats/min (bpm) (range: 51 to 250 bpm). The associations between DBP and temperature, DBP and heart rate, or heart rate and tem-perature were not significantly correlated.

Underlying disease process, sepsis, and surgical therapyBy study design, all cats were critically ill, with a wide range of conditions. Twenty-four cats had evidence of sepsis based on

bacterial (n = 18) or fungal (n = 1) cultures or supportive diag-nostics and conclusions as noted in the medical record (n = 5). Sources of sepsis included gastrointestinal (n = 6), hepatobiliary (n = 6), generalized peritonitis (n = 5), pulmonary (n = 4), pleu-ral space (n = 2), and reproductive tract (n = 1). Seventeen cats did not have evidence of infection; in these cats, the underlying disease included traumatic liver rupture and intraabdominal hemorrhage (n = 1), diabetic ketoacidosis (n = 3), cardiopulmo-nary disease (n = 3), renal disease (n = 2), liver disease (n = 2), anaphylaxis (n = 1), and systemic neoplasia (n = 5). Surgical treatment was performed in 21 cats for source control or to treat the underlying disease while 20 cats were considered to have non-surgical conditions. All cats received intensive medical therapy at the discretion of the attending clinician and all cats were resuscitated with intravenous fluids prior to the initiation of vasopressors.

ResuscitationFive cats suspected of being volume overloaded at the time of documented hypotension did not receive additional fluid boluses. Two cats had been transferred from another hospital and were already receiving vasopressors following an unknown volume of administered crystalloids. The remaining 34 cats received a combination of 1 to 4 crystalloid boluses ranging from 5 mL/kg body weight (BW) to 20 mL/kg BW and contin-ued to receive crystalloid fluids at rates of 45 to 120 mL/kg BW per day. Eight cats were administered synthetic colloid boluses (5 to 20 mL/kg BW, IV), while 9 cats received blood products (fresh and stored whole blood) immediately before vasopres-sor initiation. Four cats had CVP measurements taken which ranged from 4 to 10 mmHg. All cats, except those thought to be volume overloaded, continued to receive further crystalloids, colloids, and blood products during vasopressor use as ongo-ing resuscitative efforts. Seven cats started vasopressor therapy during surgery after receiving multiple 5 to 10 mL/kg BW crystalloid and/or synthetic colloid boluses and vasopressors were continued after surgery. The medical records stated that the attending clinicians assessed the cats as adequately volume resuscitated or volume overloaded before starting vasopressors.

Vasopressor usedAll vasopressors were given as continuous rate infusions. Dopamine was used as the first-line vasopressor in 33 cats, while 7 cats were treated with norepinephrine, and 1 cat was administered epinephrine. All cats ultimately received either dopamine, norepinephrine or both. Prior to 2014, norepineph-rine was the first choice in 1 of the 34 cats treated compared with being the first choice in 6 of 7 cats treated during or after 2014 (P 0.001). Fourteen cats did not appear to respond to the initial vasopressor by an increase in blood pressure and had another vasopressor added or had the vasopressor changed. Of the 14 cats that were given 2 vasopressors in the ICU, 13 cats were on 2 vasopressors concurrently while 1 cat was switched from one vasopressor to another. Other drugs used in 6 cats in addition to either dopamine or norepinephrine included dobutamine (n = 3), epinephrine (n = 1), vasopressin (n = 1), or phenylephrine (n = 1).



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Dopamine was used in 35 cats with a median starting dose of 10 g/kg BW per min (range: 3 to 15 g/kg BW per min) and a median maximal dose of 10 g/kg BW per min (range: 5 to 15 g/kg BW per min). Seventeen cats treated with dopamine had their dose increased during treatment. Norepinephrine was used in 14 cats with a median starting dose of 0.5 g/kg BW per min (range: 0.05 to 1 g/kg BW per min) and a median maximal dose of 1.5 g/kg BW per min (range: 0.05 g/kg BW per min to 2 g/kg BW per min). Ten cats treated with norepinephrine had their dose increased during therapy. Doses were incrementally adjusted based on clinician preference and adjustments were generally performed not more frequently than every 30 min. Dopamine infusion rates were increased by 2.5 to 5 g/kg BW per min increments, while norepinephrine doses were adjusted in increments of 0.1 to 0.2 g/kg BW per min. When there were multiple vasopressors in use, only 1 vasopressor dose was changed at any given time.

Side effects attributed to vasopressorsDue to the critically ill nature of the cats, it was difficult to ret-rospectively attribute side effects specifically to the use of vaso-pressor therapy. In cats with acute kidney injury, 7/21 (33%) survived compared with 9/18 (50%) cats that did not have an increase in creatinine of 26.6 mol/L (P = 0.34). However, there was no documentation in the record attributing AKI to vasopressor use compared with multi-organ failure associated with critical illness, and vasopressors rates were not adjusted based on the development of AKI.

Ventricular arrhythmias were documented in the record of 2 cats as increasing in frequency during vasopressor use. Both of these cats were receiving dopamine, 1 at 10 and 1 at 15 g/kg BW per min. One of these cats had a prior diagnosis of hypertrophic cardiomyopathy and was being treated for a dia-betic ketoacidotic crisis, but his cardiac condition worsened, he developed congestive heart failure, and acute kidney injury, and was euthanized due to his moribund condition. The other cat presented in a diabetic ketoacidotic crisis and based on point-of-care ultrasound in the ICU was noted to have poor cardiac contractility throughout hospitalization, developed oliguric renal failure, and was euthanized before having a formal echo-cardiogram done. No other adverse events, such as evidence of splanchnic hypoperfusion (new onset vomiting or bloody diar-rhea), were noted in the medical record to have been suspected to be a result of vasopressor use.

Twenty-three (56%) cats received type-specific whole blood or component therapy as part of supportive care, with packed red blood cells being transfused to 18 cats, whole blood to 12 cats, and plasma to 4 cats. There was no survival difference in cats receiving or not receiving each component, nor was there a documented effect of transfusion on blood pressure. No cat had a documented transfusion reaction; transfusion reactions may result in hypotension.

SurvivalOverall, 16 (39%) cats survived and were discharged from the hospital. Fourteen (34%) cats were euthanized, and 11 (27%)

cats died. All cats that were euthanized were considered mori-bund. Thirty-two cats (78%) survived to 24 h. Of these 32 cats, 21 (65%) had been weaned off vasopressors while 11 (35%) were still receiving vasopressor therapy. Eight of these 11 cats were being administered single agent dopamine while 3 cats had been started on dopamine and had norepinephrine added. Twenty-six (63%) cats survived to 48 h. Nineteen (73%) of these cats had been weaned off vasopressors while 7 (27%) cats continued to receive vasopressors. Twenty-four (58%) cats survived to 72 h, and in this group, 21 (88%) cats had been weaned from vasopressor therapy, while 3 (12%) cats remained on vasopressors. For these 3 remaining cats, 1 cat was weaned at 75 h and survived, 1 cat was weaned at 112 h and survived, and 1 cat died at 102 h. Median duration of hospitalization was 6 d, with a range of 1 to 35 d.

Blood pressure effectsPrior to the initiation of vasopressor therapy the DBP was 80 mmHg or not detectable in all cats. Thirty-four cats (83%) had a documented DBP of at least 80 mmHg associated with vasopressor therapy while 7 cats (17%) did not, and 28 cats had a documented DBP of 90 mmHg or were discharged from hospital.

A single vasopressor was administered to 24 cats that achieved a DBP of at least 80 mmHg, and 20 of these cats received dopamine while 4 were administered norepinephrine. Two vasopressors were given to 10 cats, with 6 of these cats receiving norepinephrine and dopamine while 1 cat each received a com-bination of either norepinephrine and epinephrine, dopamine and dobutamine, dopamine and vasopressin, or norepinephrine and phenylephrine.

Seven cats did not achieve a DBP of at least 80 mmHg, and 3 of these were on single agent therapy while 4 cats received a vasopressor combination. Three cats were treated with dopamine alone and 2 cats each received either dopamine and norepineph-rine or dopamine and dobutamine.

A DBP of at least 80 mmHg was achieved by all 4 cats which received norepinephrine as a single agent and by 11/23 cats (48%) on dopamine as the single agent.

The 34 cats that developed a DBP of at least 80 mmHg required a median time of 6 h (range: 1 to 80 h) to achieve this target, and the 28 cats that developed a DBP of 90 mmHg required a median of 6 h (range: 0 to 96 h) from the time of initiation of vasopressor therapy. Median heart rate at the time of documented DBP 90 mmHg was 180 bpm (range: 51 to 232 bpm). At the time of discontinuation of vasopressor therapy median body temperature was 37.8°C, range 36.4°C to 39.5°C, and median heart rate was 186 bpm (range: 102 to 250 bpm).

Twenty-nine cats became normotensive based on a DBP 90 mmHg in 27 cats or survival to discharge without docu-mented normotension (n = 2). Twenty-seven cats survived to be weaned off vasopressors, although 4 cats did not have docu-mented normotension. Eleven cats overall were weaned from vasopressors but did not survive to discharge. In this group of non-survivors, all were off vasopressors with no evidence of hypotension for at least 24 h before a clinical decline associated with progression of their underlying illness.



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Influence of surgery and sepsisSurgical treatment was performed in 21 cats to control or treat the underlying disease, while 20 cats were considered to have non-surgical conditions. Survival to discharge was 62% (13/21) for cats treated surgically as compared to 15% (3/20) for cats treated non-surgically (P = 0.004). Twelve of the 24 cats with sepsis survived (50%), while 4 of the 17 cats without evidence of sepsis survived (24%; P = 0.11). Surgical intervention in cats with sepsis resulted in 11 cats surviving (61%) compared to survival of 1 of the 6 cats (17%) with sepsis that did not have surgery due to a lack of surgical options for source control (e.g., cholangiohepatitis) (P = 0.15).

Glucocorticoids and cortisol determinationGlucocorticoids were given to 13 cats. Five of these cats had been diagnosed with either lymphoma or a mast cell tumor, while 3 cats were receiving chronic glucocorticoid therapy for suspected inflammatory bowel disease. Three cats received glucocorticoids for support of suspected/confirmed sepsis and possible critical illness associated corticosteroid insufficiency; 1 cat received glucocorticoids for the treatment of anaphylaxis, and 1 cat was given steroids to decrease airway inflammation secondary to upper airway obstruction as a result of suspected laryngeal paralysis. Five (38%) of the 13 cats that received glu-cocorticoids survived, while 11 (39%) of the 28 cats that did not receive glucocorticoids survived (P = 1.0).

Cortisol levels were determined for 4 cats, including 3 with septic conditions. Baseline cortisol values ranged from 129.7 to 460.8 nmol/L. ACTH stimulation tests were performed on 2 cats, 1 with sepsis and 1 with liver disease. One septic cat had an ACTH stimulation test result consistent with diminished adrenal reserves (13) (delta cortisol 52.4 nmol/L), received hydrocortisone therapy and survived to be discharged.

Influence of vasopressorTwenty-three cats received only dopamine as a vasopressor, and 8 (47%) survived. Four cats received only norepinephrine and 2 survived. Fourteen cats received 2 vasopressors and 6 (42%) survived. There was no statistical benefit of dopamine compared with norepinephrine or the use of multiple vasopressors. The median time to normalization of blood pressure (6 h) was similar whether cats received either dopamine or norepinephrine.

DiscussionThe results of this retrospective study describe the use of vaso-pressors in a population of critically ill cats with hypotension. Cats being treated with vasopressors generally had an increase in their blood pressure, with 29 of 41 cats achieving normotension. Persistent hypotension in cats has previously been associated with a poor outcome (1,2). In septic human patients, the sur-viving sepsis guidelines (4) recommend providing vasopressors if the mean blood pressure is 65 mmHg despite adequate fluid resuscitation. In critically ill animals, most clinicians also recommend use of vasopressors when administration of an adequate fluid replacement volume has failed to improve blood pressure (8). All of the cats that were perceived to be fluid tolerant in this study received fluid therapy consisting of

crystalloids prior to vasopressor initiation, and further resuscita-tion with colloids as well as blood products was initiated before and during vasopressor therapy. Although the exact indication for initiating vasopressors was poorly recorded in the medical record, blood pressure measurements were consistently low or undetectable despite fluid resuscitation. As in humans, it is dif-ficult to determine at times if an adequate fluid challenge has been administered before starting vasopressors (14), but there is growing evidence that a positive fluid balance is linked to an increase in mortality (15,16).

All the cats in this study were assessed by the clinician as being adequately volume resuscitated, but considerable chal-lenges exist in accurate determination of volume status. Physical examination parameters, response to fluid boluses, and CVP were all used to determine volume status and perfusion. Central venous pressure has recently been recognized as a less useful tool in determining volume status (17). Echocardiography may have some role in determining volume status, but was not used in this study for this purpose. Point-of-care ultrasound examination was performed to assess left ventricular volume as a surrogate indicator of adequacy of preload. As a retrospective study, it is impossible to determine if some cats may have responded to further fluid resuscitation rather than vasopressor therapy.

Vasopressor choice in this retrospective study was based on clinician preferences, with a recent shift from dopamine to norepinephrine presumably paralleling guidelines in humans (4). Dopamine was historically favored as a vasopressor, but due to apparent improved outcome in septic shock in humans, norepinephrine is now preferred over dopamine in this subset of human vasopressor-dependent patients (18). Whether this recommendation is applicable to critically ill cats with a more heterogeneous spectrum of disease is unknown. In this study 80% of cats were started on dopamine compared with 17.5% on norepinephrine, but no conclusions could be drawn as to their relative effectiveness due to the small number of cats and the variability of the clinical picture.

Dobutamine provides primarily inotropic support and only has indirect vasopressor actions. Dobutamine was given to 3 cats with refractory hypotension, 2 of which had underlying cardiac disease with reduced contractility documented with an echo-cardiogram. In cats, use of dobutamine has been infrequently reported, with documented increases in myocardial performance in healthy cats (19,20), but limited data applicable to our ICU patient population exist. Potential side effects of dobutamine include seizures at doses 5 g/kg BW per min (21), which was not noted in our patient population.

Epinephrine was used in 1 cat as a CRI following a severe anaphylactic event. In veterinary medicine, epinephrine is largely reserved for anaphylaxis due to concerns over beta-agonist effects and increased myocardial oxygen consumption as well as splanchnic ischemia due to excessive vasoconstriction (5,22). Vasopressin is a non-adrenergic vasopressor that acts directly to increase vasoconstriction and potentiate the effects of adrenergic agonists (5). Prolonged hypotension in humans and dogs results in a depletion in vasopressin stores (23) and it has been suggested that vasopressin therapy may be helpful in cases of prolonged refractory hypotension (24) or hypotension



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in association with a severely acidemic patient. Vasopressin has not been explored as a single agent in cats. However, studies in humans have not indicated a clear benefit (25) and the current cost of vasopressin limits its use.

The use of multiple vasopressors, most commonly dopamine and norepinephrine, was described in this study, as was chang-ing from 1 vasopressor to another. Practical considerations in switching vasopressors include inadvertent bolus associated with flushing the IV catheter and increased potential for drug calculation errors. From a clinical perspective, in human medi-cine, current recommendations for sepsis include starting with norepinephrine, and adding either epinephrine or vasopressin if norepinephrine is ineffective or with vasopressin to allow the down titration of the infusion rate of norepinephrine. Direct switches from 1 vasopressor to another are rare unless there is evidence of significant side effects, such as ectopy.

Cats that were treated surgically did significantly better than cats that did not have a surgical intervention. Cats treated sur-gically were more likely to have sepsis. A recent human study clearly documented a survival benefit in patients with sepsis who underwent source control compared to patients who did not have source control, supporting the theory that control of the source of sepsis is useful (26).

Limitations of this study include those of most retrospective studies, namely a varied approach to vasopressor use by indi-vidual clinicians, and lack of a standardized approach to fluid resuscitation prior to beginning vasopressors. Volume status in cats is particularly difficult to assess, and cats are prone to fluid overload from occult cardiomyopathy (27). Additionally, measurement of blood pressure in cats is challenging at times, particularly in hypotensive and/or vasoconstricted cats (28–30). The specific rationale behind vasopressor decisions was not always clear, which might have impacted outcome. There was no apparent benefit to norepinephrine over dopamine, but due to the small sample size, the possibility of a type 2 error exists. It is possible other cats hospitalized during the study period had hypotension, but did not receive vasopressors and survived, and it is certainly possible that some cats in this study may have responded to more aggressive fluid therapy alone.

From a practical standpoint, based upon the results of this study, vasopressors appear to have a role in support of blood pressure in critically ill cats. Recommendations for clinical management of cats with hypotension include an aggressive search for an underlying cause and aggressive fluid resuscita-tion with crystalloids (10 to 20 mL/kg BW boluses repeated as needed). Electrolyte and acid-base disturbances should be corrected. If hypotension persists, either dopamine starting at 5 g/kg BW per min or norepinephrine starting at 0.1 g/kg BW per min is acceptable and should be initiated and titrated to effect. Vasopressors may be slowly decreased after a DBP of 90 mmHg is maintained for at least 1 h, but the cat should be closely monitored for relapse.

In conclusion, this study describes the use of vasopres-sors in cats with various underlying causes of critical illness. Vasopressors appear appropriate for use in critically ill cats and hypotensive cats recovering from surgery in particular may benefit from the use of vasopressors. CVJ

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1. A) Taurine and arachidonic acid are not found in plant sources and are required by cats. Cats cannot convert the vitamin A precursors found in plants to vitamin A; therefore, vitamin A from meat sources is required by the cat.

A) La taurine et l’acide arachidonique ne sont pas rencontrés dans les plantes et les chats en ont besoin. Les chats ne peuvent pas convertir les précurseurs de la vitamine A trouvés dans les plantes en vitamine A. La vitamine A provenant des viandes est dont nécessaire pour les chats

2. B) A swelling under the tongue could be associated with a ranula or, potentially, a neoplastic process. While neoplasia may lead to laryngeal paralysis, the neoplasia is typically found in the ventral cervical region or the cranial mediastinum, not under the tongue. The other 4 answers are common present-ing complaints in dogs afflicted with laryngeal paralysis.

B) L’enflure sublinguale est associée à une ranula ou, potentiellement, à une néoplasie. Bien que la néoplasie puisse conduire à une paralysie laryngée, la néoplasie est rencontrée de façon caractéristique dans la région cervicale ventrale ou dans le médiastin cranial et non sous la langue. Les quatre autres réponses sont des troubles fréquents des chiens atteints de paralysie laryngée.

3. D) Surgery in this region is usually not possible. The ureters are located there, and it is usually not possible to resect the entire tumor. Cystectomy with the creation of an external bag for urine collection is the preferred treatment for humans but is not a practical therapy for pets. Radiation therapy has limited benefits to date. Chemotherapy with platinum com-pounds has limited response over that of piroxicam alone; nephrotoxicity is a limiting side effect.

D) La chirurgie dans cette région n’est pas habituellement possible. Les uretères se terminent à cet endroit et il n’est habituellement pas possible d’enlever la tumeur au complet. La cystectomie avec la pose d’un sac externe de récupération de l’urine est le traitement de choix chez les humains, mais n’est pas pratique chez les animaux. La radiothérapie possède des effets limités à ce jour. La chimiothérapie à l’aide de composés de platine possède une réponse limitée sur le traitement au proxicam seul; la néphrotoxicité représente un effet secondaire limitant.

4. A) The correct answer is to treat all contact animals. Chorioptic mange is common in draft breeds, is not associated with poor nutrition or hygiene, and is not a reportable condition. It is transmitted via direct and indirect contact and pruritus may not be present; thus, all contact animals should be treated.

A) La bonne réponse est de traiter tous les animaux qui ont des contacts. La gale chorioptique est commune chez les races de chevaux de trait et n’est pas associée à la mauvaise nutrition ou à la mauvaise hygiène et n’est pas une maladie à déclaration obligatoire. Elle est transmise par contact direct ou indirect et le prurit peut être absent; ainsi, tous les animaux qui ont des contacts doivent être traités.

5. A) Mycoplasma polyarthritis is common in feedlots and rare on dairy farms. Otitis interna is common in dairy calves but not beef. Mycoplasma spp. are not implicated in the etiology of puerperal metritis. Mycoplasma pneumonia is common in all bovine settings.

A) La polyarthrite à Mycoplasma est commune dans les parcs d’engraissement mais rare dans les fermes laitières. L’otite interne est commune chez les veaux de races laitières mais non chez ceux de races de boucherie. Mycoplasma sp. n’est pas impliqué dans l’étiologie de la métrite puerpérale. La pneumonie à Mycoplasma est commune chez tous les bovins.

Answers to Quiz Corner Les réponses du test éclair

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DH 318 CVJ Quiz_3.indd 2 2018-09-25 10:04 AM



Article

Many Canadian dog and cat foods fail to comply with the guaranteed analyses reported on packages

Stuart W. Burdett, Wilfredo D. Mansilla, Anna K. Shoveller

Abstract — We compared analyzed nutrient contents of Canadian-specific dry dog and cat foods to the guaranteed analyses on packages and to the Association of American Feed Control Officials (AAFCO) 2018 nutrient targets to assess compliance with the Consumer Packaging and Labelling Act. We also explored differences in macronutrient content between species (dog and cat) and life stage for adult pet foods (all life stages and senior). Extruded dog (n = 16) or cat (n = 11) foods advertised as all life stage or senior, sold only in Canada, and carrying an AAFCO nutritional adequacy statement were selected. Proximate analyses and amino acid analyses were completed on all diets. Of the 27 foods, 25 met or exceeded the AAFCO nutrient recommendations. Only 9 foods met all nutrient content claims listed in their guaranteed analyses. Nutrient content between species or life stages was not different (P 0.10).

Résumé — Bon nombre d’aliments pour chiens et chats ne sont pas conformes aux garanties analyses rapportées sur bag. Nous avons comparé a analysé la teneur en éléments nutritifs du sec spécifiques au Canada chien et chat aliments pour la garantie d’analyses sur l’emballage et à l’Association of American Feed Control Officials (AAFCO) 2018 objectifs d’éléments nutritifs. Nous avons également examiné les différences de teneur en macronutriments entre espèces (chien et chat) ou de la vie des aliments pour animaux adultes (tous les stades de la vie et les cadres supérieurs). Chien extrudé (n = 16) ou de la nourriture pour chats (n = 11) annoncé comme tous les stades de la vie ou senior, vendu uniquement au Canada, et la réalisation d’un état nutritionnel approprié de l’AAFCO ont été sélectionnés. L’analyse immédiate et en acides aminés ont été effectuées sur tous les régimes alimentaires. De l’alimentation 27, 25 ont atteint ou dépassé les recommandations nutritionnelles de l’AAFCO. Cependant, seuls les régimes alimentaires 9 satisfait à toutes les allégations relatives à la teneur en éléments nutritifs énumérés dans leurs garanties d’analyses. Teneur en éléments nutritifs entre les espèces ou étapes de la vie n’était pas différent (P 0,10).

(Traduit par les auteurs)

Can Vet J 2018;59:1181–1186

Introduction

I n Canada, there is no enforcement for the nutrient com-position of dog and cat foods, or their compliance with

current United States of America (USA) or European standards for nutrient density. Although the Association of American Feed Control Officials (AAFCO) has no enforceable author-ity, it is responsible for setting model regulations for pet foods

including labelling requirements, ingredient definitions, and nutrient requirements in the USA (1). Moreover, pet food manufacturers in the USA not only have to comply with federal regulating agencies such as the Federal Drug Administration (FDA), Federal Trade Commission (FTC), and United States Department of Agriculture (USDA), but also with State Feed Control Officials who may adopt some or all of the AAFCO standards and nutritional recommendations for different species and life stages. The AAFCO nutritional standards are based on the National Research Council (NRC) nutrient recommenda-tions (2). The NRC compiles and reviews scientific literature on a variety of species during various life stages and provides recommendations regarding nutrient requirements. These rec-ommendations are considered by AAFCO and used to set regulatory standards, and where applicable, increased nutrient recommendation levels account for the effects of digestibil-ity among pet foods (3). The AAFCO additionally presents acceptable analytical variations specific for each nutrient in the

Department of Animal Biosciences, University of Guelph, Guelph, Ontario.Address all correspondence to Dr. Anna K. Shoveller; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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guaranteed analysis (GA). However, it is the responsibility of the manufacturer to ensure that they remain within the acceptable limits for analytical variation, as well as account for this and formulate products to contain enough nutrients to meet the acceptable range for the GA.

In Canada, regulation of pet food is only at the federal level and less rigorous than in the USA. The Guide for the Labelling and Advertising of Pet Foods highlights the standards for label-ling, such as reporting the GA. The GA includes a minimum content on an “as is” basis for crude protein (CP), crude fat, and a reported maximum content for crude fiber and moisture. Nutrient profile claims are also contained within the guide; however, these standards are not required by law and are fol-lowed on a voluntary basis. Because of this and as a commercial strategy, many pet food companies in Canada include an AAFCO nutritional adequacy statement. Once a food is labelled with an AAFCO statement, companies are responsible for ensuring that the nutrient content meets the AAFCO nutrient profile and the GA provided on the package. The objective of this study was to assess whether Canadian pet food manufacturers were comply-ing with the Consumer Packaging and Labelling Act in regard to nutrient content claims for moisture, protein, and the essential amino acids, ash, and fat. We compared analyzed nutrient con-tent to individual GA reported on the package and to guaran-teed AAFCO nutrient recommendations (3). We also explored differences in macronutrient content between species (dog and cat) and life stage for adult pet foods (all life stages and senior).

Materials and methodsCriteria for selection of dietsIn total, 27 diets (16 dog, 11 cat; 21 all life stages and 6 senior formulations) were purchased from pet specialty retailers with Canada-wide distribution based on the following criteria: i) diets were manufactured and distributed solely within Canada and not marketed in the USA or any other foreign market to our knowledge; ii) diets were extruded, over-the-counter dog and cat foods intended and labelled as “all life stage” or “senior” formulations; and iii) diets claimed the product met or exceeded the AAFCO (3) nutrient profiles for the respective species and stage of life. No diets produced by the big 3 global pet food companies were included. Moreover, considering the influence of the American market on the Canadian market (50% of pet food is imported from USA) and the high level of regulation and need for product registration in each USA state, products sold in the USA were not included.

Sampling and analysisFor each bag of pet food, two 250 g representative samples were taken immediately after opening. Samples of each food [blinded with no indication of brand or stock-keeping unit (SKU)] were delivered to the Central Analytical Laboratory at Royal Canin (Guelph, Ontario). Analysis of amino acids (AA) was performed in the Department of Animal Biosciences at the University of Guelph. Proximate analyses (PA) and AA content were deter-mined in duplicate for all samples taken.

Proximate analyses. Dry matter (DM) content of samples was determined by weight loss in a 2-gram ground subsample

after placing samples in an oven at 102°C 6 2°C for 24 h according to ISO standards (ISO 6496:1999, Animal feeding stuffs, Determination of moisture and other volatile matter.) Crude protein (CP) content in diet samples was determined using the Dumas method (4) [validated by ISO (ISO 16634-1, 2008, Food products, Determination of the total nitrogen content by combustion, according to the Dumas principle and calculation of the crude protein content)]. Crude fat content was determined by solvent extraction according to the Association of Official Agricultural Chemists (AOAC) method (5) validated by ISO (ISO 6492:1999, Animal feeding stuffs, Determination of fat content), and ash content was determined by calcination at 550°C for 8 h, according to ISO validated (ISO 5984:2002, Animal feeding stuffs, Determination of crude ash) AOAC method (6).

Amino acid analyses. Amino acid profiles of the diets (except Met, Cys, and Trp) were determined in duplicate using AOAC methods (7). Briefly 0.1 g of ground sample was mixed with 5 mL of 6 M HCl containing 1% (w/v) phenol in a screw cap test tube. Tubes were purged of oxygen with nitrogen gas and sealed before they were placed in a heating block at 110°C for 24 h. After acid digestion, 1 mL of norvaline internal standard (5 mM, Sigma Aldrich, Oakville, Ontario) was added to each test tube. After filtration (syringe filter, 0.22 m membrane filter), samples were stored at 20°C until further processing. Before derivatization, 100 L acid samples were neutralized with 100 L of 6 M NaOH. Neutralized samples and the stan-dard were derivatized by ACCQ Tag Ultra derivatization kit (Waters Corporation, Milford, Massachusetts, USA) according to Boogers et al (8).

Calculations and statistical analysisDescriptive statistics were used to measure the number of diets that were above or below the maximum or minimum nutrient densities labelled within the GA on the product packaging on an “as is” basis. Individual AA, CP, crude fat, and ash contents were standardized to DM and compared using descriptive statistics to determine the number of diets that were below the AAFCO (3) nutrient profiles (Table 1) for CP, crude fat, and essential AA. The MIXED procedure of SAS (SAS Version? SAS, Cary, North Carolina, USA) was used to determine differences among AA content, with species (dogs and cats) and life stage (all life stages and senior) as fixed effects. For all statistical analyses, differences were considered significant at P # 0.05 and a trend at 0.05 P # 0.10.

ResultsComparison with guaranteed analysisAll diets sampled included a GA for CP and crude fat, but only 20 included ash and 26 included moisture on their product packaging. Among the 27 diets that reported minimum CP and crude fat contents, 3 had lower CP concentrations and 7 had lower crude fat content than the labelled minimum. Of the 20 diets that reported maximum ash content, 11 contained con-centrations of ash above their product’s guaranteed maximum. All of the 26 diets that reported maximum moisture contents were below these levels. In general, of the 27 diets analyzed,



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only 9 successfully met all the claims listed in their GA label (Table 2).

Comparison with AAFCO profilesCrude protein, crude fat, and AA concentrations in 25 of the 27 diets had nutrient profiles that met or exceeded the nutri-ent recommendations set forth by the AAFCO (Table 3). The 2 diets that failed to meet or exceed the AAFCO nutrient profiles were below the AAFCO recommendation of 1.04% for threonine (3).

Species and life-stage effectCrude protein, crude fat, and ash contents were not different between species (dog versus cat; P 0.10) or life stages (all life stage versus senior; P 0.10). Dog food tended to have a greater tyrosine content than cat food (0.05 P 0.10; Table 4). All other AA were similar between species and life stage (P 0.1).

DiscussionThe lack of nutritional standards and pre-market product review on pet foods in Canada has left the Canadian industry vulner-able to inadequate diet formulations and misleading product labels. Therefore, we tested different pet food products for CP, crude fat, and individual AA content to compare with the prod-uct GA and nutrient recommendations from the AAFCO (3). Crude fiber was not analyzed in the present study as the current recommendations suggest moving towards dietary fiber, not crude fiber. It would have been interesting to analyze products for sulfur-containing amino acids (methionine, cysteine, taurine) and the methyl accepting and donating compounds (choline, betaine, B12, carnitine, creatine, and folate); however, due to limiting funding we only were able to analyze a limited number of nutrients. We, therefore, focused on nutrients listed in the product’s GA’s and non-sulfur containing amino acids. We also sought to compare nutrient concentration between species (dog and cats) and life stages (all life stages and senior).

When comparing individual nutrient content among diets with the GA on their package label, 18 of the 27 diets had GA claims that were not met and were therefore in violation of the

Consumer Packaging and Labelling Act. This may be partially attributed to an inadequate quality assurance program that monitors batch-to-batch nutrient variation in raw materials. Pet food manufacturers should maintain an up-to-date database of all their raw materials by analyzing and tracking the nutrient content of incoming ingredients. Upon arrival, the new raw material should be tested for nutrient content and compared with their databases. If the new batch is within their analytical variation, they should use a Z-score corrected quantity of that ingredient to ensure the end-product meets the GA (9). Accurate quantification of the raw material’s mathematical mean nutri-ent content and associated variability, therefore, are essential to ensure the formulated product will meet the pre-set maximum and minimums that are reported on package.

Failure to accurately account for nutrient variation can result in under- or over-estimation of nutrients in the GA and may have a detrimental impact on animal health. Hill et al (10) compared the variation between the GA and measured nutrient concentrations of dog and cat foods marketed in the USA. They determined that on average, CP and crude fat were underesti-mated by 1.5% and 1.0%, and the ash and moisture concen-trations were overestimated by 0.5% and 4.0%, respectively. Additionally, they determined that the variation between the PA and the GA resulted in a small but significant underestimation of calculated metabolizable energy density of the diets (10). The present study found similar variation between the GA and the PA. On average, the CP, crude fat, and ash were underestimated by 1.62%, 0.83%, and 0.43%, respectively, while moisture content was underestimated by 2.92%. Therefore, more precise pet food formulation practices are necessary to ensure not only the accurate reporting of the products’ GA, but also to prevent obesity and other health issues in companion animals.

In Canada, it is not required by law to include an AAFCO nutritional adequacy statement on pet food products. However, once a claim has been added on the product label, it is required to conform to the Consumer Packaging and Labelling Act (R.S.C., 1985, c. C-38), which states that “No dealer shall apply to any prepackaged product or sell, import into Canada, or advertise any prepackaged product that has applied to it a label containing

Table 1. Association of American Feed Control Officials dog and cat food nutrient profiles (%).a

Species

Cats Dogs

Nutrient Growth Maintenance Growth Maintenance

Crude protein 30.0 26.0 22.5 18.0Crude fat 9.0 9.0 8.5 5.5Arginine 1.24 1.04 1.0 0.51Histidine 0.33 0.31 0.44 0.19Isoleucine 0.56 0.52 0.71 0.38Leucine 1.28 1.24 1.29 0.68Lysine 1.20 0.83 0.90 0.63Phenylalanine 0.52 0.42 0.83 0.45Phenylalanine Tyrosine 1.92 1.53 1.30 0.74Threonine 0.73 0.73 1.04 0.48Valine 0.64 0.62 0.68 0.49a Nutrient content reported on a dry matter basis, presumes a caloric density of 4000 kcal metabolizable energy (ME)/kg, as

determined in accordance with Model Regulation PF9. Formulations 4000 kcal ME/kg must be corrected for energy density; formulations 4000 kcal ME/kg need not be corrected for energy. Formulations of low-energy density should not be considered adequate for reproductive needs based on comparison to the profiles alone.



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Table 2. Comparison of the proximate analyses (PA, as fed basis) and labelled guaranteed analyses (GA, as fed basis) of dry extruded dog and cat diets.a

Crude protein (min) Crude Fat (min) Ash (max) Moisture (max)

Species GA PA GA PA GA PA GA PA

Dog 29.0 (28.61, 29.39) 30.04 17.0 (16.15, 17.85)b 14.0 7.50 (7.17, 7.84) 7.40 12.0 (11.28, 12.72) 7.90Dog 29.0 (28.61, 29.39) 30.8 17.0 (16.15, 17.85) 19.3 7.50 (7.17, 7.84)b 10.3 12.0 (11.28, 12.72) 7.80Dog 25.0 (24.65, 25.35) 27.1 15.0 (14.25, 15.75) 17.1 NP NP 10.0 (9.40, 10.60) 6.00Dog 34.0 (33.56, 34.44) 36.4 18.0 (17.10, 18.90) 19.0 NP NP 10.0 (9.40, 10.60) 7.30Dog 24.0 (23.66, 24.34) 25.3 13.0 (12.35, 13.65) 12.7 8.00 (7.66, 8.35)b 10.9 10.0 (9.40, 10.60) 5.50Dog 38.0 (37.52, 38.48)b 37.3 18.0 (17.10, 18.90)b 17.0 NP NP 10.0 (9.40, 10.60) 8.30Dog 36.0 (35.54, 36.46)b 33.5 16.0 (15.20, 16.80) 18.2 8.00 (7.66, 8.35)b 13.3 10.0 (9.40, 10.60) 5.50Dog 38.0 (37.52, 38.48) 38.0 18.0 (17.10, 18.90)b 15.0 NP NP 10.0 (9.40, 10.60) 5.30Dog 38.0 (37.52, 38.48) 39.2 18.0 (17.10, 18.90)b 16.5 NP NP 10.0 (9.40, 10.60) 5.30Dog 29.0 (28.61, 29.39) 31.1 17.0 (16.15, 17.85)b 16.0 7.50 (7.17, 7.84) 5.50 12.0 (11.28, 12.72) 7.60Dog 26.0 (25.64, 26.36) 27.8 15.0 (14.25, 15.75) 18.0 10.0 (9.63, 10.38) 6.40 NP NPDog 21.0 (20.69, 21.31) 25.7 8.00 (7.60, 8.40) 11.2 NP NP 10.0 (9.40, 10.60) 10.4Dog 18.0 (17.72, 18.28) 24.1 8.00 (7.60, 8.40)b 7.40 6.00 (5.69, 6.32)b 7.70 10.0 (9.40, 10.60) 7.60Dog 38.0 (37.52, 38.48)b 37.3 15.0 (14.25, 15.75) 17.1 8.00 (7.66, 8.35) 7.40 10.0 (9.40, 10.60) 10.3Dog 33.0 (32.57, 33.43) 36.0 14.0 (13.30, 14.70) 15.2 7.00 (6.67, 7.33)c 7.40 12.0 (11.28, 12.72) 10.5Dog 20.0 (19.70, 20.30) 21.1 8.00 (7.60, 8.40) 11.1 NP NP 10.0 (9.40, 10.60) 3.70Cat 32.0 (31.58, 32.42) 32.3 19.0 (18.05, 19.95) 20.5 6.00 (5.69, 6.32)b 8.50 10.0 (9.40, 10.60) 7.80Cat 31.0 (30.59, 31.41) 32.8 12.0 (11.40, 12.60) 14.7 6.00 (5.69, 6.32)b 6.90 10.0 (9.40, 10.60) 7.40Cat 42.0 (41.48, 42.52) 44.5 20.0 (19.00, 21.00) 20.8 8.50 (8.15, 8.85)b 9.70 10.0 (9.40, 10.60) 7.80Cat 31.0 (30.59, 31.41) 33.9 16.0 (15.20, 16.80) 16.8 8.00 (7.66, 8.35)b 8.70 10.0 (9.40, 10.60) 8.70Cat 40.0 (39.50, 40.50) 40.3 18.0 (17.10, 18.90) 20.8 9.00 (8.64, 9.36) 8.50 12.0 (11.28, 12.72) 8.30Cat 32.0 (31.58, 32.42) 36.6 20.0 (19.00, 21.00) 20.2 8.00 (7.66, 8.35) 8.10 10.0 (9.40, 10.60) 7.30Cat 35.0 (34.55, 35.45) 37.4 20.0 (19.00, 21.00) 19.5 7.00 (6.67, 7.33)b 7.70 10.0 (9.40, 10.60) 6.80Cat 42.0 (41.48, 42.52) 42.2 20.0 (19.00, 21.00)b 15.9 7.50 (7.17, 7.84) 7.40 10.0 (9.40, 10.60) 7.30Cat 34.0 (33.56, 34.44) 34.2 11.0 (10.45, 11.55) 12.0 6.00 (5.69, 6.32)b 6.40 10.0 (9.40, 10.60) 8.50Cat 30.0 (29.60, 30.40) 29.8 9.00 (8.55, 9.45) 10.0 8.00 (7.66, 8.35) 7.30 10.0 (9.40, 10.60) 9.00Cat 28.0 (27.62, 28.38) 32.3 9.00 (8.55, 9.45) 16.1 7.00 (6.67, 7.33) 7.10 10.0 (9.40, 10.60) 6.80a Nutrient content reported on an “as is” basis.b Quantified nutrient content failed to comply with the diets labelled guaranteed nutrient content.GA — Guaranteed analysis (GA 6 Acceptable AV based on AAFCO); PA — proximate analysis; NP — Not present on product packaging.Values within parenthesis are the acceptable ranges for the GA 6 Acceptable AV based on AAFCO.

Table 3. Crude protein (CP, DM basis), crude fat (DM basis), and amino acid composition (%, DM basis) of dry extruded cat and dog diets.a

Life Crude Crude Phenylalanine Species stage protein fat Arginine Histidine Isoleucine Leucine Lysine Threonine Valine Phenylalanine Tyrosine

Dog ALS 32.75 15.11 2.39 0.85 1.23 2.35 1.45 1.26 1.62 1.75 3.18Dog ALS 33.15 20.75 1.86 0.65 0.87 1.93 1.05 1.02b 1.27 1.40 2.60Dog ALS 28.73 18.13 2.09 0.78 1.01 1.98 1.37 1.10 1.30 1.43 2.49Dog ALS 39.06 20.39 2.89 0.98 1.51 2.77 1.94 1.53 1.94 1.99 3.53Dog ALS 26.78 13.39 1.93 0.54 0.76 1.65 1.16 0.97b 1.17 1.16 2.12Dog ALS 40.32 18.35 2.72 0.97 1.41 2.89 1.95 1.61 1.96 2.08 3.63Dog ALS 40.01 15.74 2.31 0.82 1.34 2.39 1.81 1.36 1.80 1.77 3.12Dog ALS 41.21 17.37 2.94 0.99 1.30 2.90 1.99 1.60 1.87 2.09 3.66Dog ALS 35.34 19.20 2.47 0.79 1.12 2.15 1.49 1.15 1.49 1.57 2.77Dog ALS 33.41 17.22 2.30 0.74 1.07 2.28 1.54 1.23 1.39 1.67 2.94Dog ALS 29.57 19.09 2.15 0.86 1.14 2.36 1.46 1.21 1.53 1.57 2.80Dog Senior 28.30 12.30 1.81 0.66 1.00 1.85 1.07 0.97 1.29 1.40 2.51Dog Senior 25.93 7.91 1.55 0.77 0.98 1.69 1.46 1.00 1.27 1.22 2.23Dog Senior 41.09 18.86 2.81 1.01 1.40 2.90 1.91 1.61 1.83 2.17 3.89Dog Senior 39.71 16.73 3.01 0.97 1.35 2.84 2.03 1.58 1.71 1.12 2.74Dog Senior 21.88 11.46 1.27 0.47 0.75 1.44 0.96 0.80 1.03 0.98 1.75Cat ALS 34.77 22.10 2.39 0.82 1.07 2.21 1.36 1.31 1.41 1.70 3.08Cat ALS 35.21 15.73 2.48 0.91 1.27 2.67 1.55 1.36 1.70 1.99 3.54Cat ALS 47.92 22.37 3.28 1.17 1.86 3.36 2.26 1.86 2.38 2.54 4.53Cat ALS 36.80 18.21 2.65 0.89 1.28 2.57 1.79 1.53 1.66 1.81 3.26Cat ALS 43.41 22.46 2.98 1.02 1.58 2.96 1.98 1.68 2.02 2.20 3.91Cat ALS 39.27 21.62 2.64 0.84 1.24 2.53 1.71 1.47 1.62 1.78 3.19Cat ALS 39.92 20.82 2.81 0.94 1.44 2.73 1.91 1.51 1.86 2.02 3.55Cat ALS 45.21 17.00 3.35 1.12 1.65 3.03 2.29 1.60 2.03 2.39 4.21Cat ALS 37.09 12.96 2.84 1.00 1.58 3.05 1.97 1.66 2.08 2.24 4.07Cat ALS 32.41 10.90 2.22 0.94 1.29 3.34 1.26 1.30 1.74 2.08 3.75Cat Senior 34.49 17.19 2.42 0.87 1.30 2.45 1.49 1.28 1.67 1.84 3.27a Nutrient content reported on a dry matter basis.b Failed to meet the AAFCO nutrient profile for intended animal.ALS = all life stages.



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any false or misleading representation that related to or may reasonably be regarded as relating to that product” (11). Based on the results of this study, 2 of the 27 diets carrying an AAFCO adequacy claim, violated the Act by having lower threonine concentrations than recommended by the AAFCO. During heat processing threonine becomes heat labile and losses are observed with increasing time and heat (12). It is possible that pet food manufacturers are failing to conduct nutrient analyses after extrusion to account for losses accrued during process-ing, resulting in the overestimation of end-product nutrient density. For the 2 diets below the recommended AAFCO level for threonine, the lowest represented 93% of the AAFCO level, and both were above the NRC recommended allowances (0.81 for growing puppies). However, the NRC recommendations for threonine are estimated in highly digestible diets underestimat-ing total threonine requirements. It is therefore necessary for commercial diets to comply with the AAFCO recommendations that account for potential losses or reductions in digestibility in processed pet foods. More than 70% of dietary threonine is used first pass in the gastrointestinal tract for mucin synthesis (13), and undersupply may reduce mucin synthesis exposing the intestinal lining to colonization by pathogenic bacteria (14). There are mathematical methods that can be used to estimate protein quality (total intake, balance, and digestibility), such as the protein digestibility corrected amino acid score that is used to make claims on packaged foods for humans. These models would be useful in the pet food industry to allow for the quantification of digestibility and to determine the content of available nutrients in pet foods.

There was no life stage effect on any of the measured nutri-ents when life stage nutrients were compared among formula-

tions. This is inconsistent with current literature as nutrient requirements for cats and dogs in all life stages (i.e., growth and maintenance) are higher than those for maintenance only (2). Therefore, diets that are formulated for adult and senior animals are oversupplying individual nutrients. When formu-las intended for dogs or cats were compared, there were no significant differences among formulations of the nutrients analyzed, despite the different nutritional requirements of dogs and cats (2). Similarities in the nutrient composition of dog and cat specific formulations can be partially attributed to recent trends in the pet food industry. Retail trends such as meat-rich and high-protein formulations for dogs have had a dramatic effect on the nutrient composition of pet food formulations (15). The AAFCO (4) recommends CP requirements for dogs in maintenance at 18% on a dry matter basis presuming that the diet contains a caloric density of 4000 kcal/kg, yet there are products in the current North American market, not included in this study, that report as much as 69.3% protein on a DM basis. Although an oversupply of protein is important for maintenance of lean body mass in aging animals (3), it is not appropriate for dogs and cats at all life stages. Apart from the continued debate that high dietary protein consumption is believed to play a role in the etiology of renal disease (16,17), undigested protein is simply fermented and excreted in feces producing odor com-pounds (18). Furthermore, AA absorbed above requirements are catabolized and used as an energy source, increasing nitro-gen excretion in urine without further benefit to the animal. Excessive nitrogen excretion negatively impacts the environ-ment due to the increased acidification and eutrophication of soil. Overall, the high protein trend in pet food, especially in adult dog food, results in potentially negative consequences for

Table 4. Effect of species or life stage on the nutrient composition (%) of dry extruded dog and cat food.a

Species

Nutrient Dogs Cats P-value

composition ALS Senior ALS Senior Life(%) n = 22 n = 10 n = 20 n = 2 stage Species

Crude protein 32.4 6 1.67 28.8 6 5.28 36.4 6 1.59 32.3 6 2.36 0.229 0.243Crude fat 16.6 6 1.02 12.4 6 3.22 17.1 6 0.97 16.1 6 1.44 0.183 0.278Ash 8.87 6 0.49 7.26 6 1.56 7.90 6 0.47 7.05 6 0.70 0.195 0.525Moisture 6.61 6 0.48 8.48 6 1.51 7.86 6 0.46 6.80 6 0.68 0.654 0.812Alanine 1.77 6 0.10 1.50 6 0.30 2.02 6 0.09 1.79 6 0.14 0.179 0.148Arginine 2.22 6 0.13 1.92 6 0.42 2.56 6 0.13 2.23 6 0.19 0.211 0.199Aspartate 2.47 6 0.15 2.33 6 0.47 2.75 6 0.14 2.28 6 0.21 0.280 0.676Glycine 2.76 6 0.20 2.21 6 0.64 3.23 6 0.19 2.93 6 0.29 0.268 0.128Histidine 0.77 6 0.04 0.71 6 0.13 0.89 6 0.04 0.80 6 0.06 0.370 0.190Isoleucine 1.09 6 0.07 1.00 6 0.22 1.32 6 0.07 1.20 6 0.10 0.430 0.108Leucine 2.19 6 0.13 1.97 6 0.41 2.64 6 0.12 2.26 6 0.18 0.221 0.132Lysine 1.47 6 0.11 1.37 6 0.33 1.68 6 0.10 1.37 6 0.15 0.312 0.594Phenylalanine 1.58 6 0.10 1.45 6 0.31 1.92 6 0.09 1.69 6 0.14 0.335 0.119Proline 1.92 6 0.14 1.58 6 0.43 2.05 6 0.13 2.12 6 0.19 0.584 0.197Serine 1.41 6 0.09 1.25 6 0.27 1.64 6 0.08 1.31 6 0.12 0.142 0.373Threonine 1.20 6 0.07 1.09 6 0.22 1.42 6 0.07 1.18 6 0.10 0.205 0.251Tyrosine 1.22 6 0.07 1.14 6 0.23 1.51 6 0.07 1.32 6 0.10 0.310 0.091Valine 1.48 6 0.08 1.31 6 0.27 1.72 6 0.08 1.54 6 0.12 0.282 0.150Aromatic 3.56 60.21 3.30 6 0.66 4.33 6 0.20 3.81 6 0.29 0.326 0.116a Nutrient content reported on an as is basis. Values are least square means 6 standard error.Aromatic = histidine phenylalanine tyrosine; ALS — All life stages.Significant difference was considered at P # 0.05 and a trend when 0.05 P # 0.10).



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dogs and the environment, and compromises the sustainability of protein ingredients (19–22) used in the pet food industry. Inaccurate quantification of fat, ash, and moisture will result in an incorrect prediction of energy content and an increased risk of urinary stone formation (10,23).

In conclusion, the present findings suggest that a large portion of Canadian pet food product selected herein fail to meet the GA and claims made for their products. Because of these inadequacies, pet food manufacturers are failing to meet the requirements of the Consumer Packaging and Labelling Act. The pet foods analyzed in this study had similar nutrient profiles labelled as intended for different species and/or life stages. The latter is of importance as oversupply of nutrients above nutrient requirements may negatively impact the health status of dogs and may increase the price of food. Pet food companies need to ensure that they are accurately tracking the nutrient content of incoming ingredients and outgoing final products to ensure that the consumer receives accurate product information. CVJ

References 1. Pet Food Institute 2017 Regulation. Available from: http://www.

petfoodinstitute.org/pet-food-matters/commitment-to-safety/pet-food-regulations/ Last accessed August 22. 2018.

2. National Research Council. Nutrient Requirements of Dogs and Cats. 10th ed. Washington, DC: National Academy Press, 2006.

3. Association of American Feed Control Officials. In: Official Publication Association of American Feed Control Inc. Oxford, UK: AAFCO, 2018.

4. AOAC official method 990.03: Protein (crude) in animal feed. Combustion method. In: Official Methods of Analysis of AOAC International. Washington, DC: AOAC International, 2000.

5. AOAC official method 920.39: Fat (crude) or ether extract in ani-mal feed. In: Official Methods of Analysis of AOAC International. Washington, DC: AOAC International, 2000.

6. AOAC official method 942.05: Ash of animal feed. In: Official Methods of Analysis of AOAC International. Washington, DC: AOAC International, 2000.

7. AOAC official method 982.30: Amino acid profile without tryptophan. In: Official Methods of Analysis of AOAC International. Washington, DC: AOAC International, 2006.

8. Boogers I, Plugge W, Stokkermans YQ, Duchateau AL. Ultra-performance liquid chromatographic analysis of amino acids in protein hydrolysates using an automated pre-column derivatisation method. J Chromat A 2008;1189:406–409.

9. Colan SD. The why and how of Z scores. J Am Soc Echocardiogr 2013;26:38–40.

10. Hill RC, Choate CJ, Scott KC, Molenberghs G. Comparison of the guaranteed analysis with the measured nutrient composition of com-mercial pet foods. J Anim Physiol Anim Nutr 2009;234:347–351.

11. Camire ME, Camire A, Krumhar K. Chemical and nutritional changes in foods during extrusion. Crit Rev Food Sci Nutr 1990;30:35–45.

12. Bellows J, Center S, Daristotle L, et al. Evaluating aging in cats: How to determine what is healthy and what is disease. J Feline Med Surg 2016; 18:551–570.

13. Van der Schoor SR, Wattimena DL, Huijmans J, Vermes A, Van Goudoever JB. The gut takes nearly all: Threonine kinetics in infants. Am J Clin Nutr 2007;86:1132–1138.

14. Nichols NL, Bertolo RF. Luminal threonine concentration acutely affects intestinal mucosal protein and mucin synthesis in piglets. J Nutr 2008;138:1298–1303.

15. US Pet Market Outlook, 2016–2017. Available from: https://www.prnewswire.com/news-releases/us-pet-market-outlook-2016-2017- 300340234.html Last accessed August 22, 2018.

16. Schwingshackl L, Hoffmann G. Comparison of high vs. normal/low protein diets on renal function in subjects without chronic kidney dis-ease: A systematic review and meta-analysis. PloS One 2014;9:e97656.

17. Guidi G, Rossini C, Cinelli C, Meucci V, Lippi I. Canine chronic kidney disease: Retrospective study of a 10-year period of clinical activ-ity. In: Pugliese A, Gaiti A, Boiti C, eds. Veterinary Science. Berlin, Germany: Springer-Verlag, 2012.

18. Gross KL. Macronutrients. In: Small Animal Clinical Nutrition. 5th ed. Topeka, Kansas: Mark Morris Institute, 2010:49–105.

19. National Research Council. Critical Role of Animal Science Research in Food Security and Sustainability. Washington, DC: National Academies Press, 2015.

20. Swanson KS, Carter RA, Yount TP, Aretz J, Buff PR. Nutritional sustain-ability of pet foods. Adv Nutr 2013;4:141–150.

21. Meeker DL, Meisinger JL. Companion Animal Symposium: Rendered ingredients significantly influence sustainability, quality, and safety of pet food. J Anim Sci 2015;93:835–847.

22. Kim E, Kim DB, Park JY. Changes of mouse gut microbiota diversity and composition by modulating dietary protein and carbohydrate contents: A pilot study. Prev Nutr Food Sci 2016;21:57–61.

23. Robertson WG, Jones JS, Heaton MA, Stevenson AE, Markwell PJ. Predicting the crystallization potential of urine from cats and dogs with respect to calcium oxalate and magnesium ammonium phosphate (struvite). J Nutr 2002;132:1637S–1641S.



Article

Sartorius muscle flap for body wall reconstruction: Surgical technique description and retrospective case series

Sebastian Mejia, Sarah E. Boston, Owen T. Skinner

Abstract — The objectives of this study were to describe the sartorius muscle flap for body wall reconstruction, including description of the anatomy and surgical technique and to report its clinical application for abdominal wall reconstruction in dogs and cats. The descriptive report involves a retrospective case series for 2 dogs and 3 cats. Inclusion criteria were cats or dogs that had a tumor resection resulting in an abdominal wall defect that was reconstructed using an ipsilateral or contralateral sartorius muscle flap. Signalment, pre-operative clinical signs, location and tumor extent, diagnostic imaging and clinical pathology findings, surgical methods, and complications were recorded. Abdominal wall defect reconstructions using the sartorius muscle flap were successfully performed in all 5 patients with good return to function. All complications were minor and were successfully medically managed. This case series demonstrates that the sartorius muscle flap is a feasible option for the closure of large caudal abdominal wall defects.

Résumé — Rabat du muscle sartorius pour la reconstruction de la paroi du corps : description de la technique chirurgicale et série de cas rétrospectifs. Les objectifs de cette étude étaient de décrire le rabat du muscle sartorius pour la reconstruction de la paroi du corps, y compris la description de l’anatomie et de la technique chirurgicale et de faire rapport sur son application clinique pour la reconstruction de la paroi abdominale des chiens et des chats. Le rapport descriptif porte sur une série de cas rétrospectifs pour 2 chiens et 3 chats. Les critères d’inclusion étaient des chats ou des chiens ayant subi une résection de tumeur qui avait produit un défaut de la paroi abdominale qui avait été reconstruite à l’aide d’un rabat du muscle sartorius ipsilatéral ou contralatéral. Le signalement, les signes cliniques avant l’opération, l’emplacement et l’étendue de la tumeur, les résultats de l’imagerie diagnostique et de la pathologie clinique, les méthodes chirurgicales et les complications ont été consignés. Les reconstructions du défaut de la paroi abdominale en utilisant le rabat du muscle sartorius ont été réalisées avec succès chez les 5 patients avec un bon retour de fonction. Toutes les complications étaient mineures et ont été médicalement gérées avec succès. Cette série de cas démontre que le rabat du muscle sartorius représente une option possible pour la fermeture de larges défauts de la paroi abdominale caudale.


Can Vet J 2018;59:1187–1194

Introduction

C losure of large caudal abdominal wall defects due to wide tumor resection or trauma can prove challenging. The

goal of repair is to provide a strong and functional support for the intra-abdominal contents, under minimal tension, with the lowest associated morbidity (1). Options for body wall repair include prosthetic mesh, autogenous tissue, and com-posite techniques (a combination of autogenous and prosthetic techniques). The advantages of autogenous muscle flaps versus

prosthetic mesh and composite techniques have been described (2–6). Liptak et al (2) concluded that autogenous muscle flaps alone were significantly less likely to have complications, such as infections and seromas, after reconstruction of chest wall defects. Lower complication rates are likely due to the fact that vascularized autogenous tissue augments the blood supply to the repair site while improving delivery of healing factors and immune mediators, leading to faster healing times, higher repair success, and more efficient eradication of infection (3,7).

Colorado State University College of Veterinary Medicine and Biomedical Sciences, Fort Collins, Colorado 80523-1678, USA (Mejia); VCA Canada 404 Veterinary Emergency & Referral Hospital, Surgical Oncology, Newmarket, Ontario L3Y 0B3 (Boston); University of Missouri Veterinary Health Center, Surgical Oncology, Columbia, Missouri (Skinner).Address all correspondence to Dr. Sebastian Mejia; e-mail: [email protected] was no proprietary interest and no funding for this project.Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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Conversely, based on human literature, prosthetic mesh can predispose to persistent infections due to bacterial adherence and biofilm formation (8).

The sartorius muscle is part of the superficial layer of the adductor muscle group. It flexes the hip and stifle while the limb is being protracted and contributes to stifle extension during stance, functions that are shared with multiple other hindlimb muscles (9,10). It is a long, flat muscle that extends in 2 bellies, each on the cranio-medial contour of the thigh from the region of the tuber coxae to the medial surface of the stifle joint. The cranial belly arises from the iliac crest, ventral iliac spine, and thoracolumbar fascia and inserts at the middle femoral fascia just proximo-medial to the patella (9). The caudal belly lies adjacent to the cranial one, entirely at the medial surface of the thigh. It originates on the tuber coxae of the ileum and forms an aponeurosis, which blends with the gracilis, finally radiating into the crural fascia and into the cranial tibial border. There is no complete anatomic separation of these 2 portions, except for their distributed insertion from the patella to the medial surface of the tibia in the cat (9). The vascular supply for the cranial belly is a single dominant pedicle branching from the femoral artery at the proximal third of the muscle, usually at its caudal border, while the vascular supply of the caudal belly is segmental with the saphenous artery and vein providing a vascular pedicle at the distal third of the muscle belly (11–14).

The sartorius muscle possesses desirable qualities for autog-enous reconstruction. It is broad, pliable, available bilaterally, easily harvested, has minimal donor site morbidity, it has an ideal shape and size, it has a relatively redundant function and there are no major structures liable to compromise at the time of harvesting (1,11). Sylvestre et al (3) reported the successful use of the sartorius muscle flap in a composite procedure with prosthetic mesh for the repair of abdominal wall hernias in 2 cats. There are no current studies reporting success or compli-cation rates. The objective of this manuscript was to i) describe the sartorius muscle flap in a practical manner with a detailed description of the anatomy and surgical technique; and ii) report its clinical application for abdominal wall reconstruction in dogs and cats.

Materials and methodsData collectionFor the retrospective case series, medical records of patients referred to the Surgical Oncology Service at the University of Florida Small Animal Veterinary Hospital between 2012 and 2016 were reviewed. Inclusion criteria were cats or dogs that had a tumor resection resulting in an abdominal wall defect that was reconstructed using an ipsilateral or contralateral sartorius muscle flap. Both autogenous and composite muscle flaps were included. Composite techniques, with synthetic polypropylene mesh graft were employed when the defect was considered too large to be repaired by autogenous sartorius muscle flap alone.

Signalment, clinical signs at the time of the procedure, preoperative rationale for a sartorius muscle flap, location and extent of the tumor, diagnostic imaging, clinical pathol-ogy findings, surgical methods, postoperative assessment of reconstruction, and any complications were recorded. Surgical complications were categorized as short-term ( 14 d) and long-term ( 14 d). Also, complications were deemed major if they required revision or surgical intervention and minor if they were manageable with medical therapy. Follow-up data were acquired by direct communication with the owner when available.

All patients underwent thorough preoperative diagnostic investigation to assess for metastatic or concurrent disease. Preoperative diagnostics included complete blood (cell) count (CBC) and serum biochemical analysis, urinalysis, computed tomography (CT) (Figures 1A, B), fine-needle aspirate (FNA), and incisional biopsy for histopathology. Select patients had additional preoperative diagnostic tests when indicated. All resected tumor tissue specimens were submitted for review by a Board-certified pathologist and the resection was classified using the scheme described by Wittekind (15). In summary, complete gross and microscopic resection at a distance 1 mm from the resection margins was classified as R0 1 mm. Complete gross resection with # 1 mm margins was classified as R1 # 1 mm, while microscopically incomplete resection was classified as R1-dir. Grossly incomplete resection would be classified as R2. Progression-free and overall survival time were recorded.

Figure 1. Transverse (A) and sagittal (B) plane images from preoperative computed tomography of Dog 1 revealing a large, mixed attenuation, contrast-enhancing, soft tissue mass in the left paralumbar fossa region (arrows).



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ResultsSurgical techniqueThe sartorius muscle flap can be divided into 2 broad categories: i) ipsilateral technique, and ii) contralateral technique, which is employed when the ipsilateral technique is not available.

The ipsilateral or contrateral limb (depending on indication and technique used) was clipped and aseptically prepared from the level of the tarsocrural joint to the contralateral coxofemoral

joint. For the ipsilateral technique, the patient was placed in contralateral recumbency; for the contralateral technique the patient was placed in dorsal recumbency. The skin was asepti-cally prepared and draped using a hanging limb technique.

An incision was made along the medial aspect of the proxi-mal pelvic limb, extending from the distal stifle to the ingui-nal region. The subcutaneous tissues were bluntly dissected from the caudal and cranial aspects of the sartorius muscle.

Figure 2. Intra-operative and post-operative images from Dog 1. A — Sartorius muscle harvesting from donor site; B — Harvested sartorius muscle and planned resection tumor site; C — Abdominal wall defect after en-bloc resection; D — Composite autologous and prosthetic mesh repair — edges of mesh (black) and edges of muscle flap (white); E — Central area of dehiscence — Day 12; F — Healthy granulation tissue present — Day 15.



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The sartorius muscle was transected distally from its inser-tions at the patella and proximal tibia using blunt dissection and electrosurgery, then the muscle bellies were progressively released proximally, carefully preserving the proximal vascular pedicle (Figures 2A–C) and taking care not to disrupt the fascia between the cranial and caudal muscle bellies. Once the origi-nally indicated procedure was performed (i.e., mass removal, hemipelvectomy), the sartorius muscle was rotated at its origin and tunneled through subcutaneous tissue if necessary to allow introduction to the body wall defect. Prior to suturing the sartorius, omentum was tacked at the margins of the defect. The sartorius muscle was then draped around the defect and the muscle borders were sutured to the adjacent fascial planes (with the goal of obtaining an edge to edge apposition) with absorbable suture material (Figures 3A, B and 4A–C). In one case (Dog 1), a 15 cm 15 cm polypropylene mesh was used for reconstruction of the defect in conjunction with the sartorius muscle flap (Figure 2D). The overlying tissues were closed in a routine fashion. Gloves and instruments were changed between the removal of a neoplastic mass and elevation of the muscle flap to prevent seeding of neoplastic cells to the donor site (16). Medical buttons were used in one patient (Dog 2) for relief of tension (Figures 3C, D).

Case reportsSignalment, significant medical history, and gross findings regarding the tumor are presented in Table 1. No evidence of pulmonary or regional metastasis was identified on CT in any patient before surgery.

Preoperative cytology, postoperative histopathology, and surgery performed are summarized in Table 2. After surgery, both dogs were treated with intravenous fluids, / maropi-tant (Cerenia; Zoetis, Parsippany, New Jersey, USA), 1 mg/kg body weight (BW), q24h, a fentanyl constant rate infusion (CRI) (Fentanyl Citrate; Hospira, Lake Forest, USA), 2 to 6 g/kg BW per hour, IV, meloxicam (Metacam; Boehringer Ingelheim Vetmedica, St. Joseph, Missouri, USA), 0.1 mg/kg BW initial dose IV, then PO, q24h or carprofen (Rimadyl; Zoetis, Parsippany, New Jersey, USA), 2.2 mg/kg BW, IV, q12h, and / bupivacaine (Bupivacaine Hydrochloride Injection; Hospira), 1.5 mg/kg BW via soaker catheter q6h. Medications at discharge included tramadol (Tramadol Hydrochloride; Sun Pharmaceutical, Cranbury, New Jersey, USA), 3 to 4.2 mg/kg BW, PO, q8–12h, as needed, cephalexin (Cephalexin Capsules; Lupin Pharmaceutical, Baltimore, Maryland USA) 29.9 to 31.5 mg/kg BW, PO, 2 to 3 times daily, meloxicam 0.1 mg/kg BW, PO, q24h or carprofen 2.2 mg/kg BW, PO, q12h, and /

Figure 3. Intra-operative and post-operative images from Dog 2. A — Sartorius muscle elevation over defect after en-bloc mass resection; B — Sartorius muscle flap sutured in place prior to skin closure; C — Surgical site following skin closure with medical buttons used for relief of tension; D — Eleven days postoperative recheck.



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trazodone (Trazodone Hydrochloride; Teva Pharmaceuticals, North Wales, Pennsylvania, USA), 3 mg/kg BW, PO up to 3 times per day as needed.

All cats were managed with a fentanyl CRI (2 to 6 g/kg BW per hour, IV), meloxicam (0.05 mg/kg BW, IV once), bupiva-caine (1.5 mg/kg BW via soaker catheter q6h) and intravenous fluids. The cats were discharged with buprenorphine (Buprenex; Reckitt Benckiser Pharmaceuticals, Richmond, Virginia, USA), 0.015 to 0.02 mg/kg BW sublingually 2 to 4 times per day, as needed, / meloxicam (0.05 mg/kg BW, PO, q24h), / amoxicillin/clavulanic acid (Clavamox; Zoetis), 17 mg/kg BW, PO, q12h for 5 d. One cat was discharged with a soaker catheter in place to allow delivery of bupivacaine (1 mg/kg BW, q6h) for a further 3 d.

Complications, adjuvant therapy (including antibiotic selec-tion, which was based on culture and sensitivity), and survival data are detailed in Table 3.

DiscussionThis case series demonstrates that the sartorius muscle flap is a feasible option for the closure of large caudal abdominal wall defects after large en-bloc tumor resection and to repair defects

resulting after hemipelvectomy. The harvesting of the sartorius muscle is a relatively simple technique if the surgeon is familiar with the anatomy of the region. A contralateral sartorius muscle may prove useful when the tumor resection involves removal of the entire limb and pelvis and the origin of the ipsilateral sartorius cannot be preserved.

Abdominal wall defect reconstruction using the sartorius muscle flap was successfully performed in all patients. The most common and clinically significant complication in this case series was minor infection of the surgical site, with the second most common being mild dehiscence. All of the patients with infection responded well to antibiotic therapy and none required surgical corrections. The complications were readily managed, given the presence of autogenous tissues and contin-ued blood supply, as opposed to reliance on avascular prosthetic mesh exclusively. The antibiotic selection for treatment of the complications was based on culture and sensitivity. In the case of Dog 1, the culture revealed the presence of Escherichia coli, which was resistant to the originally prescribed cephalexin and to the combination of amoxicilin and clavulanic acid, but it was susceptible to enrofloxacin. The use of a fluoroquinolone for the treatment of a surgical site infection should be reserved as

Figure 4. Intra-operative images from Cat 3. A — Sartorius muscle elevation; B — Sartorius muscle flap for closure after hemipelvectomy.



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a last resort to reduce the chances of development of multidrug resistant strains of bacteria, and ideally should always be based on culture and sensitivity results.

While initial reports described a cranial and a caudal sartorius muscle flap as separate procedures with different indications in the canine model (14,17), this study demonstrates potential for the transposition of both muscle bellies without separating them. When evaluated separately, the cranial sartorius muscle is considered a type II muscle based on its vascular anatomy and supply, having a dominant vascular pedicle near the origin and/or insertion, which is likely to survive despite the ligation or disruption of minor pedicles during elevation and transposi-tion. The caudal sartorius (as well as the whole muscle with both muscle bellies) is classified as a type IV muscle, which is supplied

by smaller segmental vascular pedicles between the origin and insertion, and its survival may be inconsistent based on which pedicles are ligated (12,13). Buckland et al (11) reported that the progressive ligation of the different pedicles supporting the caudal belly of the sartorius muscle, leading to only the preservation of the dominant proximal pedicle, resulted in vas-cularization of the entire sartorius muscle after surgical delay. It is possible that even in a single stage procedure, low volume blood flow through these vessels may help sustain the caudal belly via the superficial circumflex iliac and lateral circumflex femoral arteries. It is also possible that small vessels from the cranial belly of the sartorius muscle could help supply the caudal belly, although this remains to be assessed. Given the uncertainty regarding the vascular supply for the distal portion of the caudal

Table 1. Signalment, significant medical history, tumor size and location at presentation for each patient.

Age Weight Tumor size Case Breed Gender (y) (kg) Significant medical history Tumor location (cm)

Dog 1 Mixed breed FS 8 20.8 Infiltrative lipoma at left flank/inguinal Left paralumbar fossa 6.4 3.4 6.3 region, cytoreduced 3 y prior to presentation, with adjuvant CFRT

Dog 2 Soft-coated FS 7 16.7 — Body wall of the right caudal 6 4.5 3.5 wheaten terrier thorax and lateral abdomen

Cat 1 DSH FS 14 3.1 2-week history of lameness Proximal left femur 3 1.7 2.3

Cat 2 DSH FS 13 3.7 2-month history of lameness Proximo-medial aspect of 4.9 5.9 6.0 the left pelvic limb

Cat 3 DSH FS 10 4.5 — Right lateral proximal 2.3 3.6 3.5 quadriceps region

DSH — Domestic shorthair; FS — Female spayed; CFRT — Conventionally fractionated radiotherapy.

Figure 5. Post-operative images from Dog 2. A — Hyperpigmentation and moist desquamation secondary to radiotherapy at Day 54 post-surgery; B — Surgical site healed.



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belly, relative ischemia may have played a role in the infections seen in this case series.

Both sartorius muscle bellies can be either transposed proxi-mally by ligating the most distal dominant vascular pedicles for caudal abdominal wall defects and femoral hernias, or transposed distally by ligating the most proximal pedicles for stifle and tibial region defects. Sylvestre et al (3) reported that a single sartorius muscle can be positioned over the abdomen in a transverse manner along the pubic region to cover 30% of the caudal abdomen (both left and right sides), while it can also be positioned and extended in a cranial to caudal fashion covering approximately 80% of the length and 75% of the width of the ipsilateral abdomen in the feline model.

The tumors in this case series were aggressive locally, as evi-denced by the narrow or incomplete margins noted in 3 cases, despite radical excisions. It is important to consider that postop-erative radiation may be recommended after removal of a locally aggressive tumor. Care should be taken to leave surgical clips at the margins of excisions to guide radiation therapy if necessary. The presence of autologous tissue may help minimize the risk

and/or significance of complications such as wound dehiscence or infection due to the vascular supply and sustained local immune function (3,5).

The sartorius muscle flap is a versatile surgical technique, which has proven successful for repairing ipsilateral and con-tralateral abdominal wall defects after hemipelvectomy and en bloc tumor removal as shown by this case series. It has also been used for ipsilateral femoral and prepubic hernia repairs, treatment of trochanteric ulcers, and abdominal wall hernia repairs (3,13,18–20).

Limitations of this case series include the small sample size and heterogenous population, which are associated with the specialized nature of the procedure, as well as the retrospective nature of the study. No conclusions can be drawn regarding success or complication rates. Further larger-scale and ideally prospective studies comparing autologous, composite, and mesh reconstruction methods are required.

This case series demonstrated adequate return to function and low morbidity associated with the harvesting of the sartorius muscle. Sartorius muscle flaps are an easily adaptable technique

Table 2. Summary of cytology, surgery, and histopathology for each patient.

Gross lateral Preoperative margins Postoperative Resection Case cytology (cm) Procedure Type of flap histopathology classification

Dog 1 Soft tissue 1.3 to 2 En-bloc abdominal wall resection Ipsilateral Anaplastic osteosarcoma, R0 sarcoma composite suspect radiation-induced

Dog 2 Soft tissue 3 En-bloc abdominal wall and 13th rib Ipsilateral Soft tissue sarcoma R1-dir sarcoma resection, with diaphragmatic autologous (grade I) advancement

Cat 1 Sarcoma 5 Left external hemipelvectomy and Ipsilateral FISS R1 # 1 mm caudal abdominal wall resection autologous

Cat 2 Spindle cell 1 Left external hemipelvectomy and Contralateral Chondroblastic R1 # 1 mm proliferation caudal abdominal wall resection autologous osteosarcoma

Cat 3 Non- 4 Right subtotal external Contralateral Fibrosarcoma, suspect R1-dir diagnostic hemipelvectomy and caudal autologous FISS abdominal wall resection

FISS — feline injection site sarcoma.

Table 3. Summary of complications, adjuvant therapy and follow-up for each patient.

Progression-free Overall survival survival Case Complications Treatment Adjuvant therapy (days) (days)

Dog 1 Seroma, superficial Enrofloxacin (11.4 mg/kg BW, Carboplatin (300 mg/m2), then 84 (pulmonary 330 surgical site infection PO, q24h). Wound management (transitioned to doxorubicin metastasis) (E. coli), 6 cm dehiscence with dressings until healthy (30 mg/m2) IV every 3 to 4 wk granulation bed (Figures 2E, F)

Dog 2 Delayed healing (dog Replaced missing suture with staples CFRT: 18 3 Gy 223* 223* removed sutures), Hyperpigmentation and moist mild seroma desquamation during therapy (Figures 5A, B)

Cat 1 None — — 930* 930*

Cat 2 Superficial surgical site Topical SSD and pradofloxacin — 730* 730* infection (Nocardia and (6.5 mg/kg BW, PO, q24h) Pseudomonas) and partial dehiscence

Cat 3 None — Hypofractionated RT: 4 8 Gy 213* 213*

* Most recent follow-up of a living animal. CFRT — Conventionally fractionated radiotherapy; RT — Radiotherapy; SSD — Silver sulfadiazine.



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to provide autogenous tissue to aid closure of caudal abdomi-nal wall defects, although further investigation is warranted to define complication rates. CVJ

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11. Buckland A, Pan WR, Dhar S, et al. Neurovascular anatomy of sartorius muscle flaps: Implications for local transposition and facial reanimation. Plast Reconstr Surg 2009;123:44–54.

12. Pavletic MM. Atlas of Small Animal Reconstructive Surgery. 2nd ed. Phildelphia, Pennsylvania: WB Saunders, 1999:484–501.

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14. Weinstein MJ, Pavletic MM, Boudrieau RJ, Engler SJ. Cranial sartorius muscle flap in the dog. Vet Surg 1989;18:286–291.

15. Wittekind C, Compton C, Quirke P, et al. A uniform residual tumor (R) classification: Integration of the R classification and the circumferential margin status. Cancer 2009;115:3483–3488.

16. Farese JP, Withrow SJ. Surgical Oncology. In: Withrow S, Page R, Vail DM, eds. Withrow and MacEwen’s Small Animal Clinical Oncology. 5th ed. St. Louis, Missouri: WB Saunders, 2013:149–156.

17. Weinstein MJ, Pavletic MM, Boudrieau RJ. Caudal sartorius muscle flap in the dog. Vet Surg 1988;17:203–210.

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20. Beittenmiller MR, Mann FA, Constantinescu GM, Luther JK. Clinical anatomy and surgical repair of prepubic hernia in dogs and cats. J Am Anim Hosp Assoc 2009;45:284–290.



Article

Antimicrobial resistance of bovine Salmonella enterica ssp. enterica isolates from the Alberta Agriculture and Forestry Disease Investigation Program (2006–2014)

Simon J.G. Otto, Katrina L. Ponich, Rashed Cassis, Carol Goertz, Delores Peters, Sylvia L. Checkley

Abstract — The objectives of this study were to describe the antimicrobial susceptibility and serotypes of clinical Salmonella spp. isolates from Alberta cattle, to inform antimicrobial stewardship decisions for Alberta bovine veterinarians and to provide data for national surveillance. Isolates were collected from cattle and serotyped by Alberta Agriculture and Forestry from 2006 to 2014. Susceptibility testing was completed using Canadian surveillance breakpoints. There were 81 unique Salmonella isolates from 72 visits to 27 farms. The majority of isolates were S. Typhimurium (66.7%) and S. Dublin (19.8%). The prevalence of multidrug resistance was high in S. Typhimurium (89.1%) and S. Dublin (93.8%), including ceftiofur resistance (43.6% and 68.8%, respectively), while there was no resistance in other serotypes. As ceftiofur is a recommended treatment option for enteritis and septicemia caused by Salmonella in cattle, these results reinforce that obtaining bacterial culture and susceptibility results is critical for suspected cases of bovine salmonellosis in Alberta.

Résumé — Antibiorésistance des isolats bovins de Salmonella enterica ssp. enterica provenant du Programme d’enquête du ministère de l’Agriculture et des Forêts de l’Alberta (2006–2014). Les objectifs de cette étude consistaient à décrire la susceptibilité antimicrobienne et les sérotypes des isolats cliniques de Salmonella spp. provenant du bétail de l’Alberta afin de fournir des données nationales de surveillance et d’informer les décisions d’antibiogouvernance des vétérinaires bovins de l’Alberta. Les isolats ont été prélevés du bétail et sérotypés par le ministère de l’Agriculture et des Forêts de l’Alberta de 2006 à 2014. Les tests de susceptibilité ont été réalisés en utilisant des points de référence de la surveillance canadienne. Il y avait 81 isolats uniques de Salmonella provenant de 72 visites à 27 fermes. La majorité des isolats étaient S. Typhimurium (66,7 %) et S. Dublin (19,8 %). La prévalence de la multirésistance aux médicaments était élevée pour S. Typhimurium (89,1 %) et S. Dublin (93,8 %), y compris la résistance au ceftiofur (43,6 % et 68,8 %, respectivement), tandis qu’il n’y avait pas de résistance pour d’autres sérotypes. Vu que le ceftiofur est une option de traitement recommandée pour l’entérite et la septicémie causées par Salmonella chez le bétail, ces résultats servent de renforcement pour confirmer qu’il est crucial d’obtenir des cultures bactériennes et des résultats de susceptibilité pour les cas suspectés de salmonellose bovine en Alberta.


Can Vet J 2018;59:1195–1201

Introduction

A ntimicrobial resistance (AMR) is an international, One Health concern that adversely impacts animal and human

health. Bovine salmonellosis can have severe economic implica-tions for producers due to calf mortality and loss of production, and its zoonotic potential is a public health concern (1). Parmley et al (2) suggested that antimicrobial resistance can limit treat-ment options for bovine and human Salmonella infections in

Canada and internationally. It is imperative to develop a better understanding of the prevalence of AMR in clinical bovine Salmonella infections in Canada to identify effective treatment options and to provide guidance for antimicrobial stewardship decisions in cattle that reduce AMR selection pressure on food-borne Salmonella that may be transmitted to humans (3–5).

Bovine salmonellosis is caused by many serotypes of Salmonella enterica ssp. enterica. In Alberta Salmonella

Animal Health Section, Animal Health and Assurance Branch (Otto, Peters), Agri-Food Laboratories Section, Food Safety Branch (Cassis, Goertz), Alberta Agriculture and Forestry, Edmonton, Alberta; School of Public Health, University of Alberta, Edmonton, Alberta T6G 2G7 (Otto); Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta (Ponich, Checkley).Address all correspondence to Dr. Simon Otto; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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Typhimurium and Salmonella Dublin are particularly important in cattle due to their zoonotic potential and clinical impact in cattle herds. As a result, they are reportable diseases in cattle in Alberta under the Reportable and Notifiable Diseases Regulation of the Animal Health Act (6). Bovine salmonellosis has a mor-bidity of over 50% in calves, with a death rate reaching 100% without treatment (7). A study from 2003 in Alberta found that 4 of 50 dairy herds sampled had 1 or more cows shedding Salmonella (8).

In the past, ampicillin and trimethoprim-sulfamethoxazole have been the first line antimicrobial treatment for bovine sal-monellosis (7). The most recent data for Alberta and Canada indicated that the most commonly identified resistance pat-tern for S. Typhimurium is to ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline (ACSSuT), though resistance to ceftiofur, ceftriaxone, and/or trimethoprim-sulfamethoxazole has been identified (8–12). This coincides with findings from other parts of the world (5,13). As such, therapy is increasingly dependent on the use of extra-label dosage regi-mens of antimicrobials that are important to human medicine (14), namely third generation cephalosporins (e.g., ceftiofur) and fluoroquinolones (15). There is concern that resistance to ceftiofur, a common antimicrobial for bacterial infections in cattle, including enteritis, may limit treatment options in both cattle and humans (16–18). Resistance to third generation cephalosporins in zoonotic serotypes such as S. Typhimurium or S. Dublin is concerning as these drugs (e.g., ceftriaxone) are used to treat human infections (4,18,19).

The objectives of this study were to: i) describe the antimi-crobial susceptibility and serotype profiles of Salmonella spp. isolates from Alberta cattle obtained through a provincial dis-ease investigation program, representing a clinical population; ii) provide antimicrobial stewardship information to bovine veterinarians in Alberta; and iii) provide AMR surveillance information that complements national surveillance.

Materials and methodsSalmonella enterica ssp. enterica isolates collected from cattle operations from 2006 to 2014 under the Alberta Agriculture and Forestry (AF) Disease Investigation Program (DIP) were tested for antimicrobial susceptibility. Cattle operations with suspected salmonellosis must be reported to the Office of the Chief Provincial Veterinarian (OCPV). When S. Typhimurium or S. Dublin infections were confirmed or suspected, AF vet-erinarians worked with herd veterinarians to conduct on-farm investigations to assist in controlling the outbreak. Multiple fecal and/or environmental samples were taken during each farm visit and selectively cultured and tested for Salmonella spp. at AF’s Agri-Food Laboratory (AFL).

For each farm visit, AFL stored 1 Salmonella spp. isolate at 70°C that was previously cultured as part of the investigation. These isolates were originally serotyped by the Alberta Provincial Laboratory for Public Health. Any isolates with inconclusive results were submitted to the Public Health Agency of Canada’s National Microbiology Laboratory in Winnipeg, Manitoba for serotype confirmation. Stored isolates were reconstituted and tested for antimicrobial susceptibility. The susceptibilities of

each serotype were tested in cases in which farms had multiple serotypes.

Susceptibility testing was conducted on these isolates for 14 antimicrobials using the CMV3AGNF plate for the Sensititre automated broth micro-dilution system (TREK Diagnostic Systems, Westlake, Ohio, USA) according to the manufacturer’s procedures. Clinical Laboratory Standards Institute (CLSI) volume M100-25 for Enterobacteriaceae (20) guidelines were used for interpretation of minimum inhibitory concentra-tions (MICs). Antimicrobials tested included: amoxicillin-clavulanate, ceftiofur, ceftriaxone, ciprofloxacin, ampicillin, azithromycin, cefoxitin, gentamicin, nalidixic acid, streptomy-cin, trimethoprim-sulfamethoxazole, chloramphenicol, sulfi-soxazole, and tetracycline. This commercially available plate was chosen to align with susceptibility testing protocols for bovine Salmonella isolates from the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS). This commer-cial plate includes chloramphenicol, even though this drug is no longer used in food animals, because it may represent resistance to florfenicol and allow detection of the ACSSuT pattern.

Antimicrobials that did not have CLSI MIC breakpoints were interpreted using the values selected by CIPARS, which are based on those used by the US National Antimicrobial Resistance Monitoring System (21). Salmonella spp. isolates were classified as susceptible, intermediate susceptibility or resistant based on these MIC breakpoints. Multidrug resistance (MDR) was defined as resistance to 3 or more drug classes. Data were analyzed in Excel (Microsoft Corporation, Redmond, Washington, USA) and STATA (Intercooled Stata 14; Stata Corporation, College Station, Texas, USA).

ResultsThere were 81 unique Salmonella spp. isolates obtained from 76 unique laboratory submissions from cattle operations in Alberta through the AF DIP from 2006 to 2014. These 76 sub-missions represent 72 visits to 27 farms. Of the isolates, 59.3% (48/81) were from 17 dairy farms, 24.7% (20/81) were from 3 feedlots, 9.9% (8/81) were from 3 cow-calf operations, and 6.2% (5/81) were from 3 veal calf grower operations. There were 14 Alberta veterinary clinics engaged in the investigations with

Table 1. Salmonella enterica ssp. enterica serotypes isolated from cattle operations in Alberta from the Agriculture and Forestry Disease Investigation Program (2006–2014).

Number of isolates

Salmonella Calf serotype Dairy Feedlot Cow-Calf grower Total

Typhimurium 28 18 8 1 55Dublin 13 0 0 3 16Enteritidis 2 0 0 0 2Kiambu 0 1 0 0 1Mbandaka 1 0 0 0 1Montevideo 0 1 0 0 1Newport 0 0 0 1 1Ohio 1 0 0 0 1Schwarzengrund 1 0 0 0 1Senftenberg 1 0 0 0 1Uganda 1 0 0 0 1

Total isolates 48 20 8 5 81



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63 isolates coming from southern Alberta compared to 18 from central Alberta. The breakdown of serotypes by type of cattle operation is shown in Table 1. The most common serotypes were S. Typhimurium (67.9%, 55/81 isolates) and S. Dublin (19.8%, 16/81), with 9 other serotypes present as 1 or 2 isolates. The 55 S. Typhimurium isolates came from 16 farms (10 dairy farms, 3 cow-calf operations, 2 feedlots, and 1 veal calf grower). The 16 S. Dublin isolates came from 10 farms (7 dairy farms and 3 veal calf growers).

There were 28 herd investigations for bovine Salmonella infection on 27 farms (1 feedlot had 2 investigations more than 2 y apart with different serotypes). Typically, each of the laboratory submissions represented a unique farm visit during which samples were collected. The number of farm visits per investigation, based on unique sampling dates, ranged from 1 to 12. There was 1 feedlot that was sampled on 12 different dates, resulting in 16 different submissions and all isolates were S. Typhimurium.

In samples from 5 separate visits to different farms there were 2 unique Salmonella serotypes identified at the same visit. In 4 of these, all dairy farms, 1 serotype was Typhimurium and the others were Senftenberg, Ohio, Mbandaka, or Enteritidis. The fifth was from a veal calf grower that yielded serotypes Dublin and Newport. Another veal calf grower had S. Dublin identified on the first visit and S. Typhimurium identified on a subsequent visit 9 mo later. Interestingly, the dairy farm that had Typhimurium and Senftenberg identified during 1 farm visit was under investigation for Dublin identified at the farm 3 mo earlier.

The AMR prevalence estimates and resistance patterns for the S. Typhimurium and S. Dublin isolates are shown in Tables 2 and 3. Resistance in S. Typhimurium and S. Dublin

was detected in every drug class except for macrolides (azithro-mycin). There was no resistance detected to ciprofloxacin; however, 7.3% of S. Typhimurium isolates had intermediate susceptibility. These same S. Typhimurium isolates were resistant to nalidixic acid. There were moderate to high levels of resistance in S. Typhimurium and S. Dublin to the critically important (category I) beta-lactam antimicrobials ceftiofur, ceftriaxone, and amoxicillin-clavulanic acid. Of the S. Typhimurium iso-lates, 44% were resistant to all 3 of these drugs. The highest prevalence of resistance in S. Typhimurium was to tetracycline (89.1%) and sulfisoxazole (90.9%) compared to only 3.6% for trimethoprim-sulfamethoxazole (Table 2). Resistance in S. Dublin was highest for ceftiofur and ceftriaxone (68.8%), amoxicillin-clavulanic acid (87.5%), tetracycline (93.8%), and chloramphenicol (93.8%), while all isolates were susceptible to ciprofloxacin, nalidixic acid, azithromycin, sulfisoxazole, and trimethoprim-sulfamethoxazole (Table 2).

Table 3 shows the prevalence of resistance patterns and MDR in S. Typhimurium and S. Dublin isolates. The prevalence of MDR was high for both S. Typhimurium (89.1%, 49/55 isolates) and S. Dublin (93.8%, 15/16), with most isolates displaying resistance to 4 or more drug classes. There were no S. Dublin isolates and only 4 S. Typhimurium isolates that were susceptible to all antimicrobials. In contrast, all 10 isolates of other serotypes were pan-susceptible. Of these 10 isolates, only 2 (Senftenberg and Enteritidis) had intermediate susceptibility to chloramphenicol.

There were 11 resistance patterns for S. Typhimurium (Table 3). The ACSSuT resistance pattern was present in 40.0% (22/55) of isolates. Three of these isolates were resistant to 6 drug classes. Of these ACSSuT-resistant isolates, 95.5% (21/22) were also resistant to amoxicillin-clavulanic acid, cefoxitin, ceftiofur, and

Table 2. The prevalence of resistance to different antimicrobials in Salmonella Typhimurium and Salmonella Dublin isolates from cattle operations in Alberta from the Agriculture and Forestry Disease Investigation Program (2006–2014).

Salmonella Typhimurium Salmonella Dublin n = 55, proportion (95% CIc) n = 16, proportion (95% CIc)

Antimicrobiala Sb I R S I R

Id

AUG2 45.4 (32.5–59.0) 10.9 (4.9–22.7) 43.6 (30.9–57.3) 12.5 (2.6–43.0) 87.5 (57.0–97.4) XNL 56.3 (42.7–69.1) 43.6 (30.9–57.3) 12.5 (2.6–43.0) 18.8 (5.3–48.6) 68.8 (40.2–87.8) AXO 56.3 (42.7–69.1) 43.6 (30.9–57.3) 12.5 (2.6–43.0) 18.8 (5.3–48.6) 68.8 (40.2–87.8) CIP 92.7 (81.7–97.3) 7.3 (2.7–18.3) 100

II AMP 10.9 (4.9–22.7) 89.1 (77.3–95.1) 12.5 (2.6–43.0) 87.5 (57.0–97.4) AZI 100 100 FOX 56.3 (42.7–69.1) 43.6 (30.9–57.3) 25.0 (8.6–54.3) 12.5 (2.6–43.0) 62.5 (34.8–83.9) GEN 100 68.8 (40.2–87.8) 31.2 (12.2–59.8) NAL 92.7 (81.7–97.3) 7.3 (2.7–18.3) 100 STR 30.9 (19.8–44.7) 69.0 (55.3–80.1) 37.5 (16.1–65.2) 62.5 (34.8–83.9) SXT 96.4 (86.1–99.1) 3.6 (1.0–13.9) 100

III CHL 60.0 (46.2–72.4) 40.0 (27.6–53.8) 0.06 (1.0–39.3) 93.8 (60.7–99.3) FIS 9.1 (3.7–20.5) 90.9 (79.5–96.3) 100 TET 10.9 (4.9–22.7) 89.1 (77.3–95.1) 0.06 (1.0–39.3) 93.8 (60.7–99.3)a AUG2 — amoxicillin/clavulanic acid; XNL — ceftiofur; AXO — ceftriaxone; CIP — ciprofloxacin; AMP — ampicillin; AZI — azithromycin; FOX — cefoxitin;

GEN — gentamicin; NAL — nalidixic acid; STR — streptomycin; SXT — trimethoprim/sulfamethoxazole; CHL — choramphenicol; FIS — sulfisoxazole; TET — tetracycline.

b S — susceptible; I — intermediate susceptibility; R — resistant; Assigned using Canadian Surveillance Breakpoints (21).c 95% CI — confidence interval.d Antimicrobials are grouped by their importance to human medicine as categorized by Health Canada Veterinary Drugs Directorate (14).



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ceftriaxone (AUG2-FOX-XNL-AXO) and 14.3% (3/21) were resistant to nalidixic acid. There were 6 resistance patterns for S. Dublin (Table 3). The ACSSuT resistance pattern was present in 56.3% (9/16) of isolates and 87.5% (14/16) were resistant to 5 drug classes. Five of the nine ACSSuT-resistant isolates were also resistant to AUG2-FOX-XNL-AXO.

DiscussionThis study describes the antimicrobial susceptibility and sero-type profiles of clinical Salmonella spp. isolates from bovine operations in Alberta from 2006 to 2014 obtained through the provincial DIP. In Alberta, Salmonella infection in cattle was typically only diagnosed when there was a clinical presentation of disease as there was no ongoing surveillance in healthy cattle until the Alberta sentinel site for FoodNet Canada began sam-pling feedlots in 2016 (data not yet available). Antimicrobial resistance was detected in the S. Typhimurium and S. Dublin isolates from Alberta cattle in this study, including resistance to third generation cephalosporins (ceftiofur/ceftriaxone), tetracy-cline, and chloramphenicol. Though controversial, case man-agement of bovine salmonellosis often includes antimicrobial therapy for sick calves and sometimes cows. This is in part due to the lack of a definitive etiologic diagnosis at the beginning of an outbreak and the need for rapid therapy for animals with severe diarrhea, dehydration, shock, and septicemia before a definitive bacterial culture result can be obtained (7).

The Canadian Veterinary Medical Association (CVMA) Antimicrobial Prudent Use Guidelines (2008) recommend vari-ous antimicrobial treatment options for different ages and pro-duction types of cattle for enteritis caused by Salmonella spp. or Escherichia coli (15). All of the recommended antimicrobials or

the dose regimens for bovine salmonellosis in Canada represent extra-label drug use (15). Canadian drugs with label claims for bovine salmonellosis tend to be injectable trimethoprim-sulfas or oral tetracycline antimicrobials, but the recommended doses of the former for calves with septicemia are still extra-label. The CVMA guidelines recommend either trimethoprim-sulfadoxine or ceftiofur for neonatal beef and dairy calves or adult dairy cattle with acute enteritis caused by Salmonella spp. (15). They provide an additional treatment option of danofloxacin or enrofloxacin (fluoroquinolones) for beef calves. Though chlor-amphenicol is banned for use in food animals, resistance is a concern because at least 1 of the possible genetic mechanisms for resistance, the floR gene, also confers resistance to florfenicol in the same drug class (22,23). Florfenicol resistance and resistance determinants were not evaluated in this study. Florfenicol is not included in the CVMA guidelines for treatment of Salmonella, but clinical experience of the authors suggests that it is still used to treat undifferentiated enteritis in newborn calves in Alberta. Two recent US studies in Wisconsin (24) and Minnesota (25) reported florfenicol resistance in veterinary diagnostic labora-tory collections of bovine Salmonella spp. isolates from 2006 to 2015. In both studies, S. Dublin was the most common serotype, with florfenicol resistance ranging from 96% to 100% in the S. Dublin isolates (Wisconsin), and 37% to 55% in all Salmonella isolates (Minnesota). We are not aware of data on whether newer generation macrolides (e.g., tulathromycin) are used to treat bovine salmonellosis in Alberta, but the Wisconsin study speculates that it is commonly used in the dairy industry in that state (24).

The study herein indicates that ceftiofur or florfenicol may not be the best choices for empirical treatment of suspected

Table 3. Antimicrobial susceptibility patterns and prevalence estimates of Salmonella Typhimurium and Salmonella Dublin isolates from cattle operations in Alberta from the Agriculture and Forestry Disease Investigation Program (2006–2014).

Antimicrobiala susceptibility pattern Frequency Proportion 95% CIb

Salmonella Typhimurium isolates (n = 55) — *MDRc 89.1% (95% CIb 77.3 to 95.1)

AUG2-XNL-AXO-AMP-FOX-NAL-STR-CHL-FIS-TET* 3 5.4 (1.7–16.1)AUG2-XNL-AXO-AMP-FOX-STR-CHL-FIS-TET* 18 32.7 (21.4–46.5)AUG2-XNL-AXO-AMP-FOX-STR-FIS-TET* 1 1.8 (0.2–12.5)AUG2-XNL-AXO-AMP-FOX-FIS-TET* 2 3.6 (0.8–13.9)AMP-NAL-STR-CHL-FIS-TET* 1 1.8 (0.2–12.5)AMP-STR-SXT-FIS-TET* 1 1.8 (0.2–12.5)AMP-SXT-FIS-TET* 1 1.8 (0.2–12.5)AMP-STR-FIS-TET* 13 24.6 (14.0–37.0)AMP-FIS-TET* 9 16.4 (8.6–29.0)STR-FIS 1 1.8 (0.2–12.5)Pan-susceptible 5 9.1 (3.7–20.5)

Salmonella Dublin isolates (n = 16) — *MDRc 93.8% (95% CIb 60.7 to 99.3)

AUG2-XNL-AXO-AMP-FOX-STR-CHL-FIS-TET* 5 31.3 (12.2–59.8)AUG2-XNL-AXO-AMP-FOX-GEN-CHL-FIS-TET* 5 31.3 (12.2–59.8)AUG2-XNL-AXO-AMP-STR-CHL-FIS-TET* 1 6.3 (0.7–39.3)AUG2-AMP-STR-CHL-FIS-TET* 3 18.8 (5.3–48.6)STR-CHL-FIS-TET* 1 6.3 (0.7–39.3)FIS 1 6.3 (0.7–39.3)a AUG2 — amoxicillin/clavulanic acid; XNL — ceftiofur; AXO — ceftriaxone; AMP — ampicillin; FOX — cefoxitin; GEN

— gentamicin; NAL — nalidixic acid; STR — streptomycin; SXT — trimethoprim/sulfamethoxazole; CHL — choramphenicol; FIS — sulfisoxazole; TET — tetracycline. Resistance determined using Canadian surveillance breakpoints.

b 95% CI — 95% confidence interval.c MDR — multi-drug resistance (resistance to $ 3 drug classes), denoted with *.



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bovine Salmonella in Alberta prior to obtaining culture and susceptibility results. Given that S. Typhimurium and S. Dublin are the most common serotypes detected, the potential for resis-tance to ceftiofur and possibly florfenicol is a cause for concern. The frequency of multidrug resistance in S. Typhimurium and S. Dublin, especially isolates resistant to both ceftiofur and chloramphenicol, makes empirical decisions for antimicrobial therapy even more difficult. The fact that this isolate collection is largely susceptible to trimethoprim-sulfamethoxazole sug-gests that this may still be a good empirical treatment choice. However, these findings reinforce the need to obtain a defini-tive etiologic diagnosis that includes a bacterial culture and an antimicrobial susceptibility profile to make appropriate clinical and antimicrobial stewardship treatment decisions for calves with enteritis or septicemia as the etiology and antimicrobial susceptibility can be unpredictable (3,4).

The treatment recommendations from the CVMA guidelines represent only 1 source of information available to veterinar-ians to make clinical treatment decisions. Therefore, they do not necessarily represent what is happening in practice. There is no current, ongoing antimicrobial use surveillance system that tracks antimicrobial use data at the veterinary practice or producer level for beef and dairy cattle in Canada. Antimicrobial use data have been collected by individual veterinary practices for use on their client’s operations (most commonly feedlot practices), sometimes in collaboration with CIPARS as part of pilot projects (26). However, the authors on this paper can confirm from veterinary field experience that antimicrobials such as ceftiofur or florfenicol are frequent first choice drugs for treatment of undifferentiated enteritis or septicemia in new-born calves, with fluoroquinolones (e.g., enrofloxacin) being used in more difficult cases. One author led an investigation that provided isolates to this study, during which there were anecdotal reports of enrofloxacin use for enteritis caused by Salmonella in newborn beef and dairy calves as recommended by practicing veterinarians in the area. It is also important to note that the CVMA Guidelines were published in 2008 and the recommended treatments and available drug formulations may have changed in the past decade. The CVMA is currently in the process of updating these guidelines for food and com-panion animals (27).

Frequencies of resistance in this collection of bovine Salmonella isolates from Alberta are similar to those reported in other jurisdictions in that resistance is most common to tet-racycline, streptomycin, and sulfisoxazole (28). The presence of resistance to third-generation cephalosporins in our study mir-rors that from the US from national surveillance (18) and the veterinary diagnostic collections in Wisconsin and Minnesota (24,25). Rao et al (10) found that resistance to tetracycline, streptomycin, and sulfisoxazole was common in Salmonella isolates from Alberta feedlot cattle that were collected in 2004, but there were only 20 Salmonella isolates out of 2100 samples. They detected ceftiofur resistance (5/20), but all isolates were susceptible to ciprofloxacin. They also found moderate levels (8/20 isolates) of penta-drug resistance (ACSSuT), sometimes in combination with resistance to amoxicillin-clavulanate, cefoxi-tin, ceftiofur, and/or trimethoprim-sulfa (10). The ACSSuT

resistance pattern is commonly reported in the literature for Salmonella from cattle in Canada (8–12,23,29). Most recently, an Alberta feedlot study conducted from 2007 to 2010 found only 2 Salmonella isolates in 933 composite pens samples, mak-ing susceptibility testing moot (26).

Older data from Alberta (1996 to 1999) showed similar resistance profiles for Salmonella isolates from food animals and food, including 42 isolates from cattle (11). Two other studies from Alberta dairy cattle (1999) (8) and beef cattle (1998 to 1999) (12) found resistance, but at lower frequencies. Based on the MIC breakpoints used in their study, Johnson et al (11) found 1.0% resistance to ceftiofur in 209 Salmonella isolates, with no resistance to ceftriaxone or ciprofloxacin, but it was not clear whether these isolates came from cattle or other food animals or food. Sorenson et al (12) did not find any third-generation cephalosporin or fluoroquinolone resistance in beef cattle Salmonella isolates. It was not clear from the dairy cattle study whether or not susceptibility to these antimicrobials was tested, but no resistance was reported (8).

Salmonella Typhimurium and S. Dublin dominated the sero-type distribution of this clinical isolate collection. This is not surprising in Alberta and mirrors clinical isolate collections in Wisconsin and Minnesota (24,25). It is not known if labora-tory methods have the ability to preferentially detect certain serotypes. It is uncertain as to why isolates from dairy farms are more frequent in this collection from Alberta. Dairies and veal calf grower operations were the only operation types that identified S. Dublin. Veal calf growers have a high throughput of calves sourced from dairy farms in western Canada. These isolates may represent Salmonella infections from dairy farms in the region. There were isolates from only 3 feedlots in this collection. The majority of feedlot isolates (18/20) were Typhimurium, with 16 coming from 1 feedlot over a 100-day period. The MICs varied by isolate for some antimicrobials, but the resistance phenotypes based on breakpoints were the same for all 16 isolates and 14 antimicrobials.

Previously reported data from Alberta assessed the serotype distribution of livestock Salmonella isolates from passive surveil-lance databases held by AF from 1990 to 2001 (30). In bovine isolates, S. Typhimurium and S. Dublin were the most common, but there was a higher frequency of other serotypes not identi-fied in this study. This difference may in part be explained by the fact that from 1990 to 1998, AF offered routine diagnostic services to cattle producers and veterinarians. The differences could also be explained by different source populations in that the 1990 to 2001 study represented incidental findings from a passive surveillance database compared to our isolates from investigations of clinical disease outbreaks. Recent surveillance projects in healthy Canadian cattle tend to detect Salmonella species at low frequencies, particularly in feedlot cattle. In 2004, an Alberta study found Salmonella spp. in only 1% (20/2100) of cattle manure samples from 21 feedlots of greater than 5000 head (31). Another Alberta study collected 933 composite pen samples from 4 feedlots from 2007 to 2010 and found only 2 to contain Salmonella from 2 separate feedlots (26). A 2013 study that integrated Salmonella data from multiple Canadian surveillance programs reported prevalence results of 10%



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(45/432) for cow-calf farms and 12% (80/643) for dairy farms in the C-EnterNet (now FoodNet Canada) sentinel surveillance site in Ontario between 2005 to 2010 (2). The FoodNet Canada sentinel site in Alberta started collecting samples from feedlot operations in 2016, but data are not yet available.

These Canadian studies are in stark contrast to data reported from the United States. The US National Animal Health Monitoring System Dairy study found 30.9% and 39.7% of dairy operations were positive for Salmonella in 2002 and 2007, with 13.8% of animals being positive in 2007 (32). A study in US feedlot cattle found that 64.7% of animals were posi-tive for Salmonella on arrival at the feedlot (33). The serotype distributions in these 2 US studies were much different than in this isolate collection. Comparatively, S. Dublin was the most common serotype in clinical bovine Salmonella isolates (23% and 31.8%, respectively) in the 2 US veterinary diagnostic studies in Wisconsin (24) and Minnesota (25); detection of S. Typhimurium was much less common. The bovine isolates in both studies came predominantly from dairy operations in these States. It is not known why the prevalence of Salmonella is higher in US dairy and feedlot cattle compared with Canadian cattle.

Despite the relatively low prevalence of Salmonella in Canadian cattle from available data, the clinical impact of bovine salmonellosis can be severe in an individual herd experi-encing an outbreak (7). Clinical infections in cow-calf and dairy operations tend to target newborn calves, resulting in severe diarrhea and septicemia, often with high mortality. Pregnant cows can experience abortion, while lactating dairy cattle may experience decreased milk production and enteritis (34). These are the typical cases that are reported to the Alberta OCPV. Management of such cases has 4 main objectives: to minimize the spread of Salmonella within the herd, to prevent transmission to farmers and their families, to prevent spread off the farm, and to assist the herd veterinarian in managing the clinical outbreak.

It is important to note that the isolate collection in this study is likely not representative of the cattle population of Alberta. It is more representative of a clinical case population of cattle herds experiencing outbreaks of salmonellosis in the province. Isolates from the same farm on different visit dates were included in the collection, representing clustering of isolates at the farm, veterinary clinics, and sometimes farm visit levels. There were only 3 feedlots included in this collection. Farms with resistant isolates may be more likely to be reported to the OCPV, to be under investigation, and to influence these resistance data. Farms with resistant strains may be more likely to experience antimicrobial treatment failure, translating to higher morbidity and mortality, increased likelihood of contacting a veterinarian, and ultimately seeking a bacterial culture. Lastly, there is selec-tion bias in the isolate collection towards S. Typhimurium and S. Dublin in the province (6). Due to the small sample numbers of isolates and farms, it was not possible to evaluate differences in resistance by cattle operation type. It is also important to note that there were no linked farm data from veterinarians or producers for antimicrobial use in these investigations. Such data are important to interpret subsequent resistance profiles to understand antimicrobial selection pressure (35).

The findings from our study provide valuable data to guide antimicrobial stewardship for cattle producers and veterinar-ians by providing information on the extent of antimicrobial resistance from clinical cases of bovine salmonellosis in Alberta. These findings reinforce that definitive etiologic diagnosis including a bacterial culture and antimicrobial susceptibility profile must be sought when Salmonella is suspected, as the susceptibility profile may vary widely depending on the serotype. It is desirable to collect and submit samples for bacterial culture and susceptibility at the outset of an outbreak to ensure that antimicrobial therapy is appropriate (3,4). Findings from our study reinforce the importance of considering bovine Salmonella within national antimicrobial resistance surveillance, despite the low prevalence in recent feedlot studies (26). More importantly, it brings into question the current recommended antimicrobial treatments for bovine enteritis and septicemia from the CVMA (15). Data from our study should be considered during the update of these guidelines. This isolate collection demonstrates that older drugs of relatively lower importance to human medi-cine may still be useful to treat some cases of bovine salmonel-losis in Alberta. Veterinarians should be wary of selecting drugs of high importance to human medicine, such as ceftiofur, as first line therapy.

AcknowledgmentsThe authors thank the University of Calgary Faculty of Veterinary Medicine for support and funding for the project. We also thank Alberta Agriculture and Forestry: the Agri-Food Laboratories Section for completing the laboratory work; the Animal Health Section for hosting this student project; and all the work of the AF staff that went into the herd investiga-tions. Lastly, the authors recognize the producers and herd veterinarians who cooperated closely with AF during these investigations. CVJ

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14. Government of Canada. Categorization of Antimicrobial Drugs Based on Importance in Human Medicine. 2009; Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/veterinary-drugs/antimicrobial-resistance/categorization-antimicrobial-drugs-based-importance-human-medicine.html Last accessed September 3, 2018.

15. CVMA. Canadian Veterinary Medical Association Antimicrobial Prudent Use Guidelines 2008 for Beef Cattle, Dairy Cattle, Poultry, and Swine. 2008. Available from: https://www.canadianveterinarians.net/documents/cvma-antimicrobial-prudent-use-guidelines-2008-for-beef-dairy-poultry-swine Last accessed September 3, 2018.

16. Boerlin P, White DG. Antimicrobial resistance and its epidemiology. In: Antimicrobial Therapy in Veterinary Medicine. Hoboken, New Jersey: John Wiley & Sons, 2013:21–40.

17. Jensen LB, Angulo FJ, Mølbak K, Wegener HC. Human health risks associated with antimicrobial use in animals. In: Guardabassi L, Jensen LB, Kruse H, eds. Guide to Antimicrobial Use in Animals. Ames, Iowa: Blackwell Pub, 2008:13–26.

18. Cameron A, McAllister TA. Antimicrobial usage and resistance in beef production. J Animal Sci Biotechnol 2016;7:68.

19. Otto SJG, Carson CA, Finley RL, Thomas KM, Reid-Smith RJ, McEwen SA. Estimating the number of human cases of ceftiofur-resistant Salmonella enterica serovar Heidelberg in Québec and Ontario, Canada. Clin Infect Dis 2014;59:1281–1290.

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21. Government of Canada. Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) 2013 Annual Report — Chapter 1. Design and Methods. 2015:1–46.

22. Martin LC, Weir EK, Poppe C, Reid-Smith RJ, Boerlin P. Characteriza-tion of blaCMY-2 plasmids in Salmonella and Escherichia coli isolates from food animals in Canada. Appl Environ Microbiol 2012;78:1285–1287.

23. Larkin C, Poppe C, McNab B, McEwen B, Mahdi A, Odumeru J. Antibiotic resistance of Salmonella isolated from hog, beef, and chicken

carcass samples from provincially inspected abattoirs in Ontario. J Food Prot 2004;67:448–455.

24. Valenzuela JR, Sethi AK, Aulik NA, Poulsen KP. Antimicrobial resis-tance patterns of bovine Salmonella enterica isolates submitted to the Wisconsin Veterinary Diagnostic Laboratory: 2006–2015. J Dairy Sci 2017;100:1319–1330.

25. Hong S, Rovira A, Davies P, et al. Serotypes and antimicrobial resistance in Salmonella enterica recovered from clinical samples from cattle and swine in Minnesota, 2006 to 2015. PLoS ONE 2016;11:e0168016.

26. Gow SP, McAllister TW, Booker CW, Morley PS, Benedict KM. Final Report for Alberta Beef Producers 2011: Development of a longitudinal antimicrobial resistance and antimicrobial use surveillance program for the feedlot sector in Canada. 2011:1–336.

27. CVMA. News Release: CVMA Begins Process to Update Guidelines for the Prudent Use of Veterinary Antimicrobial Medications. May 9, 2017; Available from: https://www.canadianveterinarians.net/news-events/news/cvma-begins-process-to-update-guidelines-for-prudent-use-of-veterinary-antimicrobial-medications Last accessed September 3, 2018.

28. Helke KL, McCrackin MA, Galloway AM, Poole AZ, Salgado CD, Marriott BP. Effects of antimicrobial use in agricultural animals on drug-resistant foodborne salmonellosis in humans: A systematic literature review. Crit Rev Food Sci Nutr 2017;57:472–488.

29. Poppe C, Ayroud M, Ollis G, et al. Trends in antimicrobial resistance of Salmonella isolated from animals, foods of animal origin, and the environment of animal production in Canada, 1994–1997. Microb Drug Resist 2001;7:197–212.

30. Guerin MT, Martin SW, Darlington GA, Rajić A. A temporal study of Salmonella serovars in animals in Alberta between 1990 and 2001. Can J Vet Res 2005;69:88–99.

31. Van Donkersgoed J, Bohaychuk V, Besser T, et al. Occurrence of food-borne bacteria in Alberta feedlots. Can Vet J 2009;50:166–172.

32. USDA. Salmonella, Listeria, and Campylobacter on US Dairy Operations, 1996–2007. Available from: https://www.aphis.usda.gov/animal_health/nahms/dairy/downloads/dairy07/Dairy07_is_SalCampy.pdf Last accessed September 3, 2018.

33. Dodd CC, Renter DG, Shi X, Alam MJ, Nagaraja TG, Sanderson MW. Prevalence and persistence of Salmonella in cohorts of feedlot cattle. Foodborne Pathog Dis 2011;8:781–789.

34. McGuirk SM, Peek S. Salmonellosis in Cattle: A Review. America Association of Bovine Practitioners: 36th Annual Conference, Columbus, Ohio, September 15–17, 2003.

35. Martin SW, Johnson JYM, Rajić A, McMullen LM. Prior exposure to antimicrobials affects pathogen isolation, resistance to antimicrobi-als, and resistance patterns (multiple letters) [1]. Can Vet J 2005;46: 573–574.

CorrectionRegarding the published information in The Canadian Veterinary Journal, Vol 59, July 2018, page 719, it is necessary to clarify that AVSI — Associated Veterinary Specialist Inc. should not have been included in the distributors list, because they are not a distributor of Merck Animal Health products in Canada. For information about the Merck Animal Health portfolio, please contact your local representative.



Article

A longitudinal investigation of an outbreak of toe tip necrosis syndrome in western Canadian feedlot cattle

Murray Jelinski, Sonia Marti, Eugene Janzen, Karen Schwartzkopf-Genswein

Abstract — This investigation followed a cohort (n = 21) of single-sourced Angus cross yearling heifers diagnosed with toe tip necrosis syndrome (TTNS). The animals were intensively followed for 7 months, over which time 5 animals were euthanized because of intractable lameness or life-threatening sequelae such as cellulitis and myositis. Treatment consisted of systemic antimicrobial and nonsteroidal anti-inflammatory therapy, removing the necrotic horn tissue to facilitate drainage, and relocating the cattle to an earthen-floor pen. Sixteen of the 21 heifers recovered uneventfully. Upon sectioning the feet after slaughter, all the foot lesions had healed, but in some instances, the 3rd phalangeal bone had undergone bone remodeling, indicative of an earlier pathological process. This study is unique in that it chronicled the clinical and pathological outcomes associated with TTNS over an extended period.

Résumé — Enquête longitudinale d’une éclosion du syndrome de nécrose de la pince chez les bovins de parcs d’engraissement dans l’Ouest canadien. Cette enquête a suivi une cohorte (n = 21) de génisses de race croisée Angus âgées d’un an provenant d’une seule source qui ont reçu un diagnostic de syndrome de la nécrose de la pince. Les animaux ont fait l’objet d’un suivi intensif de 7 mois, pendant lequel 5 animaux ont été euthanasiés en raison d’une boiterie intraitable ou de séquelles potentiellement mortelles comme la cellulite et la myosite. Le traitement a consisté d’antimicrobiens systémiques et de traitements anti-inflammatoires non stéroïdiens, de l’enlèvement des tissus nécrosés de la corne afin de faciliter le drainage et du déplacement des bovins dans des enclos dotés d’un plancher de terre battue. Seize des 21 génisses se sont rétablies sans incident. Au moment du sectionnement des pieds après l’abattage, toutes les lésions des pieds avaient guéri mais, dans certaines instances, l’os de la troisième phalange avait subi un remodelage osseux, ce qui indique un processus pathologique antérieur. Cette étude est unique parce qu’elle dresse l’historique des résultats cliniques et pathologiques associés au syndrome de nécrose de la pince pendant une période prolongée.

(Traduit par Isabelle Vallières)Can Vet J 2018;59:1202–1208

Introduction

T oe tip necrosis syndrome (TTNS) describes a lameness most commonly associated with feedlot cattle (1). While

TTNS is a relatively new term, the disease was first reported in 1979 in a group of dairy heifers (2). These heifers developed a hind limb lameness within 3 wk of transit, and hence the disease

was labeled as a “transit-related lameness.” Clinically, the affected feet were not swollen, but white line separation was evident and debriding the apical region of the affected claws revealed blackened (necrotic) horn tissue or a purulent solar abscess. Treatment consisted of debriding the lesion and relocating the cattle to pasture; most animals made a full recovery within 14 d. A similar outbreak was reported 3 y later in feedlot cattle (3); the epidemiology and clinical findings were consistent with those reported previously in the dairy heifers, but the lesions were described as “toe abscesses.” Some cattle also had postmortem findings consistent with bacteremia. It was noteworthy that the feedlot personnel frequently misdiagnosed the lameness as a hip injury or foot rot. Once properly diagnosed, treatment consisted of antimicrobial therapy, debridement of the abscesses, and moving the cattle to earthen-floored holding facilities. The next peer-reviewed report, in 1994, described outbreaks of toe abscesses in 5 mid-western American feedlots (4). Most lesions developed in the lateral hind claw but the medial claws and front feet were occasionally affected. Ascending tendonitis and/or cel-lulitis of the hind limb was reported. The disease was thought to be initiated by excessive wear of the soles on abrasive surfaces and it was postulated that wet weather conditions might have led to softer horn tissue, increasing the risk of abraded soles.

Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4 (Jelinski); University of Calgary Ringgold Standard Institution — Animal Production Health, 2500 University Drive NW, Calgary, Alberta T2N 1N4 (Marti); Clinical Practice, Faculty of Veterinary Medicine, Calgary, Alberta T2N 1N4 (Janzen); Agriculture and Agri-food Canada — Lethbridge Research Centre, Lethbridge, Alberta (Schwartzkopf-Genswein).Address all correspondence to Dr. Murray Jelinski; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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More recently, outbreaks of TTNS have been reported in beef calves in the United Kingdom (5,6), and in one instance the calves were being handled in a new chute system having a solid galvanized steel floor outfitted with grip bars for traction (5).

In a case series study of 53 cattle with toe ulcers and/or apical pedal bone necrosis, 49 animals had necrosis of the 3rd phalangeal bone (P3 necrosis) (7). Fourteen of 49 animals had P3 necrosis involving 2 or 3 claws. Most (73%) affected claws had necrosis of the apical regions of the white line (zone 1) and sole (zone 5) as well as white line separation, thin soles, and under-run soles. In 50% of cases, the lesions were attributed to excessive trimming with hoof grinders. More importantly, neither the degree of white line separation nor the size of the toe lesions correlated with the degree of osteolysis of P3. The uncomplicated toe ulcers were treated by debriding the horn tissue and affected corium. A bone curette or hammer and chisel were used to resect the infected P3 bone. Cases with minimal P3 involvement usually resolved within 30 d. While the toe lesions frequently fit the description of abscesses, “toe ulcer” was deemed to be a more appropriate term.

The International Committee for Animal Recording (ICAR) defines toe ulcer (Pododermatitis solearis circumscripta purulenta et neroticans chronica) as a “circumscribed chronic purulent and necrotizing inflammation of the corium of the claws at the toe” (8). Although the lesions found in feedlot cattle are frequently referred to as toe abscesses, the lesion is technically an ulcer because it is a full-thickness defect of the epidermis (horn tissue), which exposes the underlying fresh or necrotic dermis (corium) (9,10). The use of toe ulcer, however, may only serve to add fur-ther confusion. In the dairy industry, toe ulcers (TU) and thin sole toe ulcers (TSTU) are common causes of lameness; however, the etiology, pathogeneses, and clinical manifestations of these diseases are very different from TTNS of feedlot cattle (9,11,12). Therefore, it is important to appreciate that toe lesions of feedlot cattle differ from TU and TSTU of dairy animals.

While toe ulcer may be the most appropriate terminology for describing the formative stages of the disease, feedlot veteri-narians frequently encounter the more advanced stages of “toe necrosis.” The ICAR Claw Health Atlas describes toe necrosis as necrosis of the tip of the toe with involvement of bone tissue (10). This is synonymous with “P3 necrosis,” a term commonly used in western Canadian feedlots to describe toe necrosis. The term TTNS is an extension of toe necrosis, with toe tip necrosis describing the hallmark clinical findings of the disease, and syndrome encompassing all the sequelae. It has, however, been suggested that the term TTNS not be used. Rather, toe necrosis should be used to describe the primary foot lesion and any sequelae reported separately (13).

Confusion regarding the most appropriate terminology may be explained, in part, by the current understanding of the patho-genesis of TTNS. The “abrasion theory” posits that cattle abrade the apex of the toes during shipping and handling, resulting in a reduction in the integrity of the white line (14). During ambula-tion, loading forces placed on the hoof result in micro-fissures along the white line, which become colonized with bacteria such as Trueperella spp. (15). Pain, as evidenced by lameness, is manifested once the infection reaches the sensitive and highly

vascularized corium (dermis). On close inspection, necrosis of the apical white line may appear as a dry black lesion, or it may have a dark brown, gray, or black exudate. This latter presenta-tion is the classical toe abscess. The infection may underrun the sole or alternatively breach the corium and infect the pedal bone, resulting in toe necrosis. Finally, the infection may either ascend the hind limb or spread hematogenously to more distant organs.

Toe necrosis is a fitting term for describing a claw having necrosis of the horn and P3 osteolysis. However, in most feedlot situations a definitive diagnosis of toe necrosis is made at the time of postmortem examination. Unless euthanized, animals do not die of toe necrosis, rather they frequently die of the sequelae (14). Toe tip necrosis syndrome (TTNS) covers the range of clinical findings from uncomplicated necrosis of the tip of the toe (without P3 involvement) to a myriad of sequelae associated with toe necrosis. In outbreak situations, clinical signs range from early white line separation to extensive pedal bone necrosis and in some cases pathological findings consistent with bacterima (e.g., embolic pneumonia).

This report describes the clinical and pathological findings associated with an outbreak of TTNS involving a cohort of yearling beef heifers. The heifers were intensively followed for 216 d, from diagnosis to slaughter.

Materials and methodsHistory and clinical assessmentsIn the fall of 2014, 95 Angus cross yearling heifers were shipped 90 km directly from a ranch to an auction market. The cattle were sold the following day and 45 of them were transported 25 km to a commercial feedlot. Within 48 h of arrival, an unusually high number of animals developed lameness of the hind limbs. The auction market offered to take back the lame animals, which the feedlot obliged by returning 21 animals displaying varying degrees of lameness. It was undetermined whether the lame animals received antimicrobial therapy before being returned.

Day 1 of the investigation began at the auction market with an examination of the 21 heifers. Based on the clinical history and signalment, TTNS was considered the most probable cause of lameness and hence all hind claws, and when warranted the front feet as well, were examined for signs of apical white line separation and/or necrosis of the tips of the toes. The diagnosis was confirmed by paring the affected white line to the level of healthy horn tissue or to the corium. This procedure confirmed the diagnosis and facilitated drainage.

In addition to the clinical examinations, whole blood and ear notch skin samples were obtained for bovine viral diarrhea virus (BVDV) testing, and claws having a purulent discharge were swabbed for microbiological testing. Sample collection and laboratory testing procedures for BVDV and microbiological testing have been previously described (14).

A recumbent heifer (#1), having lost considerable body condition compared to her contemporaries, was euthanized. Of the remaining 20 heifers, 19 had $ 1 claw with white line separation and necrosis of the toe tip. The auction owner was advised of the clinical findings, at which point the animals were donated for research.



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The cattle were transported on day 8 from the auction to Agriculture and Agri-Food Canada’s Lethbridge Research Station (LRC), Lethbridge, Alberta. Here they were weighed, body tem-peratures taken, feet re-examined, and each administered tilmi-cosin (Micotil; Elanco, Guelph, Ontario), 10 mg/kg body weight (BW), IM, and a nonsteroidal anti-inflammatory drug (Metacam; Boehringer Ingelheim, Burlington, Ontario), 0.5 mg/kg BW, IM. The heifers were relocated to an earthen-floored feedlot pen and fed commercial feedlot rations for 7 mo.

Body temperatures were within normal range 2 wk after arrival at the LRC. On day 36, 11 animals were febrile and had clinical signs consistent with bovine respiratory disease; each ani-mal was administered tulathromycin (Draxxin; Zoetis, Kirkland, Quebec), 5 mg/kg BW, IM. One (#19) animal was re-treated with tulathromycin on day 50, along with 2 animals that had not received treatment on day 36. Animal #19 was re-treated on day 69 with tilmicosin (Micotil; Elanco), 10 mg/kg BW, IM.

Over the course of 7 mo, the feet were examined bi-weekly for the first 3 mo and then monthly until slaughter: day 216. Double sole formation was a common finding, and the over-lying sole was routinely debrided. More extensive debridement, removal of all necrotic tissue, was also undertaken when war-ranted. The feet and all carcass data were collected at slaughter.

Gross postmortem and histological examination proceduresAny animals deemed to be severely compromised, as determined by the systemic progression of the disease, were euthanized and a gross postmortem examination was performed. Hind feet and tissues having gross pathological changes were submitted to Prairie Diagnostic Services (PDS, Saskatoon, Saskatchewan) for histopathological examination and microbiological testing. In addition to standard hematoxylin and eosin (H&E) staining, a Warthin Faulkner silver stain was used to aid in the visualization of spirochetes. Sub-samples of each tissue were submitted for microbiological testing.

ResultsClinical and gross pathological findingsAll 19 animals diagnosed with TTNS had separation of the white line in the apical region of the toe. Upon initial examina-tion (day 1), most toe lesions appeared as dry black horn tissue; however, 5 heifers had a bloody, gray, or dark brown purulent exudate. Over the course of the study it was not unusual for lesions to develop in more than 1 claw; 1 heifer had TTNS in 3 of 4 hind claws. One animal developed draining abscesses above the coronary band. In total, 5 animals were euthanized over the course of the study, with animal #1 being euthanized on day 1.

Figures 1 to 4 are photographs of the clinical and gross pathological findings from 4 animals, 2 of which were eutha-nized. Figure 1 details the progression of the disease in animal #2. On day 1 (Figure 1A), the leading edge of the apex of the toe was worn and white line separation was evident. Removal of the apex (“nipping” or “tipping”) of the right lateral claw resulted in a purulent discharge. By day 50, granulation tissue was forming, and a double sole had developed (Figure 1B). The

double sole formation was a finding in nearly all the cattle. At the time of slaughter, the right lateral (RL) claw had developed a much thicker sole compared to the medial claw of the same foot (Figure 1C). There was no evidence of an ongoing pathological process such as infection in either claw; however, P3 of the RL claw was noticeably blunt, indicative of past bone remodeling.

Figure 2 is a series of photographs obtained from animal #3. The slight wear along the apex of the toe and the mild degree of white line separation were difficult to visualize. However, nip-ping the toe resulted in a bloody brown discharge (Figure 2A). By day 78, the animal had formed a double sole (Figure 2B). Sectioning of the claws after slaughter revealed evidence of P3 remodeling (Figure 2C).

Animal #4 had no evidence of an active ongoing infection in any of the hind claws on day 1 (Figure 3A). By day 8, a bloody purulent exudate was expressed with hoof testers from the

Figure 1. A series of photographs taken from animal #2 on day 1, day 50, and after slaughter. A — Initial diagnosis on day 1 was confirmed by debriding the tip of the toe. B — Double sole has formed by day 50. C — At the time of slaughter, the 3rd phalangeal bone of the right lateral (RL) claw shows evidence of remodeling (arrow) and the sole is much thicker compared to that of the medial claw (arrows).



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lateral claw of the right hind foot (Figure 3B). This animal was euthanized the same day, and the infection was found to have migrated from the foot to the level of the stifle, resulting in a necrotizing myositis and cellulitis (Figure 3C).

Animal #5 had minimal white line separation of the lat-eral claw of the right hind foot (RL) (Figure 4A) on day 1. Nipping the toes revealed an underlying septic process in the lateral claw of the right hind foot (Figure 4B) and both claws of the left hind foot (Figure 4C). The animal was euthanized on day 8 and found to have an extensive necrosuppurative cellulitis of the hind limb.

Histopathological and laboratory findingsFive animals were euthanized between October 2 and 28, 2014, all of which underwent a gross postmortem examina-

tion. Animal #1, euthanized on day 1 at the auction, had toe necrosis (P3 necrosis) of both lateral hind claws and embolic pneumonia; a heavy growth of Trueperella pyogenes was isolated from both the lungs (4) and P3 lesions (3). The lungs and P3 lesions also had moderate growth of Escherichia coli (2). Of the remaining 4 euthanized animals, all had toe necrosis involving more than 1 hind claw. Animal #4 had a necrotizing myositis and cellulitis, and animal #5 had a necrosuppurative cellulitis. Together these latter 2 animals had a mixed population of T. pyogenes, Pseudomonas spp., E. coli, and Fusobacterium spp.

Figure 2. A series of photographs obtained from animal #3 on day 1, day 78, and after slaughter. A — There was little evidence of white line separation on day 1; however, removing (nipping) the end of the toe resulted in a dark bloody discharge. B — The animal developed a double sole. C — At slaughter there was evidence of remodeling of 3rd phalangeal bone (arrow).

Figure 3. A — The lateral left hind (LH) claw shows a normal hoof after nipping. B — By day 8, both claws of the contralateral limb had evidence of toe tip necrosis. C — The animal was euthanized on day 8 and postmortem examination revealed a necrotizing myositis and cellulitis that extended past the stifle joint.



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The main pathological finding associated with the remaining 2 submissions (animals # 2 and #3) was toe necrosis of the hind claws. No spirochetes were associated with any of the toe lesions.

Bovine viral diarrhea virus (BVDV) was not detected in any of the blood samples nor in any of the ear skin notches.

Slaughter dataThe mean hot carcass weight of the 16 heifers was 348 kg 6 25.6 [standard deviation (6 SD)]. Three heifers had a yield grade 1 (Y1), 11 were Y2, and 4 were Y3. The breakdown of the carcasses by quality grade was as follows: AAA (n = 7), AA (n = 8), and A (n = 1).

DiscussionThe sporadic nature of toe tip necrosis syndrome (TTNS) com-plicates conducting well-designed clinical field studies dedicated to determining best practices for the treatment of this disease (TTNS). Therefore, this outbreak provided a unique research opportunity because the source of the cattle was known, the attack rate was very high, the cattle could be intensively studied over a period of several months, and pathological changes to the claws were correlated to the antemortem clinical findings. It was also fortuitous that the auction donated the animals and that the Lethbridge Research Centre’s facilities and personnel were available to house and study the animals over a 7-month period. Unfortunately, the health status of the remaining heifers that originated from the same ranch, but were sold to other feedlots, remains unknown. If all the heifers were similarly affected with TTNS, then this would suggest a common source of risk factors such as nutritional status while on pasture, genetics, tempera-ment (hyperexcitability), and the shipping and handling from the pasture to the auction.

This investigation underscores several important points for consideration when investigating a TTNS outbreak. The dis-ease frequently clusters and may involve a large percentage of the animals at risk. While nipping or debriding the lesions is an excellent diagnostic procedure, it is a poor prognostic tool. Administering systemic antibiotics, nipping the toes to facilitate drainage, and relocating the animals to earthen floor pens appear to have assisted healing in most animals. However, there were no nontreated controls and 25% of the affected animals were euthanized because of intractable lameness or the development of life-threatening sequelae. Finally, temperament or hyper-excitability may have been a risk factor for developing TTNS.

The serial photographs underscore some important points concerning the clinical examination of animals with suspected TTNS. Close attention must be given to examining the apex of the toe for evidence of white line separation. If the feet are heav-ily soiled or if there are poor lighting conditions, then running a probe or thumbnail along the white line is a useful procedure for diagnosing white line separation. However, finding white line separation does not confirm toe tip necrosis (osteolysis of P3). Rather, the toe must be debrided or radiographed. Debridement, however, is usually sufficient to confirm the diagnosis. Furthermore, based on first principles for managing an abscess, debriding the claw assists with drainage. Feedlot veterinarians often refer to removing the toe tips as “tipping the toes,” which involves using a set of hoof nippers to remove the apex of the toe to determine the extent of the infection. In this study, nipping or tipping the toes was performed at the time of the initial examination, while debridement was performed at the LRC when there was more time and under working conditions. It is important to distinguish nipping from debridement. In the former, the horn is removed to confirm a diagnosis, while debridement is a therapeutic procedure that involves the removal of all the necrotic tissue.

Currently, there is no standard protocol for treating TTNS. Sick et al (3) outlined a 3-pronged approach: remove 0.5 to 1.0 cm of horn from the apex of the toe to facilitate drainage;

Figure 4. A series of photographs from animal #5 taken on day 1 and day 8. A — There was minimal white line separation (arrow) of the right lateral (RL) claw on day 1. B — Tipping both right hind claws on day 8 shows an infected RL claw and a normal right medial claw. C — Both claws on the left hind foot were diseased, with the left lateral (LL) showing a typical “dry” lesion, while the medial claw appeared as a classical “toe abscess.”



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administer systemic antimicrobials; and move the animals from abrasive flooring surfaces such as concrete. These 3 principles were followed in the current study. Also, the feet were debrided on routine follow-up examinations, and all cattle received a non-steroidal anti-inflammatory drug (NSAID) on day 8. However, the amount of time and effort expended on making a diagnosis and administering treatment was not typical of what occurs in most feedlots. In large commercial feedlots a putative diagnosis of TTNS is based on observing a lower limb lameness involv-ing a hind leg, no obvious swelling of the foot, and the onset of lameness occurring within weeks of arrival at the feedlot. These animals typically receive antimicrobial therapy and are then returned to their home pen. In some feedlots, the protocol would involve “tipping the toes” to facilitate drainage or may involve administering an NSAID.

Antimicrobial therapy may be effective in the early course of the disease before P3 involvement. However, if the treatment fails, then these animals are at risk of developing deep digital sepsis (DDS), which includes conditions such as osteomyelitis, arthritis, and tenosynovitis (16–19). Chronic septic arthritis of the distal interphalangeal joint as well as a septic tenosynovitis are largely non-responsive to systemic antibiotics alone because of local ischemia. Similarly, P3 necrosis usually requires either curettage of the necrotic bone or complete amputation of the digit. In the current study, bone curettage was not performed on any of the heifers; however, 2 animals had evidence of P3 remodeling, indicative of P3 osteolysis. Regional intravenous perfusion (RIVP) antimicrobial therapy may be considered for treating toe necrosis and DDS conditions (20–22); however, it is important to appreciate that RIVP alone is unlikely to result in a satisfactory outcome. Rather, the lesion must be debrided or the digit amputated. A randomized clinical study dedicated to treatment options and outcomes is needed to determine the most appropriate treatments for the various stages of TTNS.

While the recovery rate in the current investigation was relatively good, intensive individual animal care is logisti-cally challenging in large commercial feedlots that lack proper handling systems for restraining animals for foot examination. Furthermore, most cases occur during the autumn months when North American feedlots are processing large numbers of incoming cattle (23). Complicating matters is that the degree of lameness associated with the early stages of the disease is often mild. Hence, these subtle cases may be overlooked, particu-larly if the animals are fractious. Confinement in chutes and pens during on-arrival processing also makes it more difficult to observe normal ambulatory behavior. The lack of obvious clinical signs early in the disease may result in feedlot personnel attributing the lameness to trauma or misclassifying the disease as early stage foot rot (3). For those animals misclassified as hav-ing foot rot, administering antimicrobial therapy may result in full recovery. As a result, TTNS may be underreported, which is salient because antimicrobial therapy may mask substandard facility design and management practices. If feedlots correctly identify TTNS cases, then they may be more likely to change the flooring or take additional care when handling fractious animals.

A consistent clinical finding encountered over the course of the study was the appearance of paint brush hemorrhages of the

sole as well as double sole formation. In dairy heifers, under-run or double soles are invariably preceded by solar hemorrhage (24). In a recent study of Danish bull calves fed to slaughter, 75% of animals had sole hemorrhages, with the odds increas-ing if the cattle were housed on slatted concrete versus deep litter straw, and in animals with a higher average daily weight gain (25). While the pathogenesis of double sole formation is not fully understood, fluid formation between dermal-epidermal interface is thought to result in separation of the sole from the underlying dermis. The fluid accumulation associated with the sole hemorrhage (bruising), as well as the inflammatory exudate from toe necrosis, likely led to the separation of the sole (epi-dermis) from the underlying dermis (corium), resulting in the growth of a new sole.

From a practical point of view, debriding the toes is a simple and relatively rapid diagnostic procedure for confirming toe tip necrosis. For example, heifer #5 had a minimal degree of white line separation; however, debriding revealed that 3 of 4 hind claws were affected. This animal was euthanized 7 d later because of an ascending necrosuppurative cellulitis, underscor-ing that TTNS is more than just localized toe necrosis. This case also confirms a previous report that the degree of white line separation and necrosis of the toe tip are not correlated to P3 osteolysis (7). The use of ultrasound and radiology to determine the extent of P3 involvement has been reviewed elsewhere (13).

None of the 20 heifers examined on day 1 tested positive for BVDV, which is interesting since Paetsch et al (15) found feedlot cattle with TTNS to be 4.4 times more likely to be transiently infected with BVDV compared to animals dying of all non-TTNS causes. Furthermore, few spirochetes were associated with the lesions, suggesting that they are not associated with TTNS development.

Sick et al (3) were the first to associate this disease with hyper-excitable cattle, which was likely a factor in the current investigation. No personnel ever walked amongst the cattle for fear of being physically injured. Even after 7 mo of confine-ment the animals became extremely agitated when handled. Conceivably, the pain associated with TTNS may have led to the cattle becoming irritable versus the hyper-excitability being a factor in TTNS formation. This, however, seems unlikely since most feet appeared normal at the time of slaughter. Based on the current understanding of the pathogenesis of the disease, it is logical that high-strung animals may be more likely to abrade the solar surfaces of their feet on coarse flooring. Hence, TTNS may be mitigated by modifying flooring, facility design, and handling practices. Change, however, is unlikely to occur until feedlot personnel and veterinarians gain a better appreciation of the incidence of the disease, which is contingent upon conduct-ing a careful examination of the hind feet of lame feedlot cattle, particularly cattle that are 30 d on feed.

Without a negative control group, it cannot be stated unequivocally that debridement and parenteral antimicro-bial therapy influenced the successful outcome in 16 of the 21 animals. However, administration of antimicrobials, debride-ment or resection of P3, and moving the animals to earthen-floored pens seem logical. If claw amputation is required, then it



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is critical that all the claws, including the front feet, be inspected before amputation since multiple claws are commonly affected. Finding more than 1 claw affected also has implications with respect to animal welfare and the timing of euthanasia. Lameness is an animal welfare concern and it needs to be managed as such. Lame animals that are nonresponsive to treatment after 7 to 10 d need to be reassessed. Even in feedlot conditions, restraint of the animal and lifting the foot with a rope is a simple, albeit somewhat time-consuming technique for examining the hoof. Debriding all the necrotic sole allows for visualization and assessment of P3 involvement. A decision must then be made to debride the necrotic horn tissue, resect the necrotic bone, or opt for euthanasia. The use of pain control (NSAIDs) should always be considered. CVJ

References 1. Paetsch CD, Jelinski MD. Toe-tip necrosis syndrome in feedlot cattle

in Western Canada. Proc 17th Int Symp & 9th Conf Lameness in Ruminants, Bristol UK 2013:152–153.

2. Dewes HF. Transit-related lameness in a group of Jersey heifers. N Z Vet J 1979;27:45.

3. Sick FL, Bleeker CM, Mouw JK, Thompson WS. Toe abscesses in recently shipped feeder cattle. Vet Med Small Anim Clin 1982;77: 1385–1387.

4. Miskimins DW. Bovine toe abscesses. Proc 8th Int Symp Disorders of the Ruminant Digit and Int Conf on Bovine Lameness, Banff, Alberta 1994:54–57.

5. Penny C, Bradley S, Wilson D. Lameness due to toe-tip necrosis syn-drome in beef calves. Vet Rec 2017;180:154.

6. Disease Surveillance Report, SAC Consulting: Veterinary Services. Outbreak of toe tip necrosis syndrome in calves. Vet Rec 2017;180:417.

7. Kofler J. Clinical study of toe ulcer and necrosis of the apex of the distal phalanx in 53 cattle. Vet J 1999;157:139–147.

8. ICAR: Publications — Health codes for bovine. Available from: http://www.icar.org/index.php/publications-technical-materials/amendments-recording-guidelines/diseases-codes-for-cows/ Last accessed September 3, 2018.

9. Shearer JK, van Amstel SR, Brodersen BW. Clinical diagnosis of foot and leg lameness in cattle. Vet Clin Food Anim 2012;28:535–556.

10. Egger-Danner C, Nielsen P, Fiedler A, et al. ICAR Claw Health Atlas 2015. Available from: www.icar.org/wp-content/uploads/2016/OZ/ICAR-Claw-Health-Atlas.pdf Last accessed September 3, 2018.

11. Shearer JK, van Amstel SR. Traumatic lesions of the sole. Vet Clin Food Anim 2017;33:271–281.

12. Greenough PR. Lameness in Cattle. Toronto, Ontario: WB Saunders, 1997:107–109.

13. Kofler J. Pathogenesis and treatment of toe lesions in cattle including “nonhealing” toe lesions. Vet Clin Food Anim 2017;33:301–328.

14. Paetsch CD. Epidemiology of toe tip necrosis syndrome in Western Canadian feedlot cattle [MSc thesis]. Saskatoon, Saskatchewan: University of Saskatchewan, 2014.

15. Paetsch C, Fenton K, Perrett T, et al. Prospective case-control study of toe tip necrosis syndrome (TTNS) in western Canadian feedlot cattle. Can Vet J 2017;58:247–254.

16. Trent AM, Plumb D. Treatment of infectious arthritis and osteomyelitis. Vet Clin Food Anim 1991;7:747–778.

17. Anderson DE, Desrochers A, van Amstel SR. Surgical procedures of the distal limb for treatment of sepsis in cattle. Vet Clin Food Anim 2017;33:329–350.

18. Desrochers A, St. Jean G. Surgical management of digit disorders in cattle. Vet Clin Food Anim 1996;12:277–298.

19. Desrochers A, Anderson DE, St. Jean G. Surgical treatment of lameness. Vet Clin Food Anim 2001;17:143–158.

20. Gilliam JN. Pharmacokinetics of florfenicol in serum and synovial fluid samples after regional intravenous perfusion in the distal limb of cattle [MSc dissertation]. Stillwater, Oklahoma: Oklahoma State University, 1997.

21. Navarre CB, Zhang L, Sunkara G, Duran SH, Kompella UB. Ceftiofur distribution in plasma and joint fluid following regional limb injection in cattle. J Vet Pharmacol Ther 1999;22:13–19.

22. Rodrigues CA, Hussni CA, Nascimento ES, Esteban C, Perri SH. Pharmacokinetics of tetracycline in plasma, synovial fluid and milk using single intravenous and single intravenous regional doses in dairy cattle with papillomatous digital dermatitis. J Vet Pharmacol Ther 2010;33:363–370.

23. Jelinski M, Fenton K, Perrett T, Paetsch C. Epidemiology of toe tip necrosis syndrome (TTNS) of North American feedlot cattle. Can Vet J 2016;7:829–834.

24. Leach KA, Logue DN, Kempson SA, Offer JE, Ternent HE, Randall JM. Claw lesions in dairy cattle: Development of sole and white line hemor-rhages during first lactation. Vet J 1997;154:215–225.

25. Thomsen PT, Hansen I, Martin HL, Kudahl AB. Sole hemorrhages in Danish bull calves: Prevalence and risk factors. Vet J 2017;224:44–45.



Case Report Rapport de cas

Piecemeal endoscopic polypoidectomy for the management of a canine pharyngeal hemangiosarcoma

Joseph Cyrus Parambeth, Jessica M. Vallone, John F. Griffin IV, Audrey K. Cook

Abstract — A 7-year-old castrated male Maltese dog was presented for increased respiratory sounds, inability to bark, dysphagia, and hyporexia. Radiographs revealed an ovoid, opaque mass in the caudal nasopharynx. An airway examination and computed tomography scan were followed by endoscopic polypoidectomy. The mass was a hemangiosarcoma, and the patient survived 13 months.

Résumé — Polypoïdectomie endoscopique fragmentaire pour la gestion d’un hémangiosarcome pharyngé canin. Un chien Bichon maltais mâle castré âgé de 7 ans a été présenté pour des sons respiratoires accrus, l’incapacité de japper, de la dysphagie et de l’hyporexie. Les radiographies ont révélé une masse ovoïde opaque dans le nasopharynx caudal. Un examen des voies respiratoires et une tomodensitométrie ont été suivis d’une polypoïdectomie endoscopique. La masse était un hémangiosarcome et le patient a survécu 13 mois.


Can Vet J 2018;59:1209–1212

Case description

A 7-year-old castrated male, 3.8-kg Maltese dog was presented to the Texas A&M Veterinary Medical Teaching Hospital

(VMTH) with a 2-week history of mildly increased respira-tory sounds, inability to bark, mild dysphagia, and hyporexia. Empirical therapy with diphenhydramine (unknown dose) and amoxicillin, 15 mg/kg body weight (BW), PO, q12h, for 10 d had not mitigated the clinical signs.

Physical examination did not detect any abnormalities, and results of routine hematologic and biochemical analyses were within reference ranges. Thoracic radiographs taken 3 d previ-ously by the referring veterinarian were available for review (Figure 1), and indicated an approximately 1.1 3.7 cm ovoid soft tissue opaque mass in the caudal nasopharynx. The cranial margin of the mass had a curved soft tissue/gas interface indicat-ing an intraluminal location. Differential diagnoses for the mass included a polyp, abscess, foreign body with associated cellulitis, neoplasm, and cyst.

The dog was sedated with butorphanol (Vetorphic; MWI Animal Health, Boise, Idaho, USA), 0.2 mg/kg BW, IV, and anesthesia was induced using propofol (PropoFlo; Abbott Animal Health, Abbott Park, Illinois, USA), 5 mg/kg BW, IV. Upper airway examination with a rigid laryngoscope revealed a multi-lobulated mass at the level of the right tonsillar arch. The patient was intubated using a 4.5-mm ID 19-cm cuffed endotracheal tube. Dexamethasone (Azium; Schering-Plough Animal Health, Union, New Jersey, USA), 0.1 mg/kg BW, IV, was administered to reduce airway inflammation. A computed tomography (CT) scan of the cervical region was performed with the patient positioned in dorsal recumbency. This revealed an ovoid, soft tissue attenuating, heterogeneously contrast-enhancing, broad-based mass (2.5 1.3 1.1 cm) within the caudal nasopharyngeal region (Figure 2). This mass was causing almost complete occlusion of the caudoventral aspect of the nasopharynx, with extension into the laryngopharynx. A 4.9-mm flexible endoscope (Olympus BF-P180 broncho-videoscope; Olympus, Center Valley, Pennsylvania, USA) was directed into the pharynx, revealing a disorganized and some-what pedunculated mass (Figure 3A). Adequate inflation of the endotracheal tube cuff was verified at this time. A 2-cm polypectomy snare (Olympus Gastroscope & Colonoscope Snare SD-24OU-15; Olympus) was placed around the base of the mass under direct observation and attached to an electrosurgical generator (Mega Power Generator; Megadyne Medical Product, Draper, Utah, USA) for simultaneous cutting and cautery. The settings on the electrosurgical generator were 15W and 20W for the cut and coagulation, respectively. Inhalant sevoflurane anesthesia and oxygen were discontinued briefly and the patient was allowed to breathe room air to reduce the risk of airway fire. A fentanyl bolus (Fentanyl; West Ward Pharmaceutical,

Small Animal Hospital, Texas A&M Veterinary Medical Teaching Hospital, College of Veterinary Medicine & Biomedical Sciences, 402 Raymond Stotzer Parkway, College Station, Texas 77845, USA.Address all correspondence to Dr. Parambeth; e-mail: [email protected] external funding or financial support was received.Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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Eatontown, New Jersey, USA), 3 g/kg BW was used to main-tain an adequate plane of anesthesia. A long curved hemostat was used to hold the free edge of the mass as the cutting and cautery progressed, to reduce the risk of damage to adjacent tissues and to facilitate tissue retrieval after resection. This pro-cedure was repeated a total of 3 times (i.e., piecemeal resection), and approximately 80% of the mass was removed (Figure 3B). All 4 fragments were placed in formalin for histopathologic examination. The total procedural time was less than 45 min, and minimal bleeding was observed. The endotracheal tube was partially inflated during removal. Maropitant (Cerenia; Zoetis, Kalamazoo, Michigan, USA), 1 mg/kg BW, IV, and buprenorphine (Burprenex; Reckitt Benckiser Pharmaceuticals,

North Chesterfield, Virginia, USA), 0.01 mg/kg BW, IV, were administered following extubation. Supplemental oxygen was not necessary during recovery. The dog was observed for 4 h after completion of the procedure and was discharged with liquid tramadol (Ultram; Janssen Pharmaceuticals, Titusville, New Jersey, USA), 4 mg/kg BW, PO, q8h, for the next 3 d.

Histopathologic examination revealed an infiltrative, unen-capsulated, poorly demarcated submucosal neoplasm, composed of spindle cells arranged in tight bundles and forming irregular, variably sized blood-filled vascular channels (Figure 4A). These findings were consistent with a histopathological diagnosis of a hemangiosarcoma, with extensive ulceration and incomplete excision. This diagnosis was confirmed with immunohisto-

Figure 1. Ventrodorsal and right lateral radiographic views of the nasopharynx of a 7-year-old castrated male Maltese dog with a 2-week history of mild dysphagia, inability to bark, and hyporexia. There is an ovoid, soft tissue opaque mass within the caudal nasopharynx (arrow).

Figure 2. Transverse and sagittal computed tomography (CT) images. Of the nasopharynx of a Maltese dog with a 2-week history of mild dysphagia, inability to bark, and hyporexia. Note the heterogeneous, mildly contrast-enhancing, ovoid mass (arrows) present within the caudal nasopharynx, causing near complete occlusion of the nasopharyngeal lumen at this level.



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chemistry, as staining with Factor VIII Related Antigen showed moderate cytoplasmic immunolabeling of approximately 30% of the neoplastic cells (Figure 4B).

During a follow-up appointment with the oncology service, the owners declined chemotherapy or radiation therapy. No stag-ing was done. On a 13-month post discharge follow-up phone call, the dog was reported to be doing well at home, without any clinical signs.

DiscussionHemangiosarcoma (HSA) is a malignant tumor arising from the vascular endothelium and comprises approximately 5% to 7% of noncutaneous primary malignant neoplasms in dogs. The most common sites for HSA in this species are the spleen, right atrium, subcutaneous tissues, and liver (1). Median survival times (MSTs) for dogs with visceral and subcutaneous HSA are short, with less than 10% of dogs alive 1 y after diagnosis. Using a combination of surgery and chemotherapy for stage 1 disease (i.e., no evidence of tumor or the tumor is 5 cm diameter and confined to primary site), MST is about 250 d. For stage II (i.e., the tumor can be 5 cm, or greater or ruptured, or invading subcutaneous tissues with regional lymph node involvement), MST is about 186 d, and in stage III disease (i.e., the tumor may invade adjacent structures, including muscle, may or may not have lymph node involvement, but distant metastasis is present), MST is only 87 d (2,3).

Survival times for dogs with superficial dermal hemangio-sarcomas treated surgically (1) are substantially better, with reported MSTs 2 y, and 987 d (4). Oral cancer accounts for 6% to 7% of malignancies in dogs, and males have a 2.4 times greater risk of developing oropharyngeal malignancy than females (5). There is limited information regarding outcome for dogs with oral and pharyngeal HSA, but these may carry a better prognosis than the visceral or subcutaneous forms of this disease (6,7). One dog lived 220 d following incomplete excision and chemotherapy (7) for a pharyngeal HSA. The cause of death in this case was related to an inadvertent overdose of chemotherapy rather than the disease itself. It remains unknown if oral and pharyngeal HSA behave similar to superficial dermal HSA.

This report describes successful, palliative, per-oral deb-ulking of a pharyngeal obstructive hemangiosarcoma using

a polypectomy snare. Hemorrhage was minimal and the dog recovered quickly from the procedure. Disease-free margins are not expected in this location and the primary goal of the procedure was to improve patient comfort, collect tissue for histopathology, and facilitate a smooth recovery from anesthesia. A bipolar snare device was used in this case, as this was thought to reduce the risk of bleeding and perforation compared with a monopolar snare (8).

Endoscopic polypectomy of gastrointestinal tract masses has been described in veterinary medicine for inflammatory colonic polyps (9), benign colorectal polypoid adenomas (10), and gastric polyps (11). Endoscopic polypectomy using a bipolar snare has been described as an efficient and safe complemen-tary method for the treatment of vocal cord polyps in humans (12). Endoscopic polyploidectomy and debulking did provide effective palliation (13 mo) in this dog with pharyngeal HSA.

To the best of our knowledge, this is the first report of endo-scopic polyploidectomy for the management of pharyngeal

Figure 3. A — Endoscopic image of the disorganized pedunculated mass in the caudal nasopharynx at the level of the right tonsillar arch (top of the image is dorsal and the bottom of the image is ventral). B — Endoscopic image after 80% of the mass in the caudal nasopharynx had been removed with the polypectomy snare.

Figure 4. A — The submucosa is markedly expanded by an unencapsulated, poorly demarcated, densely cellular, infiltrative neoplasm composed of spindle cells arranged in tight bundles and forming irregular, variably sized blood-filled vascular channels. [Hematoxylin & eosin (H&E) staining 20]. B — Moderate cytoplasmic immunolabeling of approximately 30% of the neoplastic cells for von Willebrand factor (40). Photographs courtesy Dr. Carolina P. Azevedo.

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hemangiosarcoma in a dog. These are uncommon tumors and carry a different long-term prognosis than visceral hemangio-sarcoma, but debulking using endoscopic piecemeal polyploid-ectomy appears to be a useful palliative option. CVJ

References 1. Smith AN. Hemangiosarcoma in dogs and cats. Vet Clin North Am

Small Anim Pract 2003;33:533–552. 2. Sorenmo KU, Jeglum KA, Helfand SC. Chemotherapy of canine hem-

angiosarcoma with doxorubicin and cyclophosphamide. J Vet Intern Med 1993;7:370–376.

3. Thamm DH. Miscellaneous tumors. In: Vail DM, Page RL, eds. Withrow and MacEwen’s Small Animal Clinical Oncology. 5th ed. St. Louis, Missouri: WB Saunders, 2013:679–688.

4. Szivek A, Burns RE, Gericota B, et al. Clinical outcome in 94 cases of dermal haemangiosarcoma in dogs treated with surgical excision: 1993–2007. Vet Comp Oncol 2012;10:65–73.

5. Withrow SJ. Cancer of the gastrointestinal tract. In: Vail DM, Page RL, eds. Withrow and MacEwen’s Small Animal Clinical Oncology. 5th ed. St. Louis, Missouri: WB Saunders, 2013:381–431.

6. Burton JH, Powers BE, Biller BJ. Clinical outcome in 20 cases of lingual hemangiosarcoma in dogs: 1996–2011. Vet Comp Oncol 2014;12: 198–204.

7. dos Anjos DS, Assis AR, Fonseca-Alves CE, Babo-Terra VJ. Clinical, pathological and immunohistochemical evaluation of a primary hem-angiosarcoma in a pinscher dog. Acta Sci Vet 2016;44:1–6.

8. Tucker RD, Platz CE, Sievert CE, Vennes JA, Silvis SE. In vivo evalu-ation of monopolar versus bipolar electrosurgical polypectomy snares. Am J Gastroenterol 1990;85:1386–1390.

9. Tsukamoto A, Ohno K, Irie M, et al. A case of canine multiple inflam-matory colorectal polyps treated by endoscopic polypectomy and argon plasma coagulation. J Vet Med Sci 2012;74:503–506.

10. Coleman KA, Berent AC, Weisse CW. Endoscopic mucosal resection and snare polypectomy for treatment of a colorectal polypoid adenoma in a dog. J Am Vet Med Assoc 2014;244:1435–1440.

11. Palma DA, Berent A. Gastrointestinal polypectomy. In: Weisse C, Berent A, eds. Veterinary Image-Guided Interventions. Wiley Online Library, 2015:155–162.

12. Minamino H, Nagami Y, Tominaga K, et al. Endoscopic resection of a vocal cord polyp with a bipolar snare in a patient with cervical disc herniation. Clin J Gastroenterol 2014;7:136–139.

Zoetis to acquire AbaxisZoetis Inc. and Abaxis, Inc. announced a definitive merger agreement pursuant to which Zoetis will acquire Abaxis, a leader in the development, manufacture and marketing of diagnostic instruments for veterinary point-of-care services. The acquisition is expected to enhance Zoetis’ presence in veterinary diagnostics, a category of the animal health industry with approximately 10% compound annual growth over the last three years.

Abaxis, founded in 1989 and headquartered in Union City, Calif., is a leading provider of diagnostic instruments and con-sumable discs, kits and cartridges to the animal health industry.

“This acquisition brings Zoetis a company that has a proven, competitive diagnostic platform for growth that we can help to accelerate in the U.S. and worldwide with our global scale and direct customer relationships in approximately 45 countries,” said Juan Ramón Alaix, Chief Executive Officer of Zoetis. “Together we can bring more veterinarian customers a broader range of products that fit into our comprehensive solutions and innovations, from prediction and early detection of disease in animals to prevention and treatment. We are very excited by the passion for customers that Abaxis and Zoetis colleagues share.”

“We see a prime opportunity to grow our business as part of Zoetis,” said Clint Severson, Chairman and Chief Executive Officer of Abaxis. “We recently invested in expanding opera-tions in Europe, Latin America, and the Asia Pacific Region, with 20% of revenue in fiscal year 2018 coming from our international operations. Zoetis has the global presence and direct veterinary customer relationships to deliver greater value to more customers around the world and accelerate the growth of our international operations. This acquisition gives recogni-tion to our record of success and the highly skilled, dedicated employees of Abaxis who helped build our company over the course of nearly three decades.”

The transaction is subject to customary closing conditions, including regulatory approvals and the approval of Abaxis shareholders. Zoetis expects to complete the acquisition before the end of 2018, and it intends to fund the purchase through a combination of existing cash and new debt.

For more information, visit www.zoetis.com and www.abaxis.com

Industry News Nouvelles de l’industrie




Successful control of disseminated follicular cysts in a dog with low dose isotretinoin

Marcin Szczepanik, Piotr Wilkołek, Łukasz Adamek, Anna Smiech, Iwona Taszkun, Grzegorz Kalisz

Abstract — A case of disseminated cysts in a dog is described. Histopathological examination revealed the presence of follicular infundibular cysts, which were treated with isotretinoin at a dose of 2 mg/kg body weight (BW), q24h for 1 week, followed by a dose of 1 mg/kg BW for 3 months. Symptoms resolved after this course of treatment.

Résumé — Contrôle réussi de kystes folliculaires disséminés chez un chien à l’aide d’une faible dose d’isotrétinoïne. Nous décrivons un cas de kystes disséminés chez un chien. L’examen histopathologique a révélé la présence de kystes infundibuliformes folliculaires qui ont été traités à l’aide de l’isotrétinoïne à une dose de 2 mg/kg poids corporel (PC), q24h pendant 1 semaine, suivie d’une dose de 1 mg/kg PC pendant 3 mois. Les symptômes se sont résorbés après ce régime de traitement.


Can Vet J 2018;59:1213–1215

F ollicular cysts are common non-cancerous tumors in dogs and cats (1). The contents of the cysts consist mostly of

sebum, keratin, or hair (2). Follicular cysts can be categorized into infundibular cysts, isthmus-catagen cysts, metrical cysts, and mixed cysts (including panfollicular cysts from all parts of the follicle) (3). The etiology of follicular cysts is unknown. It is suspected that they may have a genetic or congenital basis, or they may be a consequence of injury. Trauma can induce plugging or narrowing of follicular ostia, causing retention of follicular contents. The retention of follicular contents causes dilation and, eventually, formation of follicular cysts. Other factors, such as predisposition for follicular hyperkeratosis, may also promote cyst formation in the dog. Follicular cysts usually form single tumors, but some cases of disseminated cysts have also been reported (2). This form of the disease has been reported in dogs, alpacas, sheep, and, in few cases, in cats and horses (1,4–7). Disseminated forms of the disease involve presence of more than 20 cysts in various parts of the body and are diagnosed rarely. Follicular cysts are usually benign, but may evolve into squamous cell carcinomas (8).

Case descriptionA case of disseminated cysts was diagnosed in a 7-year-old male American Staffordshire terrier dog. At age 5 y, nodules began to appear in the deep dermis on the legs, sides of the thorax, the back/dorsum, and the tail. In the owner’s opinion, there were hundreds of small nodules. The disease had not been diagnosed before a consultation at the Veterinary Clinic at the University of Life Sciences. The animal had been treated with antibiotics [amoxicillin with clavulanic acid (Synulox; Zoetis, Warszawa, Poland), 25 mg/kg body weight (BW), PO, q12h for 5 wk, cephalexin (Kefavet; Orion Corporation, Esppo, Poland), 22 mg/kg BW, PO, q12h, for 4 wk and enrofloxacin (Enroxil; Krka, d.d., Novo mesto, Poland), 5 mg/kg BW, PO, q24h for 3 wk], glucocorticoids [prednisone (Encorton; Pabianickie Zakłady Farmaceutyczne Polfa, Pabianice, Poland), 1 mg/kg BW for 2 wk, dexamethasone (Pabi-Dexamethason; Pabianickie Zakłady Farmaceutyczne Polfa), 0.1 mg/kg BW for 10 d] and shampoos (Malseb; Dechra Veterinary Products, Uldum, Poland and Sebolytic; Virbac, Warszawa, Poland), without any substan-tial improvement in the dog’s clinical condition.

During the consultation, extensive alopecia and hair thinning were observed on the limbs (especially on the hind limbs), the dorsum, the tail and the sides of the thorax (Figures 1, 2). Also, in the same body region, there were numerous (200 to 300) nodules in the dermis that were 3- to 4-mm in diameter. Fistulae discharging blood and pus were also observed. The animal had moderate pruritus.

The results of a complete blood (cell) count (CBC), serum biochemistry, and tests for free thyroxine (T4), total T4 and thy-roid stimulating hormone (TSH) were all within the reference ranges. Skin scrapings were used to rule out demodicosis. The cytological examination of pus revealed numerous degenerated

Clinical Diagnostics and Veterinary Dermatology, Faculty of Veterinary Medicine (Szczepanik, Wilkołek, Adamek, Taszkun, Kalisz), Department of Pathology (Śmiech), University of Life Sciences in Lublin, Głęboka 30, Lublin, Poland.Address all correspondence to Dr. Marcin P. Szczepanik; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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neutrophils, single macrophages, and keratin accumulation. Only keratin accumulation was found in the cytological exami-nation of material from non-inflammatory cysts collected by fine-needle aspiration. Staphylococcus pseudintermedius suscep-tible to a wide range of antimicrobials was found on bacte-rial culture. After sedation with detomidine (Dexdomitor; Orion Corporation) and local anaesthesia with 1% lignocaine (Lignocain 1%; Polfa Warszawa, Poland), a 5-mm punch biopsy specimen was collected for histopathological examination. Samples were taken from 3 areas of the body: thorax, right hind limb, dorsum. The histopathological examination of samples stained with hematoxylin and eosin (H&E) revealed the pres-ence of follicular cysts (Figure 3). The cyst wall was thin and made of a multilayer epithelium with a granular layer and a tendency to hyperkeratosis. In the lumen of the cyst, extensive keratin deposits were visible as concentrically arranged thin plaques. Based on these histological features, the cysts were clas-sified as infundibular cysts. Infundibular cysts were observed in all histopathological samples.

After diagnosing that the dog had disseminated follicular cysts, treatment began, using isotretinoin (Aknenormin; Almirall

Hermal GmbH, Reinbek, Germany) at an initial dose of 2 mg/kg BW, PO, q24h. At the same time, antibiotic treatment (amoxicillin with clavulanic acid, Synulox; Zoetis), 25 mg/kg BW, PO, q12h, was used to reduce bacterial complication. The starting dose of isotretinoin was used for 1 wk. In the following week, vomiting was observed and the dose of isotretinoin was reduced to 1 mg/kg BW q24h, PO. After reduction of the dose of isotretinoin vomiting stopped. In the second month of treat-ment the largest cysts began to shrink, the number of nodules decreased by half and there were no new cysts. Antibiotics were stopped in the second month of therapy but isotretinoin therapy was continued for an additional 2 mo. In the second month of therapy we noted only about 40 to 50 nodules. In the third month of treatment there were only about 10 small cysts on the hind limbs and tail (Figure 4).

DiscussionMany differential diagnoses need to be considered in cases of single or multiple dermal or subcutaneous nodules. Abscesses, cysts, papillomas, infectious diseases, neoplasias, and immune-mediated diseases should also be considered.

Figure 1. Numerous areas with alopecia and nodules on limbs and sides of the dog’s body.

Figure 3. Follicular cyst filled with amorphous material. Stratum granulosum is present, indicating an infundibular cyst. H&E, 400.

Figure 2. Close-up of rear limb showing alopecia and numerous nodules.

Figure 4. Appearance of the dog after 6 months of treatment. There was no alopecia and there were no nodules.



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The case reported here is a rare form of disseminated fol-licular cysts. We speculate that follicular cysts were a primary developmental abnormality in this case, because formation of cysts and nodules was first observed before development of deep pyoderma. In such cases, use of the term disseminated follicular cysts or multiple follicular cysts is proposed. In the literature both terms can be found, but it seems reasonable that the name multiple cysts should be used in cases in which multiple cysts are located on only one part of the body and disseminated cysts in cases in which cysts are noted on several body regions. In dogs, this form of the disease has been reported for infundibular cysts, and in horses and llamas, other types of disseminated cysts (isthmus-catagen or hybrid) have been reported as well (2,4,5). A case with numerous (about 100) follicular cysts (infundibular) located in the perianal area of a dog has been described (7).

The treatment of follicular cysts usually requires surgical dis-section, but this method is not possible in cases of numerous cysts. Laser therapy has been successfully used in canine inter-digital palmar and plantar comedones and follicular cysts (9). Laser surgery is a good treatment option in addition to tradi-tional surgery. As far as pharmacological treatment is concerned, isotretinoin is used at a dose of 1.5 to 3 mg/kg BW, q24h, PO, which, in some cases, blocks the development of the disease (2). The effect of isotretinoin is based on significantly reduced keratinization, although the exact mechanism of this process is not known. In one case, treatment with vitamin A (466 IU/kg BW per day) was reported to stop progression of the disease (1). In horses with epidermal inclusion cysts, intralesional injections of neutral-buffered 10% formalin have been successfully used, but this method is restricted to cases in which cysts are large and low in numbers (10).

The side effects of retinoids are well-documented in humans (11). Most commonly these include keratoconjunctivitis sicca, cheilitis, xerosis, pruritus, and facial dermatitis, thinning and

loss of hair, palmo-plantar scaling, sight alteration, high liver enzyme serum levels, bone pain, skeletal abnormalities, and myopathies. Retinoids have teratogenic effects as well. In dogs, side effects are rare. The most frequent are elevation of serum liver enzymes and serum lipids, and keratoconjunctivits sicca (12). Monitoring of liver enzymes, lipids, and tear production is recommended during retinoid treatment.

In the present case the use of retinoids successfully blocked the development of the disease despite using lower than recom-mended doses. CVJ

References 1. Scott D, Miller W, Griffin C. Muller & Kirk’s Small Animal Dermatol-

ogy. Philadelphia, Pennsylvania: WB Saunders, 2001:1375–1378. 2. White A, Stern A, Campbell K. Multiple (disseminated) follicular cysts

in five dogs and one cat. Vet Rec 2013;173:269–271. 3. Gross T, Ihrke P, Walder E, Affolter V. Skin Diseases of the Dog and

Cat: Clinical and Histopathologic Diagnosis. Oxford, UK: Blackwell Science, 2005:607–612.

4. Ginel PJ, Zafra R, Lucena R, Bautista MJ. Multiple generalized follicular cysts in a stallion. Vet Dermatol 2007;18:456–459.

5. Newkirk KM, Frank LA. Multiple follicular cysts in four alpacas (Vicugna pacos). Vet Dermatol 2011;22:275–278.

6. Oz HH, Foil CS, Memon MA, Al-Bagdadi FK, Turk MA, Sims D. Follicular cysts in sheep. J Am Vet Med Assoc 1985;187:502–503.

7. Park JK, Hong IH, Ki MR, et al. Multiple perianal infundibular fol-licular cysts in a dog. Vet Dermatol 2010;21:303–306.

8. Scott D, Teixeira E. Multiple squamous cell carcinomas arising from multiple cutaneous follicular cysts in a dog. Vet Dermatol 1995;6: 27–31.

9. Duclos DD, Hargis AM. Hanley PW. Pathogenesis of canine interdigital palmar and plantar comedones and follicular cysts, and their response to laser surgery. Vet Dermatol 2008;19:134–141.

10. Frankeny RL. Intralesional administration of formalin for treatment of epidermal inclusion cysts in five horses. J Am Vet Med Assoc 2003;223: 221–222.

11. Saurat JH. Side effects of systemic retinoids and their clinical manage-ment. J Am Acad Dermatol 1992;27:23–28.

12. Power HT, Ihrke PJ. Synthetic retinoids in veterinary dermatology. Vet Clin North Am Small Anim Pract 1990;20:1525–1539.




Propofol infusion-like syndrome in a dog

John M. Mallard, Teresa M. Rieser, Nathan W. Peterson

Abstract — An 8-year-old, spayed female Chihuahua mixed breed dog was presented for dyspnea and was subsequently mechanically ventilated. Propofol was utilized as part of the anesthetic protocol. The dog developed rhabdomyolysis, myoglobinuria, cardiac arrhythmias, liver enzyme elevation, and methemoglobinemia. Propofol was discontinued and N-acetylcysteine was administered after which the clinical signs resolved.

Résumé — Syndrome s’apparentant à l’infusion de propofol chez un chien. Un chien Chihuaha mâle castré de race croisée âgé de 8 ans a été présenté pour de la dyspnée et a été subséquemment soumis à une ventilation mécanique. Le propofol a été utilisé dans le cadre du protocole anesthésique. Le chien a développé de la rhabdomyolyse, de la myoglobinurie, de l’arythmie cardiaque, une élévation des enzymes hépatiques et de la méthémoglobinémie. Le propofol a été discontinué et de la N-acétylcystéine a été administrée après la résolution des signes cliniques.


Can Vet J 2018;59:1216–1222

S ince its introduction in 1986, propofol has gained popular-ity for induction and maintenance of anesthesia in human

and veterinary medicine because of a favorable profile of rapid induction, reliable anesthesia, short recovery time, and rela-tively low cost. Additionally, propofol decreases cerebral oxygen requirements in patients with CNS disease, reduces intracranial pressure, and has antiepileptic properties (1).

Despite attractive pharmacologic profiles, use for sedation at higher doses [ 4 mg/kg body weight (BW) per hour] and for prolonged periods of time in humans can lead to a constella-tion of clinical manifestations termed propofol-related infusion syndrome (PRIS). Originally reported signs included metabolic acidosis, myocardial failure, renal failure, and death. Propofol-related infusion syndrome was first described in 1990 with the death of a Danish child but failed to receive notoriety until a case series in 1992 described 5 deaths of children hospitalized for respiratory tract disease (2,3). In 1996, the first case report of an adult with PRIS-like symptoms was published describ-ing development of metabolic acidosis that resolved following

removal of propofol (4). Over 150 case reports have been pub-lished describing variations of the clinical syndrome and out-come. The incidence of PRIS among adults in a trauma center intensive care unit (ICU) administered propofol infusions for at least 3 d is 4.1% (5). Although PRIS is rare, mortality rates average 51% but reach as high as 74% (6).

There is debate regarding the cause, risk factors for, and clini-cal course of PRIS as it has no universally accepted definition. An expanded list of clinical features for reported cases includes severe metabolic acidosis, cardiac arrhythmias, cardiovascular failure, rhabdomyolysis, myoglobinuria, renal failure, hyperka-lemia, lipemic plasma, hepatomegaly, liver enzyme elevation, and death (3,6–9). This syndrome is most commonly identified in critically ill pediatric and adult patients that are treated for neurologic or respiratory diseases, with 90% of patients receiving propofol for non-procedural sedation (6).

To date, there have been no reports of PRIS in animals. This report describes a clinical syndrome of metabolic acidosis, ventricular arrhythmias, rhabdomyolysis, myoglobinuria, liver enzyme elevation, and methemoglobinemia consistent with PRIS in a dog administered a continuous propofol infusion.

Case descriptionAn 8-year-old spayed female, 5.1 kg Chihuahua mixed breed dog was referred for progressive tachypnea, lethargy, hypo-rexia, and fever. Medical history included keratoconjunctivitis sicca and presumptive dietary allergies managed with oph-thalmic cyclosporine (Optimmune; Intervet/Merck Animal Health, Madison, New Jersey, USA) and a hydrolyzed diet (Hill’s Prescription Diet z/d; Hill’s Pet Nutrition, Topeka, Kansas, USA), respectively. Travel history within the past 3 y included Arizona, Oregon, Washington, western Europe, and

Department of Emergency and Critical Care, VCA West Los Angeles Animal Hospital, Los Angeles, California, USA.Address all correspondence to Dr. John M. Mallard; e-mail: [email protected]. Mallard’s current address is VCA West Coast Specialty & Emergency Animal Hospital, 18300 Euclid Street, Fountain Valley, California 92708, USA.Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.



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Canada. The dog had regular exposure to horses and barns. Evaluation by the primary veterinarian occurred 4 separate times over the week preceding referral. A complete blood (cell) count (CBC) and serum biochemistry showed decreased T4 [6.44 nmol/L; reference range (RR): 10.3 to 45 nmol/L]; creatine kinase (CK) was 129 IU/L (RR: 59 to 895 IU/L). Thoracic radiographs showed evidence of mild bronchopneu-monia in the right caudal lung lobe with normal cardiovascular and extrathoracic structures. A combined heartworm anti-gen and tick antibody test (Accuplex 4; Antech Diagnostics, Fountain Valley, California, USA) for Dirofilaria immitis, Ehrlichia canis, Anaplasma phagocytophilum, and Borrelia burg-dorferi was negative. Treatments included subcutaneous flu-ids, meloxicam (Metacam; Boehringer Ingelheim Vetmedica, St. Joseph, Missouri, USA), mirtazapine (Teva Pharmaceutical, Jerusalem, Israel), amoxicillin/clavulanic acid (Clavamox; Zoetis, Kalamazoo, Michigan, USA), and enrofloxacin (Baytril; Bayer Animal Health GmbH, Leverkusen, Germany).

Upon presentation, the patient’s temperature was 39.5°C and respiratory rate was 110 breaths/min (bpm) with mild to moderate dyspnea. No abnormal cardiac sounds were detected and thoracic auscultation revealed normal bronchovesicular sounds. Prothrombin time/activated partial thromboplastin time (PT/aPTT) (PT/aPTT Combination Test; Abaxis, Union City, California, USA) was 16.8 s/92.9 s (RR: 14 to 19 s/75 to 105 s) and SpO2 was 94% with FiO2 0.21. Thoracic radiographs

showed evidence of moderate to severe bronchopneumonia with a bilateral, dependent unstructured interstitial pattern and mild bronchial pattern in the caudodorsal lungs with no cardiovascu-lar or pleural space abnormalities. Oxygen supplementation was provided and analysis of venous blood gas (Stat Profile pHOx Ultra; Nova Biomedical Corporation, Waltham, Massachusetts, USA) revealed a metabolic acidosis with pH 7.39, pvCO2 27.2 mmHg, pvO2 93.4 mmHg, HCO3

16.7 mmol/L (RR: 18 to 26 mmol/L), base excess (BE) 6.1 mmol/L (RR: 5 to 1 mmol/L), Na 141.5 mmol/L (RR: 140 to 150 mmol/L), K 4.36 mmol/L (RR: 3.9 to 4.9 mmol/L), Cl 113.2 mmol/L (RR: 109 to 120 mmol/L), ionized Ca 1.16 mmol/L (RR: 1.25 to 1.5 mmol/L), ionized Mg 0.52 mmol/L (RR: 0.43 to 0.6 mmol/L), lactate 2.1 mmol/L (range: 0.5 to 2.5 mmol/L). The dog was hospitalized with oxygen supplementation FiO2 0.40, ampicillin/sulbactam (Ampicillin/Sulbactam; AuroMedics Pharma, Dayton, New Jersey, USA), enrofloxacin, Plasma-lyte A (Baxter Healthcare, Deerfield, Illinois, USA), mirtazapine, and nebulization/coupage.

The respiratory rate on day 2 transiently decreased to 60 bpm and body temperature was 38.9°C. An abdominal ultrasound was unremarkable. Cytology of pulmonary parenchyma obtained via fine-needle aspiration revealed mixed cell inflammation without evidence of infectious organisms or neoplasia.

On day 3, an echocardiogram revealed mildly thickened mitral valves with trace regurgitation, mild tricuspid regurgitation, and

Table 1. Blood gas data.

Day 3 — Day 4 — Day 4 — Day 4 — Day 5 — Day 6 — Test Reference range 21:58 (A) 08:43 (A) 10:30 (A) 18:48 (A) 06:00 (A) 04:30 (CV)

pH 7.35 to 7.46 7.24 7.27 7.32 7.38 7.40 7.45

pCO2 4.26 to 5.72 kPa 5.87 (44.1) 5.76 (43.3) 4.79 (36.0) 4.99 (37.5) 4.69 (35.3) 3.44 (25.9) (32 to 43 mmHg)

pO2 10.64 kPa 54.9 (412.7) 60.7 (456.5) 40.9 (307.4) 36.6 (275.6) 19.6 (147.1) 6.3 (47.1) ( 80 mmHg)

SO2 (calculated) 94% (A) 99.5% 97.3% 96.8% 99.0% 98.6% 84.7% 70% (CV)

Lactate 0.5 to 2 mmol/L 0.5 0.7 0.7 1.1 0.8 0.9

HCO3 18 to 26 mmol/L 19.0 20.1 18.8 22.4 22.2 18.3

BE 5 to 1 mmol/L 7.3 6.0 5.9 1.8 1.5 3.4

THb 133 to 205 g/L 117 115 100

O2Hb 84.4% 91.8% 96.0%

COHb 1% 1.6% 2.4% 1.7%

MetHb 1% 13.1% 4.9% 1.5%

HHb 0.9% 0.8% 0.8%

tBili 1.7 to 5.1 mol/L 8.5 126.6 145.4

Na 140 to 150 mmol/L 143.6 145.5 144.5 145.1 145.7 143.7

K 3.9 to 4.9 mmol/L 4.44 3.34 3.26 3.17 3.85 3.65

Cl 109 to 120 mmol/L 117.3 116.5 116.0 114.0 115.7 116.3

FiO2 1.0 1.0 0.75 0.60 0.40 0.21

A — arterial; BE — base excess; COHb — carboxyhemoglobin; CV — central venous; HHb — unbound hemoglobin; MetHb — methemoglobin; O2Hb — oxyhemoglobin; SO2 — saturation of oxygen; tBili — total bilirubin; THb — total hemoglobin.



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no evidence of pulmonary hypertension. Repeat thoracic radio-graphs indicated progressive pulmonary infiltrates extending into the caudal lung regions. Coccidioidomycosis titers were negative (IgM and IgG). Progressive dyspnea and tachypnea were noted despite the addition of butorphanol (Torbugesic; Zoetis) for seda-tion. The dog had been anorexic for 4 days prior to referral and for 3 days in our hospital. Out of concern for respiratory fatigue, positive pressure ventilation was initiated at 8 pm.

Anesthesia was induced with butorphanol, midazolam (Midazolam; Hospira, Lake Forrest, Illinois, USA), and propofol (PropoFlo; Zoetis), 3 mg/kg BW, IV. Following aseptic intuba-tion, an endotracheal wash was completed and submitted for cytology, aerobic and anaerobic culture/sensitivity, and canine respiratory PCR panel (Canine Respiratory PCR Panel; Antech Diagnostics, Fountain Valley, California, USA). Anesthesia was maintained with midazolam (Hospira), 0.5 mg/kg BW per hour and propofol (Zoetis), 15 mg/kg BW per hour, IV. It was confirmed that propofol with benzyl alcohol was not used in this patient. Arterial blood gas evaluation 2 h after induction revealed a moderate acidemia (Table 1).

Overnight into day 4, there were multiple episodes of hypotension (mean arterial pressure 60 mmHg) that were responsive to crystalloid boluses. An accelerated idioventricular rhythm (AIVR) and hypoglycemia developed; hypoglycemia was treated with a dextrose bolus and supplementation in intrave-nous fluids. Urine output was 1.3 mL/kg BW per hour with development of red pigmenturia. Centrifugation of the urine revealed persistent red pigmenturia with no evidence of RBCs on examination of the sediment. Serum was straw-colored at that time. Arterial blood gas values indicated moderate to severe acidemia (Table 1). Pulse oximetry reading the morning of day 4

decreased to 90% despite arterial partial pressure of oxygen values appropriate for the current FiO2. Co-oximetry (Stat Profile pHOx Ultra; Nova Biomedical Corporation, Waltham, Massachusetts, USA) revealed methemoglobinemia 13.1% (reference value: 1%) (10). Propofol was discontinued and anesthesia was subsequently maintained with fentanyl (Fentanyl; West-Ward, Eatontown, New Jersey, USA), midazolam, and dex-medetomidine (Dexdomitor; Zoetis). N-acetylcysteine (NAC; 20% Acetylcysteine; Hospira) was started with a 140 mg/kg BW intravenous loading dose followed by 70 mg/kg BW, IV, q6h. Serum biochemistry revealed CK 13 963 IU/L, aspartate transaminase (AST) 467 IU/L (RR: 15 to 66 IU/L), alkaline phosphatase (ALP) 312 IU/L (RR: 5 to 131 IU/L), and total bilirubin 109.8 mol/L (RR: 1.7 to 5.1 mol/L). The CBC findings were indicative of mild neutrophilic inflammation with Döhle bodies and mild anemia [hematocrit (HCT) 34%; RR: 36% to 60%] with no morphologic abnormalities or inclu-sions. D-dimer concentration was normal at 0.62 nmol/L (refer-ence value: 1.37 nmol/L). By the end of day 4, the acidemia, AIVR, decreased pulse oximetry values had resolved and the methemoglobinemia was improved (4.9%).

On day 5, results of endotracheal wash cytology revealed neutrophilic and mixed-cell inflammation with no evidence of septic processes. A previously submitted test for leptospirosis by polymerase chain reaction (PCR) was negative in blood and urine. The respiratory PCR panel was positive for parainfluenza but negative for canine influenza (H3N8), canine adenovirus type 2, canine herpesvirus, canine respiratory coronavirus, influenzas H1N1 and H5N1, canine distemper virus, Bordetella bronchiseptica, Mycoplasma cynos, and Streptococcus equi subsp. zooepidemicus. Neospora caninum and Toxoplasma gondii titers

Figure 1. Propofol mitochondrial toxicity sites. Mitochondrion that displays the basic sites of propofol inhibition denoted by the red asterisks including long-chain fatty acid uptake, beta oxidation, the electron transport chain, and the ATP synthase. ADP — adenosine diphosphate; ATP — adenosine triphosphate; CACT — carnitine acylcarnitine translocase; CPT I — carnitine plamitoyltransferase I; CPT II — carnitine palmitoyletransferase II; FADH2 — flavin adenine dinucleotide hydroquinone form; IMM — inner mitochondrial membrane; IMS — intermembrane space; LACS — long-chain acyl-CoA synthase; LCFA — long-chain fatty acid; MCFA — medium chain fatty acid; MM — mitochondrial matrix; NADH — reduced nicotinamide adenine dinucleotide; OMM — outer mitochondrial membrane; Pi — inorganic phosphate; SCFA — short-chain fatty acid; TCA — tricarboxylic acid cycle. Roman numerals represent complexes I–V in the electron transport chain.



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were negative (IgM and IgG). Repeat thoracic radiographs showed resolving pulmonary infiltrates. Methemoglobin con-centration decreased to 1.5%. Due to increased stability and resolving pulmonary disease, a spontaneous breathing trial was performed and the dog was successfully weaned from ventila-tory support.

Repeat serum biochemistry profile on day 6 revealed pro-gressive changes as follows: CK 37,942 IU/L, AST 1,338 IU/L, alanine transaminase (ALT) 227 IU/L (RR: 12 to 118 IU/L), ALP 589 IU/L, total bilirubin 94.1 mol/L. A central venous blood gas analysis was mostly unremarkable (Table 1). S-Adenosylmethionine/Silybin (Denamarin; Nutrimax Laboratories Veterinary Sciences, Lancaster, South Carolina, USA) was started following discontinuation of NAC after the 7th dose. The dog continued to clinically recover, tolerated transition to room air, and began eating voluntarily.

On day 7, a biochemistry profile showed resolving CK eleva-tion at 6593 IU/L. Liver enzyme values remained elevated: AST 302 IU/L, ALT 287 IU/L, ALP 666 IU/L, gamma-glutamyl transferase (GGT) 18 IU/L (RR: 1 to 12 IU/L). Total bilirubin was 83.8 mol/L. Endotracheal wash cultures were negative. Due to continued improvement, the dog was discharged from the hospital. Two days later during re-check examination bio-chemistry values revealed normalization of CK at 253 IU/L but liver enzymes remained elevated. Thoracic radiographs revealed resolving pulmonary infiltrates. One month following discharge, the dog had persistent mild muscle atrophy but was clinically normal with no CBC or biochemical abnormalities. Thoracic radiographs showed complete resolution of pulmonary infiltrates.

DiscussionCurrent explanations for the development of PRIS involve the presence of a priming event followed by a triggering event

which includes propofol infusion and often catecholamine or glucocorticoid use (7). Priming events include critical illness of respiratory (severe infections or asthma) or neurologic (status epilepticus, intracranial hemorrhage, traumatic brain injury) origin, low carbohydrate supply, or genetic disorders (medium-chain acyl CoA dehydrogenase deficiency) (7,9). Although PRIS is typically associated with prolonged ( 48 h) propofol administration, there is documentation of PRIS in patients with propofol infusions as short as 5 h (11,12).

The underlying etiology of PRIS remains elusive, leading to debate and confusion regarding the hallmark features and clinical course of disease. Propofol’s primary adverse effects are related to mitochondrial toxicity and impairment of free fatty acid (FFA) utilization (Figure 1). Propofol is structurally similar to co-enzyme Q, which is integral to movement of electrons from complexes I and II to complex III in the electron transport chain (13). Additionally, propofol inhibits flux of electrons along the electron transport chain, but only uncoupling oxidative phosphorylation at very high doses (6). A review of patients with mitochondrial disorders who received propofol indicates that propofol not only disrupts electron flow along the respiratory chain but also decreases the activity or inhibits complexes I, II, III, and IV (Figure 2), although these abnormalities were not uniformly present in any of the reviewed articles (14). Many of the previously described mechanisms may be caused by downregulation of gene expression induced by propofol (15). It is conceivable that this dog had a pre-existing mitochondrial disorder that was uncovered after propofol administration, but this cannot be confirmed as it was not investigated.

Impairment of FFA oxidation occurs via 2 mechanisms (Figure 3). First, propofol increases the activity of malonyl CoA thereby inhibiting carnitine palmitoyl transferase I which trans-ports long-chain fatty acids across the mitochondrial membrane. Second, short- and medium-chain fatty acids, which freely cross

Figure 2. Electron transport chain. A — Normal representation of the electron transport chain with complexes I-IV and complex V also known as ATP synthase. B — Sites of inhibition of the electron transport chain due to propofol represented in red. H — hydrogen; NAD — nicotinamide adenine dinucleotide; FAD — flavin adenine dinucleotide; CoQ — coenzyme Q; Cyt C — cytochrome C; ATP — adenosine triphosphate.

A B



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the mitochondrial membrane, are unable to be utilized due to uncoupling of beta-spiral oxidation within the mitochondria (9,16). Impairment of FFA oxidation has been demonstrated by increased circulating acylcarnitine levels as well as ultra-structural changes to the mitochondria seen by transmission electron microscopy (16,17). Benchtop analysis of the effects of propofol on human skeletal myocytes strongly demonstrates inhibition of fatty acid oxidation and a subsequent reduction in spare electron transfer chain capacity (18). The result is an inability to utilize FFAs for energy generation vital for cardiac and skeletal muscle during times of fasting and critical illness. Additionally, carbohydrate deficiencies can place further reliance on FFA oxidation for energy production; however, carbohydrate intake of 6 to 8 mg/kg BW per minute is sufficient to suppress metabolism of fats in critically ill pediatric patients, which may reduce or prevent PRIS (16). The resulting imbalance between energy supply and demand from mitochondrial toxicity and impaired FFA utilization ultimately yields myocytolysis and therefore elevated CK and cardiac troponin I.

Treatment history in humans with PRIS commonly includes catecholamines and glucocorticoids. Catecholamines have been documented to cause myofibrillar degeneration in humans. Catecholamine-induced persistent opening of calcium chan-nels maintains myocardial cells in a persistently contracted state which ultimately leads to cell death (9). Aside from direct cardiotoxic effects, catecholamines increase cardiac output thereby decreasing plasma levels of propofol necessitating higher propofol rates to maintain appropriate sedation or anesthesia (7,9,19). Glucocorticoids also contribute to rhabdomyolysis seen in PRIS. Although glucocorticoids have been documented to cause ICU-acquired paresis, the primary mechanism is pro-teolysis and disarrangement of contractile myofilaments via activation of the ubiquitin-proteasome system (9). The dog in the present report was not administered catecholamines or

glucocorticoids; however, critical illness was present which is associated with potentially elevated endogenous concentrations of catecholamines and/or glucocorticoids (19).

Documented cardiovascular abnormalities with PRIS include supraventricular arrhythmias, ventricular arrhythmias, bradycar-dia, hypotension, and asystole. The predominant ECG abnor-mality associated with PRIS is a convex-curved ST segment elevation seen in leads V1, V2, and V3 similar to patients with Brugada syndrome (3). Causes of cardiovascular abnormalities may be a direct result of myocytolysis, hypoperfusion, cyto-pathic hypoxia, or alterations in beta-adrenergic receptors and calcium channel proteins (3,6,9). Propofol directly antagonizes beta-adrenoceptor binding and acts directly on calcium-channel proteins thereby diminishing contractility (19). Additionally, intramyocardial FFA accumulation is proarrhythmogenic. In this dog, hypotension could be attributed to PRIS, although previously described hypotensive effects of propofol (venodila-tion causing decreased preload, decreased cardiac output, and arterial dilation) are more likely given the improvement of blood pressure following intravascular volume expansion (20,21). Although propofol sensitizes the heart to epinephrine-induced arrhythmias, AIVR is likely due to PRIS since other potential causes remained constant and AIVR developed during propofol infusion and resolved upon its removal. Measurement of cardiac troponins would be helpful to assess for myocardial damage, but this was not done in this dog.

This dog has many clinical and biochemical features that are associated with PRIS in humans. Prior to initiation of high-dose propofol infusion (0.25 mg/kg BW per minute), acid-base status and CK values were normal. Acidemia, CK elevation, myoglo-binuria, and arrhythmias in the absence of significant cardiac structural abnormalities developed during the 14-hour time period of propofol administration. Other causes of CK elevations that were clinically relevant were ruled out with negative titers

Figure 3. Fatty acid mitochondrial transport. A — Normal fatty acid transport across the outer and inner mitochondrial membrane. B — Sites of inhibition of fatty acid transport across the mitochondrial membrane due to propofol. Propofol upregulated Malonyl-CoA inhibits Acyl-CoA utilization by inhibiting beta-oxidation. Abbreviations: See Figure 1.

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for T. gondii and N. caninum. All of the abnormalities resolved following removal of propofol and administration of NAC. The dog developed a new acidemia soon after the initiation of propofol infusion which has been an early indicator of PRIS in humans (6).

Liver enzyme elevation, although not a core feature of PRIS, has been reported in numerous case reports and has been attributed to hepatic lipidosis as well as acute liver insufficiency (3,6,8). Elevations of AST and ALT in this patient are likely multifactorial processes with skeletal muscle damage and hepa-tocellular damage as contributing factors. Development of ALP and GGT elevations as well as hyperbilirubinemia may be due to hepatic lipidosis secondary to PRIS, intrahepatic cholestasis secondary to liver damage, or sepsis. Biopsies were not obtained to further investigate liver enzyme elevation. Transient hypogly-cemia may have been a result of hepatic insufficiency or sepsis but ultimately resolved with supportive treatment.

Propofol is a phenolic compound with the potential to cause methemoglobinemia, although it has never been impli-cated directly in development of methemoglobinemia (22). Methemoglobinemia results from oxidative injury and in this case, may be secondary to propofol administration since there was an absence of other medications commonly associated with methemoglobinemia or congenital defects (22). Treatment with NAC as a glutathione precursor in an effort to prevent further oxidative injury along with removal of propofol led to resolu-tion of methemoglobinemia. A definitive cause for the methe-moglobinemia in this case is unknown and without definitive co-oximetry data from presentation, it cannot be excluded as a pre-existing condition. Because methemoglobinemia leads to decreased arterial oxygen content, it would be reasonable to attribute some of this dog’s clinical manifestations to hypoxia. However, methemoglobin levels between 10% and 20% may be tolerated well as dyspnea and tachycardia develop once met-hemoglobin reaches 30% (22,23). Although oxidative injury can cause Heinz bodies leading to anemia (24), they were not reported on any of the blood smears performed with CBCs. Anemia in this case is more likely due to repeated blood sam-pling (25). Because the evidence for hemolytic anemia is weak, hyperbilirubinemia is suspected to be hepatic in origin.

The time course of PRIS in this dog is atypical compared to reports in human medicine. Typically, PRIS is associated with propofol infusion rates 4 mg/kg BW per hour and with a duration of 48 h. This dog was hyporexic for 4 d and anorexic for 3 d before propofol initiation. This, combined with critical illness, likely caused heavy reliance on FFA oxidation for energy requirements, establishing increased risk for developing PRIS similar to children with decreased carbohydrate stores (16). Cumulative dose is a significant risk factor for death separate from rate and duration of infusion in humans (6). Most human patients described were administered rates (1.2 to 13 mg/kg BW per hour) lower than those administered to this dog; however, the duration of infusions was typically longer (8). The higher infusion rate or cumulative dose may be reasons that this dog showed clinical signs earlier than typically encountered in humans.

Treatment of PRIS relies on supportive care and removal of offending agents. Bradycardia is typically resistant to chrono-

tropic support or cardiac pacing. Intensive supportive care mea-sures such as extracorporeal membrane oxygenation have been reported (3,8,26,27). Blood purification techniques have been investigated as a treatment option for PRIS (27), but no studies evaluating direct intervention of the underlying pathophysiology exist. An abstract was published evaluating the effects of NAC in a rat model of PRIS and showed that when NAC was admin-istered concurrently with propofol, it reduced acidosis, AST, ALT, LDH, troponin-I, lactate, and inflammation and necrosis of hepatocytes in comparison to propofol infusion alone (28). Others have postulated that due to the structural similarity of propofol to co-enzyme Q, it may be beneficial as an “antidote,” but this requires further investigation (6,15,29).

Although there are differences between the cases of this dog and of humans with PRIS, the clinical course of disease in the dog is consistent with PRIS. It is unclear whether this dog rep-resents a typical case of PRIS in veterinary medicine or if there were extenuating circumstances that made this dog susceptible to PRIS while other cases may follow a more typical clinical course similar to humans. Furthermore, differences in the use of propofol for total intravenous anesthesia or sedation may exist between human and veterinary medicine, influencing the prevalence and clinical course of PRIS in veterinary medicine. Because this patient may represent a sentinel case of PRIS in veterinary medicine, close investigation is warranted for canine patients that fit the at-risk criteria and develop an unexplained metabolic acidosis, cardiovascular collapse, or evidence of rhabdomyolysis while receiving a propofol infusion. Further investigation is needed to determine if PRIS is a significant clinical entity in veterinary medicine.

AcknowledgmentThe authors thank Audrey Tinsman, DVM for designing and creating Figures 1 to 3. CVJ

References 1. Berry SH. Injectable anesthetics. In: Grimm KA, Lamont LA, Tranquilli

WJ, et al. eds. Veterinary Anesthesia and Analgesia: Lumb and Jones. 5th ed. Ames, Iowa: John Wiley & Sons, 2015:277–296.

2. Parke TJ, Stevens JE, Rice AS, et al. Metabolic acidosis and fatal myo-cardial failure after propofol infusion in children: Five case reports. BMJ 1992;305:613–616.

3. Kam PC, Cardone D. Propofol infusion syndrome. Anaesthesia 2007; 62:690–701.

4. Marinella MA. Lactic acidosis associated with propofol. Chest 1996;109: 292.

5. Diaz JH, Prabhakar A, Urman RD, Kaye AD. Propofol infusion syn-drome: A retrospective analysis at a level 1 trauma center. Crit Care Res Pract 2014:ID 346968.

6. Krajcova A, Waldauf P, Andel M, Duska F. Propofol infusion syndrome: A structured review of experimental studies and 153 published case reports. Crit Care 2015;19:398.

7. Fodale V, La Monaca E. Propofol infusion syndrome. Drug Saf 2008;31: 293–303.

8. Mirrakhimov AE, Voore P, Halytskyy O, Halytskyy O, Khan M, Ali AM. Propofol infusion syndrome in adults: A clinical update. Crit Care Res Pract 2015:ID 260385.

9. Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: A simple name for a complex syndrome. Intensive Care Med 2003;29:1417–1425.

10. Harvey JW. The erythrocyte: Physiology, metabolism and biochemi-cal disorders. In: Kaneko JJ, Harvey JW, Bruss ML, eds. Clinical Biochemistry of Domestic Animals. 6th ed. San Diego, California: Elsevier, 2006:173–240.



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11. Liolios A, Guerit JM, Scholtes JL, Raftopoulos C, Hantson P. Propofol infusion syndrome associated with short-term large-dose infusion during surgical anesthesia in an adult. Anesth Analg 2005;100:1804–1806.

12. Motsch J, Roggenbach J. Propofol-infusions syndrome. Anaesthesist 2004;53:1009–1024.

13. Turunen M, Olsson J, Dallner G. Metabolism and function of coenzyme Q. Biochim Biophys Acta 2004;1660:171–199.

14. Finsterer J, Frank M. Propofol is mitochondrion-toxic and may unmask a mitochondrial disorder. J Child Neurol 2016;31:1489–1494.

15. Kido K, Ito H, Yamamoto Y, Makita K, Uchida T. Cytotoxicity of pro-pofol in human induced pluripotent stem cell-derived cardiomyocytes. J Anesth 2018;32:120–131.

16. Wolf A, Weir P, Segar P, Stone J, Shield J. Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 2001;357:606–607.

17. Vollmer J, Haen S, Wolburg H, et al. Propofol related infusion syn-drome: Ultrastructural evidence for a mitochondrial disorder. Crit Care Med 2017;46:e91–e94.

18. Krajčová A, Løvsletten N, Waldauf P, et al. Effects of propofol on cellular bioenergetics in human skeletal muscle cells. Crit Care Med 2018;46:e206–e212.

19. Fudickar A, Bein B. Propofol infusion syndrome: Update of clinical manifestation and pathophysiology. Minerva Anestesiol 2009;75:339.

20. Brüssel T, Theissen JL, Vigfusson G, Lunkenheimer PP, Van Aken H, Lawin P. Hemodynamic and cardiodynamic effects of propofol and

etomidate: Negative inotropic properties of propofol. Anesth Analg 1989;69:35–40.

21. Goodchild CS, Serrao JM. Cardiovascular effects of propofol in the anaesthetized dog. Br J Anaesth 1989;63:87–92.

22. Rehman HU. Methemoglobinemia. Western J Med 2001;175:193–196.23. Wray JD. Methaemoglobinaemia caused by hydroxycarbamide (hydroxy-

urea) ingestion in a dog. J Small Anim Pract 2008;49:211–215.24. Andress JL, Day TK, Day DG. The effects of consecutive day propofol

anesthesia on feline red blood cells. Vet Surg 1995;24:277–282.25. Lynch AM, Respess M, Boll AE, et al. Hospital-acquired anemia in

critically ill dogs and cats: A multi-institutional study. J Vet Intern Med 2016;30:141–146.

26. Fudickar A, Bein B, Tonner PH. Propofol infusion syndrome in anaes-thesia and intensive care medicine. Curr Opin Anaesthesiol 2006;19: 404–410.

27. Levin PD, Levin V, Weissman C, Sprung CL, Rund D. Therapeutic plasma exchange as treatment for propofol infusion syndrome. J Clin Apher 2015;30:311–313.

28. Tezcan AH, Ozturk O, Adali Y, Erdem E, Yagmurdur H. The effects of N-acetylcysteine in a propofol infusion syndrome model in rats. Abstract PR462. Anesth Analg 2016:123–Suppl p154.

29. Vanlander AV, Okun JG, de Jaeger A, et al. Possible pathogenic mechanism of propofol infusion syndrome involves coenzyme Q. Anesthesiology 2015;122:343–352.



Veterinary Practice Management Gestion d’une clinique vétérinaire

Companion animal practices versus mixed and large: A 10-year comparison

Cliniques pour animaux de compagnie et cliniques mixtes et pour grands animaux : comparaison sur une période de 10 ans

Darren Osborne

T he Canadian veterinary economy is strong. Results from the most recent Practice Owners Economic Survey show

increased revenues and net incomes for both mixed and large and companion animal hospitals. According to Scotiabank Global Economics, the outlook for 2018 is guardedly positive, suggesting continued growth for veterinary hospitals. To better prepare for the future, one can look to the past to see if we’ve learned anything.

In the past decade, Canadian veterinarians endured a global financial crisis, a ruinous drop in oil prices, politics turning into a reality show, record high prices for cattle, and both a glut and shortage of veterinarians. How did the average Canadian veterinarian fare?

RevenueAs a baseline, consider that inflation for Canada over the past 10 years was 14%. This means any financial growth over that period must exceed 14% to be considered an achievement. Growth of 14% is simply status quo and growth less than 14% means the situation is worse.

L’ économie vétérinaire canadienne est vigoureuse. Les résultats du plus récent Sondage économique auprès des

propriétaires de pratique montrent une hausse des revenus et du bénéfice net des cliniques mixtes et pour grands animaux et des cliniques pour animaux de compagnie. Selon des Études économiques de la Banque Scotia, les résultats s’annoncent provisoirement positifs pour 2018, ce qui laisse suggérer une croissance continue pour les cliniques vétérinaires. Afin de mieux se préparer pour l’avenir, nous pouvons examiner le passé pour voir si nous avons appris quelque chose.

Au cours de la dernière décennie, les vétérinaires canadiens ont enduré une crise financière mondiale, une baisse désastreuse du prix du pétrole, un contexte politique de téléréalité, des sommets records pour le prix du bétail et à la fois un surplus et une pénurie de vétérinaires. Comment le vétérinaire moyen a-t-il tiré son épingle du jeu?

RevenusConsidérons, comme données de référence, que l’inflation au Canada a été de 14 % au cours des dix dernières années. Cela

Darren Osborne has been the Director of Economic Research for the Ontario Veterinary Medical Association for 20 years. He completed an MA (Economics) from York University and has worked as an economic analyst in veterinary medicine, dentistry, human medicine, and the transport industry.Address all correspondence to Darren Osborne; e-mail: [email protected] article is provided as part of the CVMA Business Management Program, which is co-sponsored by IDEXX Laboratories, Petsecure Pet Health Insurance, Merck Animal Health, and Scotiabank.Address all correspondence to the CVMA Business Management Committee; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

Darren Osborne est directeur de la recherche économique de l’Ontario Veterinary Medical Association depuis 20 ans. Il a obtenu une maîtrise en économie de l’Université York et a travaillé à titre d’analyste économique en médecine vétérinaire, en dentisterie, en médecine humaine et dans l’industrie du transport.Veuillez adresser toute correspondance à Darren Osborne; courriel : [email protected] présent article est rédigé dans le cadre du Programme de gestion commerciale de l’ACMV, qui est cocommandité par IDEXX Laboratories, Petsecure Insurance, Merck Santé Animale et la Banque Scotia.Veuillez adresser toute correspondance au Comité de la gestion commerciale de l’ACMV; courriel : [email protected]’usage du présent article se limite à un seul exemplaire pour étude personnelle. Les personnes intéressées à se procurer des réimpressions devraient communiquer avec le bureau de l’ACMV ([email protected]) pour obtenir des exemplaires additionnels ou la permission d’utiliser cet article ailleurs.



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signifie que toute croissance financière au cours de cette période doit dépasser 14 % pour être considérée comme une réussite. Une croissance de 14 % représente seulement le statu quo et une croissance inférieure à 14 % signifie que la situation s’est détériorée.

De 2008 à 2017, les cliniques mixtes et pour grands animaux ont obtenu un meilleur rendement que les cliniques pour animaux de compagnie. En effet, les cliniques mixtes et pour grands animaux affichaient une croissance supérieure des revenus, un meilleur contrôle des coûts et une croissance du bénéfice net significativement supérieure. Les cliniques pour animaux de compagnie affichaient de solides revenus, mais après

From 2008 to 2017, mixed and large animal veterinary practices outperformed companion animal practices. Mixed and large animal hospitals had stronger revenue growth, better cost containment, and significantly higher net income growth. Companion animal hospital revenue was strong, but after accounting for inflation, they had lower net incomes in 2017 than they did in 2008.

Revenue growth is the result of increased fees, more clients, and increased spending per client. All 3 factors contributed to increased veterinary revenue, but in companion animal practices, the increase in parasite medication and — to a lesser extent — food sales top the list for factors leading to increased revenues.

Table 1/Tableau 1. Comparing expenses — 2008–2017./Comparaison des dépenses — 2008–2017.

Change Companion Animal Hospitals/Cliniques pour animaux de compagnie 2008 2017 Changement

Drugs and supplies/Médicaments et fournitures 26.0% 28.2% 2.2%Wages and benefits (non-DVM)/Salaires et avantages sociaux (non-vétérinaires) 20.0% 21.0% 1.0%Specialists/Spécialistes 0.3% 0.5% 0.2%Rent/Loyer 5.0% 5.7% 0.7%Office/Bureau 1.8% 1.7% 0.2%Accounting and legal/Services comptables et juridiques 0.9% 0.8% 0.0%Bank charges/Frais bancaires 1.7% 1.8% 0.1%Depreciation/Dépréciation 1.3% 1.3% 0.0%Utilities/Services publics 1.8% 1.3% 0.5%Repairs and maintenance/Réparations et entretien 1.4% 1.3% 0.1%Laboratory/Laboratoire 2.3% 2.2% 0.0%Professional dues/Cotisations professionnelles 0.6% 0.6% 0.1%Other/Autre 0.1% 0.0% 0.1%Advertising/Publicité 1.0% 0.8% 0.2%Equipment rental/Location d’équipement 0.5% 0.6% 0.1%Bad debt/Mauvaises créances 0.1% 0.1% 0.0%Grooming/Toilettage 0.2% 0.1% 0.1%Continuing education/Formation continue 0.6% 0.7% 0.1%Insurance/Assurance 0.6% 0.7% 0.1%Non-DVM expenses/Dépenses non liées aux vétérinaires 66.2% 69.4% 3.2%

Net income (all DVMs)/Bénéfice net (tous les vétérinaires) 33.8% 30.6% 3.2%

Change Mixed & Large Animal Hospitals/Cliniques mixtes et pour grands animaux 2008 2017 Changement

Drugs and supplies/Médicaments et fournitures 33.2% 35.0% 1.8%Wages and benefits (non-DVM)/Salaires et avantages sociaux (non-vétérinaires) 14.6% 13.3% 1.2%Specialists/Spécialistes 0.1% 0.3% 0.1%Rent/Loyer 3.1% 2.8% 0.2%Office/Bureau 1.6% 1.4% 0.2%Accounting and legal/Services comptables et juridiques 0.7% 0.8% 0.1%Bank charges/Frais bancaires 1.2% 1.3% 0.1%Depreciation/Dépréciation 1.8% 1.5% 0.3%Utilities/Services publics 1.8% 1.4% 0.5%Repairs and maintenance/Réparations et entretien 1.3% 0.9% 0.3%Laboratory/Laboratoire 1.4% 1.3% 0.1%Professional dues/Cotisations professionnelles 0.6% 0.6% 0.0%Other/Autre 0.1% 0.3% 0.2%Advertising/Publicité 0.8% 0.7% 0.1%Equipment rental/Location d’équipement 0.3% 0.3% 0.0%Bad debt/Mauvaises créances 0.5% 0.1% 0.4%Vehicle/Véhicule 2.6% 1.7% 0.9%Grooming/Toilettage 0.0% 0.0% 0.0%Continuing education/Formation continue 0.6% 0.6% 0.0%Insurance/Assurance 0.8% 0.9% 0.1%Non-DVM expenses/Dépenses non liées aux vétérinaires 67.1% 65.3% 1.8%

Net income (all DVMs)/Bénéfice net (tous les vétérinaires) 32.9% 34.7% 1.8%



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avoir effectué l’ajustement pour l’inflation, elles avaient des bénéfices nets inférieurs en 2017 par rapport à 2008.

La croissance des revenus est le résultat de l’augmentation des tarifs et du nombre de clients ainsi qu’une hausse des dépenses par client. Ces trois facteurs ont contribué à une hausse des revenus vétérinaires, mais dans les cliniques pour animaux de compagnie, l’augmentation des ventes de médicaments antiparasitaires, et dans une moindre mesure, celles d’aliments pour animaux, se trouve au haut de la liste des facteurs qui ont permis une croissance des revenus. En fait, l’un des changements mesurables les plus importants pour les cliniques pour animaux de compagnie au cours des dix dernières années est la hausse de 4 % des revenus provenant des ventes d’aliments et de produits pharmaceutiques.

L’augmentation des tarifs a suivi l’inflation et la demande des clients, qui a chuté durant la crise financière et énergétique, mais a pris une tournure positive il y a quelques années. Au total, les cliniques pour animaux de compagnie ont observé une croissance de 21 % des revenus, ce qui représente un gain de 7 % par rapport à l’inflation.

Les cliniques mixtes et pour grands animaux au Canada ont connu une croissance de 31 % — soit plus du double du taux d’inflation au cours des dix dernières années. L’augmentation de la consommation de viande rouge et de produits laitiers a contribué à la croissance de la demande pour les interventions pour grands animaux et la progression de la vente des produits (de toutes les sources) a contribué encore plus à la hausse des revenus.

DépensesLes cliniques mixtes et pour grands animaux ont gagné encore plus de terrain sur les cliniques pour animaux de compagnie en raison de leur gestion des coûts supérieure. Depuis 2008, les cliniques mixtes et pour grands animaux ont obtenu une réduction de 1,8 % des dépenses non liées aux vétérinaires en tant que pourcentage des revenus. Par contraste, les cliniques pour animaux de compagnie ont observé une hausse de leurs dépenses de 3,2 % pendant la même période, qui sont passées d’une proportion de 30,6 % à 33,8 % des revenus bruts (Tableau 1). En médecine vétérinaire, les dépenses non liées aux vétérinaires les plus importantes sont les médicaments et les fournitures. Pour les deux types de pratique, il s’est produit une hausse des coûts liés aux médicaments et aux fournitures, mais cette situation était un résultat direct de la contribution accrue des ventes d’aliments et de produits pharmaceutiques. Les bonnes nouvelles sont que les revenus provenant de la vente de médicaments et de fournitures ont connu une augmentation supérieure à la hausse des coûts et que les cliniques se trouvaient donc dans une meilleure position.

Les salaires et les avantages sociaux représentent la deuxième dépense en importance non liée aux vétérinaires. Au cours de la dernière décennie, cette dépense a augmenté dans les cliniques pour animaux de compagnie mais a connu une baisse dans les cliniques mixtes et pour grands animaux. Même si beaucoup de vétérinaires désirent résoudre le problème des salaires et des avantages sociaux supérieurs en réduisant les taux horaires, plus souvent qu’autrement, le problème se résume à un trop

In fact, one of the biggest measurable changes in companion animal hospitals over the last 10 years is the 4% increase in revenue from diet and pharmacy sales.

Fee increases kept up with inflation and client demand, which dropped during the financial and energy crisis but turned posi-tive a few years ago. In total, companion animal practices saw a 21% increase in revenue, which was 7% ahead of inflation.

Mixed and large animal practices across Canada grew 31% — more than double the rate of inflation over the last 10 years. The increase of red meat and dairy product consumption helped prop up demand for large animal procedures and the boost in product sales (from all sources) raised revenues even more.

ExpensesMixed and large animal hospitals gained even more ground on companion animal hospitals with their superior cost manage-ment. Since 2008, mixed and large animal hospitals achieved a 1.8% decrease in non-DVM expenses as a percentage of revenue. In contrast, companion animal hospitals saw their expenses increase by 3.2% over the same time frame; from 30.6% of gross revenue to 33.8% (Table 1).

The largest non-DVM expense in veterinary medicine is drugs and supplies. For both practice types, there was an increase in drug and supply costs, but this was a direct result of increased contribution from diet and pharmacy sales. The good news is that revenue from drug and supply sales went up more than the cost, so practices were better off as a result.

The second largest non-DVM expense was wages and ben-efits. This expense has gone up in companion animal practices but has gone down in mixed and large animal practices over the last decade. While many veterinarians want to solve the problem of higher wages and benefits by lowering hourly wages, more often than not, it’s a problem of too many staff. From 2008 to 2017, companion animal hospitals saw an 8% increase in staff per DVM, while mixed and large animal hospitals experienced an 11% drop. Per hospital, this represents a $22 000 swing in net income to veterinarians.

Table 2/Tableau 2. Significant changes in 10 years./Changements considérables en 10 ans.

Companion Mixed & Animal Large Animal Hospitals Hospitals Cliniques Cliniques pour animaux mixtes et pour de compagnie grands animaux

Revenue 21% 31% Revenus

Income to all DVMs 9% 38% Bénéfice pour tous les vétérinaires

Diet and pharmacy sales contribution 4% 5% Contribution de la vente d’aliments de produits pharmaceutiques

Staff per DVM 8% 11% Employés par vétérinaire

Inflation 14% 14% Inflation



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The average practice had success in lowering administrative expenses. Replacing letter mail with e-mail helped lower office supply costs and replacing Yellow Page ads with websites and social media led to lower advertising budgets. Decreased utilities and repair and maintenance costs also helped lower expenses.

Net incomesThe combination of increased revenue and decreased non-DVM expenses propelled mixed and large animal net incomes to a 38% gain in 10 years. After adjusting for 14% inflation, the average mixed and large animal veterinarian had 24% more spending power than they did in 2008.

Companion animal hospitals had lower revenue growth (21%) along with a 3.2% increase in non-DVM expenses. The result was a 9% increase in net incomes over the last 10 years (Table 2). Inflation adjusted, the average companion animal veterinarian had 5% less spending power in 2017 than in 2008.

The next 10 yearsThe same Scotiabank economists who said 2018 is expected to be a good year, warn us that weak economic growth is a few years away. Veterinarians may be powerless to control outside forces such as lower oil prices, but they are in complete control of the forces inside their veterinary hospital — specifically cost management. Since 2008, mixed and large animal veterinarians have done an extraordinary job of reigning in expenses and managing staff during a period of extraordinary growth. This puts them in a strong position should there be an economic weakening in the future. Companion animal veterinarians can ensure history does not repeat itself and make a conscious effort to better manage expenses. ■

grand nombre d’employés. De 2008 à 2017, les cliniques pour animaux de compagnie ont observé une hausse de 8 % des employés par vétérinaire, tandis que les cliniques mixtes et pour grands animaux ont connu une baisse de 11 %. Cela représente une variation de 22 000 $ par clinique au niveau du bénéfice net des vétérinaires.

La clinique moyenne a connu du succès à réduire les dépenses administratives. Le remplacement des envois postaux traditionnels par les courriels a permis de réduire le coût des fournitures de bureau et le remplacement des annonces dans les Pages jaunes par des sites Web et les médias sociaux a contribué à la réduction des budgets de publicité. La diminution du coût des services publics ainsi que des réparations et de l’entretien a aussi contribué à la réduction des dépenses.

Bénéfices netsLa combinaison de la hausse des revenus et de la baisse des dépenses non liées aux vétérinaires a permis un gain fulgurant de 38 % des bénéfices nets des cliniques mixtes et pour grands animaux sur une période de 10 ans. Après l’ajustement de 14 % pour l’inflation, la clinique mixte et pour grands animaux moyenne possédait un pouvoir d’achat qui était de 24 % supérieur à celui de 2008.

Les cliniques pour animaux de compagnie affichaient une croissance inférieure des revenus (21 %) ainsi qu’une hausse de 3,2 % des dépenses non liées aux vétérinaires, ce qui a donné comme résultat une hausse de 9 % des bénéfices nets au cours des dix dernières années (Tableau 2). Après l’ajustement pour l’inflation, le vétérinaire pour animaux de compagnie moyen avait un pouvoir d’achat de 5 % inférieur en 2017 par rapport à 2008.

Les dix prochaines annéesLes mêmes économistes de la Banque Scotia qui ont dit qu’ils prévoyaient une bonne année en 2018 nous avertissaient aussi qu’une faible croissance économique se produira dans quelques années. Les vétérinaires peuvent être impuissants en ce qui a trait au contrôle des forces externes comme le prix du pétrole, mais ils peuvent entièrement maîtriser les forces à l’intérieur de leur clinique vétérinaire — plus particulièrement la gestion des coûts. Depuis 2008, les vétérinaires mixtes et pour grands animaux ont effectué un travail extraordinaire afin de limiter les dépenses et de gérer les employés durant une période de croissance extraordinaire, ce qui les place dans une position solide advenant un fléchissement de l’économie à l’avenir. D’autre part, les vétérinaires pour animaux de compagnie peuvent veiller à ce que l’histoire ne se répète pas et faire un effort conscient afin de mieux gérer les dépenses. ■



Diagnostic Ophthalmology Ophtalmologie diagnostique

History and clinical signs

A 2-year-old spayed female golden doodle was examined by the ophthalmology service at the Western College of

Veterinary Medicine. This dog was presented for red eyes and bilateral ocular discharge of a few weeks’ duration. The menace responses, and palpebral, oculocephalic, direct and consensual pupillary light reflexes were normal bilaterally. Schirmer tear test (Schirmer Tear Test Strips; Alcon Canada, Mississauga, Ontario) values were 26 and 20 mm/min in the right and left eyes, respec-tively. The intraocular pressures were estimated with a rebound tonometer (Tonovet; Tiolat, Helsinki, Finland) and were 14 and 12 mmHg in the right and left eyes, respectively. Fluorescein staining (Fluorets; Bausch & Lomb Canada, Markham, Ontario) of the corneas was negative bilaterally. On direct examination of both eyes there was mild, gray mucoid periocular discharge. Following application of 0.5% tropicamide (Mydriacyl; Alcon Canada, Mississauga, Ontario), examination of both eyes using a transilluminator (Welch Allyn Finoff Transilluminator; Welch Allyn, Mississauga, Ontario) and handheld biomicroscope (Kowa SL-15 Portable Slit Lamp; Kowa Co, Tokyo, Japan) revealed mild to moderate conjunctival hyperemia and multiple hyperplastic conjunctival follicles particularly in the ventro-medial fornix. Indirect ophthalmoscopic (Heine Omega 200; Heine Instruments Canada, Kitchener, Ontario) examination was completed and did not reveal abnormalities in either eye. Photographs of the right and left conjunctival fornices at pre-sentation are provided for your assessment (Figure 1).

What are your clinical diagnoses, differential diagnoses, therapeutic plan,

and prognosis?DiscussionThe clinical diagnosis is bilateral follicular conjunctivitis. Follicular conjunctivitis occurs secondary to chronic antigenic stimulation. Numerous characteristic-looking semitransparent conjunctival follicles are found which histopathologically repre-sent aggregates of hyperplastic lymphocytes and plasma cells. A true hypersensitivity or allergic reaction is excluded based on the

absence of mast cells and eosinophils. Conjunctival hyperemia and mucoid ocular discharge may also be part of the clinical presentation. The condition is most commonly diagnosed in younger dogs aged 2 y or less, and most often in dolichocephalic breeds that have deep conjunctival pockets owing to their deeper orbits (1).

The canine ocular surface has evolved an intricate mucosal immune system in order to respond to environmental and microbial affronts, while simultaneously tolerating self-antigens and commensal microflora. Similar to other mucosal sites in the body, the conjunctiva has conjunctival associated lymphoid tis-sue (CALT). In canine conjunctival lymphoid follicles, antigens are taken up by follicle-associated epithelium via M-cells in order to incite the production and activity of effector cells (lym-phocytes and plasma cells) (1,2). These conjunctival lymphoid aggregates can be seen in non-disease states and are identified most commonly on the bulbar surface of the third eyelid in

Marina L. Leis, Lynne S. Sandmeyer

Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4.Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

Figure 1. Clinical photographs of the right (A) and left (B) conjunctival fornices at presentation.

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close association with the gland of the third eyelid. In follicular conjunctivitis, lymphocyte and plasma cell populations dif-ferentiate and proliferate such that these follicles appear larger and in greater number, and can also be found anywhere on the conjunctival surface.

Unlike cats and horses, dogs are a species that have few types of primary conjunctivitis. In dogs, the term conjunctivitis is most often a misnomer as most cases of “red eyes” are in fact conjunctival injection or hyperemia occurring secondary to more common diseases affecting other ocular tissues (i.e., kera-titis, uveitis, orbital disease, glaucoma, scleritis). For example, conjunctivitis associated with quantitative and qualitative tear film deficiencies, and lymphoplasmacytic infiltration of the third eyelid in dogs with pannus, are not primary conjunctivitis disorders but rather reflect the secondary effects of a primary ocular disease process. For this reason, it is important for prac-titioners to complete a comprehensive ophthalmic examination to exclude more likely ocular diseases, before diagnosing primary conjunctivitis in dogs. Differentials for primary conjunctivitis in dogs are few and include infectious conjunctivitis (viral such as canine herpes virus-1 and distemper virus, parasitic such as Thelazia), contact hypersensitivity conjunctivitis, and ligneous conjunctivitis of the Doberman pinscher (3–6).

Therapy for follicular conjunctivitis is symptomatic and includes regular irrigation of the conjunctival pockets using an eye wash or saline solution and/or short-term topical ophthalmic corticosteroid application q6h. The dog in this case received twice daily (q12h) irrigation of the conjunctival pockets of both

eyes and topical dexamethasone 0.1% (Maxidex ophthalmic suspension; Alcon, Mississauga, Ontario) in both eyes starting at q6h, tapering down the frequency over 6 wk. Clinical signs resolved completely and have not recurred. Occasionally, gentle debridement of the conjunctival follicles with a dry cotton tip applicator can aid in improved penetration of topical medication and full resolution for less responsive cases.

The prognosis following these simple therapies is excellent. Most dogs will not have recurrence of clinical signs, especially as they age. However, some dogs may require long-term therapy via regular lavage of their conjunctival fornices to reduce antigen exposure or through the intermittent use of topical corticoste-roid (1,6).

References1. Gelatt KN, Gilger BC, Kern TJ. Veterinary Ophthalmology. 2-volume

set. Ames, Iowa: Wiley, 2013.2. Giuliano EA, Moore CP, Phillips TE. Morphological evidence of M cells

in healthy canine conjunctiva-associated lymphoid tissue. Graefes Arch Clin Exp Ophthalmol 2002;240:220–226.

3. Ramsey DT, Ketring KL, Glaze MB, Knight B, Render JA. Ligneous conjunctivitis in four Doberman pinschers. J Am Anim Hosp Assoc 1996;32:439–447.

4. Gervais KJ, Pirie CG, Ledbetter EC, Pizzerani S. Acute primary canine herpesvirus-1 dendritic ulcerative keratitis in an adult dog. Vet Ophthalmol 2012;15:133–138.

5. Lia RP, Traversa D, Agostini A, Otranto D. Field efficacy of moxidectin 1 per cent against Thelazia callipaeda in naturally infected dogs. Vet Rec 2004;154:143–145.

6. Glaze MB. Ocular allergy. Semin Vet Med Surg (Small Anim) 1991;6:296–302.



What Can’t Be Taught Ce qui ne s’enseigne pas

Co-ordinator, Programs & Membership.Canadian Veterinary Medical Association.Address all correspondence to Alexandra Schlesiger; e-mail: [email protected] of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

Stay positive and set boundaries

Alexandra Schlesiger

D r. Serge Chalhoub immediately expressed his eagerness to help students and to again become active in CVMA

initiatives when he was appointed as the CVMA Student Liaison Advisory Group (SLAG) faculty representative for the University of Calgary — Faculty of Veterinary Medicine (UCVM). Dr. Chalhoub’s enthusiasm for helping students was further displayed during the 2017 SCVMA Symposium, hosted by UCVM, when he volunteered as an actor, playing a “patient’s” animated and uncooperative “owner,” a role he takes on every year for UCVM’s annual CPR competition.

Born and raised in Montreal, Dr. Chalhoub graduated from the DVM program at the Université de Montréal — Faculté de médecine vétérinaire (FMV) in 2004. He then completed a 1-year rotating small animal internship at the same insti-tution. After working for 2 years as a general practitioner and emergency veterinarian at the DMV center in Montreal, Dr. Chalhoub pursued a residency in small animal internal medicine at the Animal Medical Center (AMC) in New York city. Once completed in 2009, he stayed on at the AMC as their first renal/hemodialysis fellow. During that time, he was also trained in interventional radiology/endoscopy.

When asked how he tries to cultivate a good work/life bal-ance, Dr. Chalhoub responded, “Ah, the million dollar ques-tion we all have! I greatly enjoy my work and work extremely hard, but I think the key to a good work/life balance is setting clear boundaries between your work and personal life — which took me years to truly appreciate. I make a conscious effort to turn off my phone and not check e-mails at home and I make sure to reality-check the daily and weekly tasks I would like to complete. At work, I try to stay positive as much as possible and I believe it is important to remember that days do not always go as planned and to expect surprises, in other words, be comfort-able with uncertainty.”

With mental health being top of mind in the veterinary pro-fession over the past few years, Dr. Chalhoub was asked to share

ways he helps support his own personal well-being. “Mental health is a very important topic; one we should all be aware of,” insists Dr. Chalhoub. “The work/life balance strategies I mentioned are some of the same strategies I employ to help my own mental well-being and it is also important to stay healthy and active outside of work (with family and early morning gym workouts alone).”

“It is also important to stop regularly and ask ourselves how we are doing and if something does not feel right inside of us, it is important to reach out for help sooner rather than later. This can be talking to our partners and friends to begin with and also considering mental health professionals. Our profession is fantastic, but there is no doubt it can sometimes take its toll on our well-being.”

One key piece of advice Dr. Chalhoub has for new veteri-nary graduates is to always stay actively curious, but not at the expense of health. “Our profession is rapidly evolving and it is important to keep our eyes open and our brains thinking but, no matter what, remember to stay healthy, physically and mentally, because you can’t have a career without your health.”

Dr. Chalhoub, a senior instructor at UCVM, says one thing he did not learn in veterinary college that he wishes he would have is how to communicate with owners and with team mem-bers. “The ability to communicate well is as important as our medical knowledge, and sometimes more important,” advises

Dr. Serge Chalhoub with one of his dogs, Luna.



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Dr. Chalhoub. “This includes communicating a medical plan, a patient’s status, and financial aspects of treatment. It is great that most veterinary curriculums now have some form of com-munications training and I’m proud to say UCVM has a strong communications program incorporated in each of the DVM program’s 4 years.”

Throughout his studies and career, Dr. Chalhoub had men-tors who contributed to him finding his path and one mentor with whom he kept in touch since his time at FMV is now a colleague at UCVM. “I feel having mentors along my journey was instrumental to my career and, to give back, I am now mentoring several UCVM students,” says Dr. Chalhoub. “What I believe makes a good mentor is having many years of positive experience under the belt, as well as the ability to listen and be patient, and the confidence that ‘things will likely work out’ over time, even when seemingly difficult or confusing. Being a mentor is not about having all of the answers; it is about being a helpful guide through the confusion.”

Throughout his teaching and mentoring years, the biggest mistake Dr. Chalhoub has seen a veterinary student make, unrelated to medicine, is being unprofessional or lacking colle-giality. “I have certainly seen students be unprofessional to other students and even to faculty and staff numerous times and it is so important to always be professional, not only with clients but also with classmates and faculty,” urges Dr. Chalhoub. “We can still be professional with one another even when we disagree or are frustrated about something.”

On top of Dr. Chalhoub’s CVMA volunteer roles, which include sitting on CVMA’s National Issues Committee and continuing his role as the CVMA SLAG faculty representative at UCVM, he is involved in humanitarian efforts as the coordina-tor of the UCVM-CUPS Pet Health Clinic for disadvantaged Calgarians. He has also authored and co-authored numerous scientific articles and book chapters on renal and urinary medi-cine, as well as the use of point-of-care ultrasound for triage of critically ill patients.

Dr. Chalhoub’s efforts do not go unnoticed. He was selected as the 2013 recipient of CVMA’s Teacher of the Year Award by UCVM students, and additional accolades include being the

co-recipient of the 2015 University of Calgary Team Teacher of the Year Award and the 2017 Carl J. Norden Distinguished Teacher Award. “Dr. Chalhoub is a great mentor and instruc-tor who makes school fun,” says Kira Moser, UCVM student and past-president of the SCVMA Committee. “He is always keen to help students, whether it’s spending his evenings giving lectures at student club events or having lunch with students to talk about internships.”

When asked what he would change about his career path if he could, Dr. Chalhoub explained, “To be honest, I would not change much! Life is a process, and reflecting on my career, I feel all points led to where I am now and I am very satisfied with that. All the past bumps, disappointments, or decisions I felt were not right have led me to an amazing job and career. I sometimes wonder what my career would have looked like if I became a radiologist or cardiologist, but I also know that as humans, we all have a tendency to wonder about the ‘what ifs,’ and that things always seem brighter on the other side … Okay, maybe I would go back and become an Air Force pilot!”

Dr. Chalhoub became involved in the CVMA early on while in college, first as a Jr. representative on the SCVMA Committee and then as the SCVMA Committee President who had a seat on CVMA Council and acted as the national voice for student veterinarians. Dr. Chalhoub also attended not only one SCVMA Symposium, but he took the opportunity to attend all 4 annual SCVMA Symposiums while he was a student at FMV. “I love to travel and I also wanted to experience the other Canadian veterinary colleges and see how they differ,” says Dr. Chalhoub. “I will never forget attending a WCVM Symposium event and learning how to two-step! But by far the best experience was meeting student colleagues and making life-long friends from across the country, on top of the incredibly educational labs and lectures. I urge students to try and attend at least one SCVMA Symposium while pursuing their DVM.”

Dr. Chalhoub encourages students to get involved and volunteer in their national professional association, “I greatly enjoyed learning what the CVMA was all about as a student and, all these years later, I am still happy to contribute back to this amazing organization.”

Dr. Serge Chalhoub and Dr. Søren Boysen, co-recipients of the 2015 University of Calgary Team Teacher of the Year Award.

Dr. Serge Chalhoub volunteering as an actor for UCVM’s annual CPR competition.



Veterinary Dermatology Dermatologie vétérinaire

O titis externa is a common complaint in veterinary medi-cine. In general practice, the percentage of canine cases

presenting for otitis externa ranges from 7.5% to 16.5% (1). Otitis externa is defined as inflammation of the external ear canal consisting of the pinna, and the vertical and horizontal ear canals up to the level of the tympanum. In many instances of otitis externa, secondary infection with bacteria or a fungus such as Malassezia pachydermatis, will be present. Pseudomonas aeruginosa, Staphylococcus pseudintermedius, Escherichia coli, and Klebsiella spp. are among the most common bacterial pathogens in cases of infectious otitis externa, with Pseudomonas aeru-ginosa being the most common Gram-negative isolate (1,2). Pseudomonas aeruginosa is a ubiquitous Gram-negative bacillus found in soil, water, and decaying organic matter. It is not a nor-

mal inhabitant of the canine ear and when it leads to infection, it can be challenging to manage (1,2). Selecting antibiotics for treatment can be problematic due to the bacterium’s resistance to many classes of antibiotics, and treatment is further complicated by the growing number of multidrug resistant strains (3,4).

Clinical presentationPrevious reports indicate that younger individuals are more prone to development of otitis externa and these same studies document no gender predilection (5). However, breed predis-positions do exist and breeds such as cocker spaniels, Jura des Alpes, Brittany spaniels, golden retrievers, and West Highland white terriers are overrepresented (5). Some older studies also show that Labrador retrievers, miniature poodles, Afghans, Scottish terriers, fox terriers, Maltese, and German shepherds are also predisposed (1).

Dogs presenting with Pseudomonas otitis externa (Figure 1) may exhibit one or a combination of the following clinical signs: head shaking, aural pruritus, malodor from the ear, erythema, alopecia, signs of self trauma to the pinnae and pre-auricular region, shyness around the head, discharge from the ear canal, aural hematoma, and ulceration of the external ear canal (1,2). If the infection has extended deeper into the middle or inner ear, causing an otitis media or otitis interna, neurological signs such as head tilt, vestibular disease, hearing loss, and pain when open-ing the mouth or swallowing might also be present (2). Patients may display pain on palpation of the ear canal if the canal is thickened, firm, and less pliable following chronic disease. This leads to a more guarded prognosis as it is indicative of prolifera-tive changes to the canal (1,2). The vertical and horizontal canals can also mineralize and will be hard upon palpation. In these

Pseudomonas otitis externa in dogs

Charlie Pye

Dr. Pye BSc, DVM, DVSc, Diplomate ACVD is an Assistant Professor, Atlantic Veterinary College, Charlottetown, Prince Edward Island.Address all correspondence to Dr. Charlie Pye; e-mail: [email protected] Canadian Academy of Veterinary Dermatology (CAVD) is a not-for-profit organization that promotes veterinary dermatol-ogy in Canada and provides continuing education for veterinar-ians, animal health technicians/technologists, and veterinary students. The CAVD welcomes applications for membership (www.cavd.ca).Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.

the dermatology feature is generously sponsored by royal canin.

la rubrique sur la dermatologie est généreusement commanditée par royal canin.



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cases surgery is often required (2). In any case of otitis externa, it is of utmost importance to perform a thorough dermatologic examination of the patient as approximately 76% of cases of chronic otitis externa will have other dermatologic lesions (1). The location and type of these lesions can help identify the primary factor in development of the chronic otitis externa.

PathogenesisOtitis externa develops due to primary, predisposing, and perpetuating factors. Primary factors are those that directly induce inflammation within the external ear canal, such as hypersensitivity disorders. In one study, the most common primary factors leading to otitis externa were: allergies, masses, endocrine disease, and autoimmune disease (6). Predisposing factors such as moisture act to increase the risk of development of otitis externa. Perpetuating factors such as otitis media occur following the development of otitis externa (1,2,6,7). Infectious agents have historically been categorized as perpetuating fac-tors in otitis externa but are more recently being re-classified as

secondary causes of otitis externa. Secondary causes will only lead to pathology in an abnormal ear or in combination with predisposing factors (1). In a study by Paterson et al (6), second-ary infections with Pseudomonas were found to develop more quickly if there was a mass or autoimmune disease compared with allergies and endocrinopathies.

One virulence factor contributing to the ability of Pseudomonas to cause chronic otitis is its ability to form biofilms. Biofilms increase antimicrobial resistance by protecting the bac-teria from the immune system and by preventing penetration of antimicrobials. Pseudomonas aeruginosa isolates from cases of canine otitis externa have been documented to form biofilms in about 40% of cases, and biofilm formation increases the minimum inhibitory concentration of antimicrobials needed to treat the infection (8).

DiagnosisAs for any dermatologic disease, obtaining a thorough history is the first step in diagnosis. An accurate history can not only help determine if an otitis externa may be present, but can also help identify the primary factor in development of otitis.

Otoscopic examination will help the clinician identify if the tympanum is intact, the type of lesions and discharge within the external ear canal, and whether the canal is stenotic. Otoscopic examination can also help rule out the presence of a foreign body. Both ears should be examined starting with the unaffected ear if the otitis externa is unilateral; this allows for comparison between the 2 ears. Separate cones should be used for each ear or the cone should be disinfected between use in the ears to prevent transmission of infection. Sedation or anesthesia might be required in a patient which is in pain to allow for a thor-ough otoscopic examination. Alternatively, if the patient is in pain, or the canal is stenotic, 7 to 14 days of anti-inflammatory therapy with an oral glucocorticoid such as prednisone or dexamethasone can precede the otoscopic examination. This will decrease inflammation and open up the ear canal to allow better visualization.

Cytology is the most valuable test to help confirm the pres-ence of infectious otitis externa. Cotton-tipped swabs should be inserted into the ear to the level of the vertical and horizontal canal, or where a lesion is noted. The sample taken can then be smeared onto a glass slide, heat-fixed, stained with Diff-Quik stain (Baxter Canada, Alliston, Ontario), and viewed under the microscope. The presence of rod-shaped bacteria should increase the suspicion of Pseudomonas as the infectious agent responsible for the otitis externa. White blood cells may also be noted in the sample. The presence of these cells, especially if phagocytosis of bacteria is noted, is indicative of a response from the individual’s immune system to the infection (1). As Pseudomonas and other rod-shaped bacteria are not commensals of the canine external ear canal, any time rods are noted on cytology, this indicates an infection is present and treatment is warranted.

An aerobic bacterial culture and susceptibility is required if systemic antibiotics are to be prescribed for a case of otitis externa. A culture should never be performed without concur-rent cytology verifying bacteria are present within the ear canal.

Figure 1. Otitis externa caused by Pseudomonas aeruginosa.

(Photograph provided by Dr. Anthony Yu).



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Most cases of otitis externa can be adequately treated using topi-cal antimicrobials and selection of these can be based on cytol-ogy findings. Culture and susceptibility tests show the serum level of a drug required to kill the organism. Concentrations of topically administered antimicrobials often reach levels that exceed those achieved in the circulation (9). Previous studies have shown that clinical response to topically applied antibiotics does not correlate with antimicrobial susceptibility results (10). If the canal is not ulcerated or eroded, systemic antibiotics are unlikely to reach therapeutic concentrations in the ear canal (9). However, if ulceration is present along the external ear canals, as if often the case with Pseudomonas, systemic antimicrobials will penetrate the ear canal more readily. If systemic antibiotics are to be prescribed, this should be done following an aerobic bacterial culture and susceptibility. This culture will definitively identify the species of bacteria and will allow identification of the sus-ceptibility patterns of that organism which can guide antibiotic selection. Pseudomonas are inherently resistant to many antimi-crobials due to their low cell permeability, beta lactamases, and efflux pumps. They can develop resistance easily if treatment is ineffective, if treatment is too short, or if an inappropriate antibiotic is selected (6). Pseudomonas is often susceptible to oral fluoroquinolones, but if the bacterium becomes resistant to this family of antibiotics, other systemic treatment options are often expensive, have to be administered via injection, or are not licensed for the treatment of animals (7).

TreatmentTreatment of Pseudomonas otitis externa revolves around the following: identifying and correcting the primary cause for the otitis externa, removing any debris from the ear canal, treating concurrent infections, and controlling inflammation within the ear/reversing pathological changes in the ear (7,11).

To identify and treat the primary cause of the otitis externa, further questions concerning history may be asked. A thorough dermatological examination should also be undertaken to see whether there are other clinical signs suggestive of an underly-ing etiology.

Cleaning or flushing of the ear will help to remove any debris, purulent material, or secondary infection in the external ear canal. The type and amount of exudate present will deter-mine which cleaner is most beneficial. If owners are unable to clean the patient’s ear at home, then a thorough flushing of the ear in hospital using sterile saline or an ear cleaner is warranted. This flushing should be performed under general anesthesia. Some topical antimicrobials, such as the aminogly-cosides, are inactivated in purulent material; therefore, cleaning/ flushing is imperative before their use to allow for better activ-ity of the antimicrobial (7). In Canada, there are no licensed chlorhexidine- based ear cleaners so if the clinician wants to use an antimicrobial ear cleaner, options would include those with a low pH (low levels of acetic or boric acid) or those containing isopropyl alcohol (7). Alcohol-based cleaners can potentially lead to a pain response if ulceration is noted along the ear canal. In previous studies, acetic acid has been found to be most effective against Pseudomonas, especially when used as a 2% solution (12). TrizEDTA will damage bacterial cell walls by chelating minerals

in the wall allowing better penetration of topical antimicrobials. The use of TrizEDTA will help increase antimicrobial efficacy which is especially important in cases of Pseudomonas otitis externa. Cleaning with TrizEDTA should be done approxi-mately 15 to 30 minutes before instilling topical antimicrobials and does not appear to be ototoxic (1,7). TrizEDTA has been shown, in vitro, to reduce the minimum inhibitory concentra-tion (MIC) of marbofloxacin and gentamicin for multidrug resistant P. aeruginosa (13). It has also been shown in vitro to reduce the MIC for biofilm imbedded P. aeruginosa for certain antimicrobials (14).

Cytology can aid in empirical selection of an antimicrobial to treat infectious otitis externa. Fluoroquinolones, gentami-cin, and polymixin B are usually effective against Pseudomonas (6,9). Ototoxicity has been previously reported with genta-micin instilled topically into the ear canal with a ruptured tympanic membrane. However, one study showed no ves-tibulotoxic or ototoxic effects when gentamicin was instilled twice daily into ears with ruptured tympanic membranes for a 3-week period (15). This indicates that this ototoxic-ity might be overemphasized. Most often a first line anti-microbial such as Polymixin B should be selected for acute episodes of Pseudomonas otitis externa, based on cytology and otoscopic findings (7). When using topical medication, it is most important to make sure an adequate volume of the medication is being used. A volume can be recommended based on the dog’s size. For example, in small breed dogs 0.25 mL can be instilled, medium-sized dogs: 0.5 mL, large breed: 0.75 mL, and giant breeds a full 1 mL/ear. Topical medica-tions are used once or twice daily depending on the medication selected (11).

If the otitis externa is chronic or recurrent, proliferative changes will likely be present. In these cases decreasing swell-ing, tissue proliferation, and inflammation is another goal of therapy. Glucocorticoids (especially dexamethasone), can help reverse the ototoxic effects of Pseudomonas infection (7). Oral dexamethasone dosed at 0.05 mg/kg body weight (BW) every 24 h or oral prednisone dosed at 0.5 to 1 mg/kg BW, q12 to 24h should be sufficient to control inflammation and this dose can be tapered over 2 to 3 weeks pending response and severity of disease (1,7). Cyclosporine can also aid in reducing inflam-mation and treating chronic otitis externa. Rechecks should occur every 2 to 4 weeks as medications are being tapered to assess response to the treatment protocol. With any oral anti-inflammatory drug, dosage should be decreased over time to the lowest effective maintenance dose that will treat the underlying pathology and the primary factor of the otitis externa. Topical therapy should still be recommended for chronic cases but use of a second line or third line antimicrobial will be warranted. Treatment duration in these cases may be up to 4 weeks.

In cases of chronic otitis externa or where there is concern for otitis media, systemic antibiotics should be prescribed based on bacterial culture and susceptibility results. This systemic treat-ment should continue for a minimum of 4 weeks.

At the end of the prescribed treatment, cytology should be repeated to verify that there is a cytological cure of the secondary infection leading to otitis externa.



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References 1. Miller WH, Griffin CE, Campbell KL. Muller and Kirk’s Small Animal

Dermatology. 7th ed. Toronto, Ontario: Elsevier, 2013:741–767. 2. Barnard N, Foster A. Pseudomonas otitis in dogs: A GP’s guide to treat-

ment. In Practice 2017;39. j892. DOI: 10.1136/inp.j892. 3. Lister PD, Wolter DJ, Hanson ND. Antibacterial-resistant Pseudomonas

aeruginosa: Clinical impact and complex regulation of chromosomally encoded resistance mechanisms. Clin Microbiol Rev 2009;22:582–610.

4. Mekic S, Matanovic K, Šeol B. Antimicrobial susceptibility of Pseudomonas aeruginosa isolates from dogs with otitis externa. Vet Rec 2011;169:125.

5. Saridomichelakis MN, Farmaki R, Leontides LS, Koutinas AF. Aetiology of canine otitis externa: A restrospective study of 100 cases. Vet Dermatol 2007;18:341–347.

6. Paterson S, Matyskiewicz W. A study to evaluate the primary causes associated with pseudomonas otitis in 60 dogs. J Small Anim Pract 2018;59:238–242.

7. Nuttall T. Successful management of otitis externa. In Practice 2016;38: 17–21.

8. Pye C, Yu A, Weese JS. Evaluation of biofilm production by Pseudomonas aeruginosa from canine ears and the impact of biofilm on antimicrobial susceptibility in vitro. Vet Dermatol 2013;24:446–449.

9. Morris DO. Medical therapy of otitis externa and otitis media. Vet Clin North Am Small Anim Pract 2004;34:541–555.

10. Robson D, Burton G, Bassett R. Correlation between topical antibiotic selection, in vitro bacterial antibiotic sensitivity and clinical response in 16 cases of canine otitis externa complicated by Pseudomonas aerugi-nosa. Proc North American Veterinary Dermatology Forum, Portland, Oregon, April 14–17, 2010.

11. Griffin C. Pseudomonas otitis. Proc World Small Animal Veterinary Association World Congress, San Diego, California, 2006.

12. Thorp MA, Kruger J, Oliver S, Nilssen EL, Prescott CA. The antibac-terial activity of acetic acid and Burow’s solution as topical otological preparations. J Laryngol Otol 1998;112:925–928.

13. Buckley LM, McEwan NA, Nuttall T. Tris–EDTA significantly enhances antibiotic efficacy against multidrug-resistant Pseudomonas aeruginosa in vitro. Vet Dermatol 2013;24:519–e122.

14. Pye C, Singh A, Weese JS. Evaluation of the impact of trometh-amine edetate disodium dihydrate on antimicrobial susceptibility of Pseudomonas aeruginosa in biofilm in vitro. Vet Dermatol 2014;25: 120–123.

15. Strain GM, Merchant SR, Neer TM. Tedford BL. Ototoxicity assess-ment of a gentamicin sulfate otic preparation in dogs. Am J Vet Res 1995;56:532–538.

The participation of advertisers in the CVJ is an indication of their com-mitment to the advancement of veterinary medicine in Canada. We encourage our readers to give their products and services appropriate consideration. — Ed.

Le support des annonceurs démontre leur engagement pour l’avancement de la médecine vétérinaire au Canada. Nous vous encourageons à prendre connaissance de leurs services et produits. — NDLR

Index of AdvertisersIndex des annonceurs

BordenLadnerGervaisLLP.........................................................1247

CampbellPetCompany................................................................1247

CanadianVeterinaryMedicalAssociation.................... 1143,1148

ChironCompoundingPharmacy.................................................1247

FMSMedicalSystemsLtd...........................................................1248

GallantCustomLaboratories,Inc.............................................1248

Hill’sPetNutritionCanada,Inc.................................................... IFC

IDEXXLaboratories,Inc...............................................................1137

Jackson&Associates....................................................................1247

Lebalab,Inc.......................................................................................IBC

MasseyUniversity.........................................................................1152

MerckCanada................................................................................1144

NestlePurinaCanada,Inc............................................................OBC

NovaBiomedicalCanadaLtd.....................................................1147

PawsitiveResources.....................................................................1248

PracticeOneConsulting..............................................................1248

SensorHealthVeterinaryDiagnostics,Inc..............................1247

Simmons&AssociatesCanada,Inc..........................................1248

UXR,Inc.........................................................................................1247

WesternFinancialGroupInsuranceSolutions.........................1140

WesternVeterinaryConference................................................1170

Zoetis(formerlyAbaxis)..............................................................1138



Classifieds Petites annonces

Business Directory

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Practice One cOnsulting

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Dr. Frank Richardson, DVM, MBAVeterinary Management Consultant

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