sunday, november 16, 2014 - Advanced Veterinary Specialty Group

SUNDAY, NOVEMBER 16, 2014
Wet Lab and Hands-on Learning Event!
Continuing education in a small group clinical setting on
the campus of the specialty practices in Tustin
®
A DVANCED CARE FOR PETS
Advancing the A
rt of Veterinary Dermatology
SUNDAY, NOVEMBER 16, 2014
Wet Lab and Hands-on
Learning Event!
PRESENTATION
NOTES
Groups
Speakers
Topics
ECFA
Julius Brinkis, DVM, DACVO
Eyelid Mass Wedge Resection
VSS
Tony Cambridge, BVMS, DACVS
Wound Closure Techniques and Surgical Reconstruction Options AVMI
Mike Broome, DVM Advanced Imaging Case Studies - Answering the Clinical Question.
AVIM Cindy Duesberg, DVM, ACVIM
Michelle Cieplucha, DVM
Catheterizing the Female Dog Can be a Bitch
AVCC
The Echocardiogram: When and Why (Notes available on-site)
Sarah Zimmerman,DVM, DACVIM (Cardiology)
ADC Melissa Hall, DVM, DACVD
My Five Favorite Products in Dermatology Patients and Why!
VCG Mona Rosenberg, DVM, DACVIM (Oncology)
Sara Fiocchi, DVM, DACVIM (Oncology)
Julie Bulman-Fleming, DVM, DACVIM (Oncology)
David Bommarito, DVM, MS, ACVR, DACVIM (Oncology)
Cytology and Slide Preparation for Everyday Lumps and Bumps
VNC Stephen Hanson, DVM, DACVIM (Neurology)
Stacy Dillard, DVM, DACVIM (Neurology)
Strange “Neuro” Cases
AVSG Sarah Beaman, DVM
After Hours
Diane Craig, DVM, DACVS
Taps and Tubes
OCVS Andrea McDooling, BVSc, MS, DACVIM (SAIM)
Ashley Cruse, DVM, DACVIM (SAIM)
Leyla Fatourechi, DVM, DACVECC
Immune Mediated Polyarthritis (Notes available on-site)
CE CERTIFICATES WILL BE AVAILABLE FOR PICK-UP FOLLOWING YOUR LAST SESSION
AND COMPLETION OF YOUR EVALUATIONS OF TODAY’S PROGRAM
www.AVSG.net
®
A DVANCED CARE FOR PETS
Advancing the A
rt of Veterinary Dermatology
EYELID MASS WEDGE RESECTION
Julius Brinkis, DVM, DACVO and Douglas Esson, BVSc, MRCVS, DVM, DACVO
Eyelid lacerations as well as tumors affecting the lid margins are relatively commonly
encountered. As a consequence eyelid re-apposition is a frequently performed
procedure.
Referral to an ophthalmologist is sometimes not possible; however the anatomy of this
region dictates a high risk for post-surgical complication and failure.
As a consequence we will aim to provide a brief anatomical and surgical review of
simple eyelid repair following wedge resection.
This review will take the form of a short video presentation followed by an instructional
wet lab (using pig eyes), guided by Drs. Esson DACVO & Brinkis DACVO, who will also
be available (time-permitting) to discuss interesting or challenging cases.
Eye Care for Animals acknowledges Cara Animal Care Products for providing wet
lab instrumentation & suture material.
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Wound Closure and Surgical Reconstruction Techniques
Tony Cambridge BVMS MRCVS Dip ACVS
www.vssoc.com Email: [email protected] (949) 936-0055
The majority of wounds in our patients, be it from trauma or tumour resection, are simply closed.
Having a variety of available practical techniques can allow the surgeon to avoid significant
complications associated with large wound dehiscence or the compromise of distal tissue associated
with a closure that is too tight, on a limb for example.
KISS- "Keep It Simple, Stupid" Apply the least complex method that has a high probability of success.
Use of towel clamps/skin hooks and/or temporary sutures to map or test a closure.
If you don't think it will stay closed, it probably won't. Augment the closure with Button Stents!
Be aware of distal extremity closures that are too tight. If any doubt, re-exam day 1 and day 2 post-op.
Be prepared to open the wound if a compromise occurs.
Don't be scared to admit this is a wound you can't close and convert to partially closing with a plan for
secondary intension healing augmented by stents, tie over dressing, skin stretching or a second
"planned" surgery.
Always have a plan B available whenever you think it could be less than a simple closure.
Shave much more hair than you expect to remove.
Consider the use of simple flaps or if you are feeling brave, complex flaps. Axial pedicle flaps are based
on precise anatomic vascular pedicles giving advantage of much longer flaps without a wide base.
When using Flaps the K.I.S.S. principle is out, GO BIG OR GO HOME, small flaps add little to a closure
defect. Big flaps close wounds but require LARGE areas to be shaved ahead of time.
Dead space and seroma are your enemy, plan accordingly. Use wound drains prior to closure if you think
you might need them. They can always be removed.
Penrose drain is a 2 way street- exposed drains ideally should be covered.
Buy Suction drains and have them in your clinic. If you don't have them, you won't use them.
Wound stents can be made from tubing buttons. They are simple and easiest to use;
Buy 3 sizes of Buttons have them ready in your clinic steam or cold sterilize. Use them to;
1. Assist in abolishing/compressing dead space.
2. As stents to support a wound closure.
3. As anchor points for skin stretching/traction with umbilical or suture to partially close wounds.
K.I.S.S.
meets GO BIG OR GO HOME !!
Flank Fold and Elbow fold Flaps- Simple practical flaps. Greta in cats and majority of dogs
Caution in Pit Bull/Bull terrier type breeds which have little surplus skin in these locations.
base is ideally 2:1 base to length of free flap, cat’s skin is elastic and more tolerant of narrow base, can
often make flaps 1:1 and then stretch to carpus/tarsus from Axilla/Flank
Flank fold flap used to cover lateral and medial
stifle defect and 360 degree proximal tibia
Or cover entire lateral thigh, note cranial
wound closure from donor site
Elbow Flap used to cover an axillary medial elbow defect
Elbow flap used to cover antebrachium down to the carpus
Flank folds can also be used to close large central abdomen or groin defects.
References
Hunt, G. B. (1995). Skin fold advancement flaps for closing large sternal and inguinal wounds in cats and dogs. Veterinary
Surgery : vs, 24(2), 172–175.
Hunt, G. B., Tisdall, P. L. C., Liptak, J. M., Beck, J. A., Swinney, G. R., & Malik, R. (2001). Skin-fold advancement flaps for
closing large proximal limb and trunk defects in dogs and cats. Veterinary Surgery : vs, 30(5), 440–448.
Drains available form Victor Medical.
Trochar Drain- 10Fr Jackson Pratt
SU130- 0321
Flat Drain SU130-1309 10mm Jackson Pratt Flat Drain
100ml Jackson Pratt Reservoir (grenade) SU130-1305
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PASS THE LASER POINTER, INTERACTIVE SESSION OF READING DENTAL X-RAYS
Eric Van Nice DVM, DAVDC
The group will view dental x-rays from clinical cases. Participants will take turns reading the xrays. We will practice an orderly approach:
Is the image of diagnostic quality? If not, what problems need to be improved: exposure,
contrast, elongation, foreshortening, superimposition of structures, failure to get the entire area
of interest on the image, “cone cutting” etc?
Is the image mounted correctly for viewing? Maxillary teeth roots should point upward and
crowns downward, mandibular teeth roots should point downward and crowns upward, patient’s
left is to viewer’s right and vice versa. If you think about it, it’s just like looking at a VD chest
film, just imagine moving the x-ray view up to the mouth.
What is the species of the patient?
What teeth or region are in the image? Identify which maxillary or mandibular teeth, left or right,
incisors, canines, premolars, molars. 1st, 2nd, 3rd, 4th, deciduous, permanent teeth? Sinuses,
bullae, TMJ’s?
Describe any abnormalities:
 Developmental abnormalities
 Bony lesions. May include fractures, neoplasia, osteomyelitis, osteopathies.
 Missing or supernumerary teeth
 Periodontal disease
 Endodontic disease
 Tooth resorption, true carious lesions (cavities)
Further reading:
Mulligan T, Aller MS, Williams CA. Atlas of Canine and Feline Dental Radiography. Trenton NJ:
Veterinary Learning Systems, 1998.
DuPont G, DeBowes L. Atlas of Radiography in Dogs and Cats. Saunders, 2008.
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April 27th, 2014
Advanced Veterinary Internal Medicine
Michelle Cieplucha, DVM
Victoria Vorathavorn, DVM, DACVIM
Catheterizing the Female Dog Can be a Bitch
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Indications
o Relieving an anatomic or functional obstruction
o Monitor ins/outs (e.g. Renal failure)
o Obtain a urine sample (less likely to perform in a female vs male dog)
o Recumbent patient
o Radiographic contrast procedure
Anatomy
o Review of normal anatomy
o Examine external genitalia for any anatomic abnormalities or discharge
o Palpation of distal urethra during a rectal digital exam (identify urethral mass vs urethral
stone)
Tips on urinary catheter placement
o Digital palpation of urethral orifice
o Direct visualization using speculum or otoscope
Equipment
o Type of urinary catheter (with or without a stylet)
Cystoscopy clinical applications
o Recurrent urinary tract infections, mass lesions seen on ultrasound or
radiographs, incontinence, urethral obstruction, abnormalities of
micturition, abnormal urine composition
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o - images/cases
Practical time
o Placing urinary catheter using the digital palpation method
o Placing urinary catheter using the direct visualization method
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The Echocardiogram: When and Why
Mike Lesser, DVM, DACVIM (Cardiology)
NOTES AVAILABLE ON-SITE
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My Five Favorite Products…..and Why!
AVSG WetLab-Dermatology
Animal Dermatology Clinic
Rusty Muse DVM, ACVD
Colleen Mendelsohn DVM, ACVD
It isn’t an accident that the tagline for Animal Dermatology Clinic is “Advancing the art of
veterinary dermatology” because as much as science plays a role in management of
dermatology patients, there is an equal part “art” that enters the equation. Tremendous
advancements have been made in the past decade with innovative technologies, delivery
systems and products from companies dedicated to the support of veterinary dermatology.
However the presence of these products themselves if not used correctly or in the right situation
provide little benefit to our patients. Product advancement and utilization is not a substitute for
thorough history taking, physical examinations and diagnostic workup in assessing and correctly
managing dermatology cases. Using these products without a thorough knowledge of the
science behind them will result in little progress and limited management that is manifested as
relapsing patients and frustrated clients. In the hands of experienced dermatologists or
clinicians the following products are ones that can bring significant benefit and are utilized
frequently in our case management schemes. Learning when to use these products will help
you become an integral component in the team concept of managing dermatology cases with
the dermatologist.
Convenia
Cefovecin (Convenia®, Pfizer) is a third-generation cephalosporin developed to treat aerobic
and anaerobic gram-negative and gram-positive infections. Cefovecin is bactericidal against
Staphylococcus and Streptococcus species, Escherichia coli, Pasteurella multocida, and
Klebsiella and Proteus species, but is not active against Pseudomonas or Enterococcus
species. Cefovecin has a long half-life and demonstrates prolonged concentrations in
extracellular fluid, allowing for dosing every 14 days. If required, the dose of 8 mg/kg
subcutaneously can be repeated every 14 days for a total of three doses. Cefovecin is
eliminated primarily by the kidneys but has up to 25% biliary excretion. It should not be given to
animals that are allergic to penicillins or cephalosporins, less than 8 weeks old, pregnant or
lactating, or that have severe renal dysfunction. Controlled studies in both cats and dogs show
good clinical efficacy. Treatment with cefovecin of naturally occurring bacterial infections of skin
and soft tissues in dogs has shown to be as effective as amoxicillin/clavulanic acid administered
orally. The author finds that this drug offers the additional benefits of enhancing owner
compliance and the injectable form in pyoderma cases is helpful when issues of oral absorption
are a concern. It is particularly beneficial in cats because of the usual difficulties of oral
administration. Recently in vitro cefovecin disk-diffusion test results were found helpful in
predicting the presence of the mecA gene in Staphylococcus pseudintermedius, as well as the
in vivo efficacy of cefovecin therapy in dogs with superficial pyoderma.
Douxo Chlorhexidine Shampoo/Spray
The most commonly used antibacterial agent found in shampoos is chlorhexidine. It is generally
well tolerated and is not drying or irritating and at 2-3% concentrations in shampoo formulations
has generally been found to be clinically effective. However, newer formulations with 3% or
higher have been quite impressive in clinical cases and are available commercially. Recently
multiple in vivo and in vitro studies have demonstrated the efficacy of chlorhexidine and
chlorhexidine containing shampoo formulations on both methicillin sensitive and methicillin
resistant Staphylococcus pseudintermedius strains. Douxo Chlohexidine Shamoo and Spray
(Sogeval) is a 3.2% Chlorhexidine product that has become the product of choice at our
practice. These products have the added benefit of including phytospingosine which is a
ceramide that is present in the cutaneous barrier of the skin and helps to provide improved
barrier function of the skin to protect against secondary bacterial infection.
A simulated in vivo study looked at the residual effects of chlorhexidine on the hair shafts of
dogs bathed with various concentrations; 0.8%, 2%,3% and 4% chlorhexidine containing
shampoos. Dogs were bathed and hairs were removed immediately and then again at 2, 4 and
7 days after bathing. These hairs were inoculated onto a culture agar plate streaked with
Staphylococcus pseudintermedius organisms. Zones of inhibition around the hair shafts were
then measured to assess antimicrobial activity that was present around the hair. There was
inhibition noted even at 7 days in some cases. Efficacy was noted to be greater in 2% and 3%
containing shampoos however other factors including shampoo formulation are likely to have
played a role in the final results. In addition, factors such as the ability to penetrate into the hair
follicle and deeper layers of the epidermis may affect the efficacy of various formulations of
chlorhexidine-containing shampoos. However given the increasing prevalence of more resistant
strains of Staphylococcus noted in clinical dermatology, these studies suggest that the role of
topical therapy is a critically important factor in managing bacterial infections in the canine.
Atopica
Cyclosporine has low cytotoxicity relative to its immunosuppressive potency. It blocks IL-2
transcription and T-cell responsiveness to IL-2, leading to impaired T-helper and T-cytotoxic
lymphocytes. It also inhibits IFN-α transcription, thus diminishing amplification signals for
macrophage and monocyte activation. The production of other cytokines, including IL-3, IL-4, IL5, TNF-α, and IFN-α may be impaired. In these ways, cyclosporine inhibits mononuclear cell
function, antigen presentation, mast cell and eosinophil production, histamine and prostaglandin
release from mast cells, neutrophil adherence, NK cell activity, and growth and differentiation of
B cells. It has also been suggested that a mechanism of action in the treatment of AD involves
the inhibition of mast cell degranulation by affecting the interaction between mast cells and
nerves. Cyclosporine also directly inhibits histamine release from dog mast cells.
Cyclosporine has been extensively evaluated for the treatment of canine AD and found to be
highly effective and comparable in efficacy to prednisolone and methylprednisolone, making it a
practical alternative to glucocorticoids. Another advantage of using cyclosporine in canine AD
patients is the benefit of controlling pruritus while still allowing intradermal skin testing to be
performed. A recent double-blinded placebo study evaluated two groups of intradermal positive
dogs before and 30 days after therapy. Group A contained 8 dogs treated with Atopica (Novartis
Animal Health) at 5 mg/kg every 24 hours, and group B contained 8 dogs treated with a
placebo. At the end of 30 days, there was no effect on immediate intradermal test reactivity in
the Atopica-treated dogs.
Different cyclosporine formulations are available, both human brand-name products and generic
formulations. Two formulations are available, an emulsion and a microemulsified preparation;
the microemulsified form is better absorbed. Atopica is a microemulsion concentrate that is
absorbed quickly and more effectively through the gastrointestinal tract of dogs than nonmicroemulsified formulations. Although absorption is better with Atopica, it is still poorly and
erratically absorbed, and bioavailability varies from 23% to 45%. Presence of food in the
gastrointestinal tract increases the range of bioavailability and can reduce it by 20%, although
some dogs will have increased absorption, especially when the food is high in fat. The only
product approved by the FDA for veterinary use is Atopica, which is available in a variety of
different sizes (10 mg, 25 mg, 50 mg, and 100 mg). Recently, Atopica for cats has been
released as a cyclosporine oral solution (USP Modified), making it easier to prescribe for cats
and small dogs. Some generic formulations carry a warning on the label that states they are not
bioequivalent, and it is anecdotally stated by many specialists that some dogs will not respond
as well to generic formulations. For this reason and because this is the only FDA-approved
veterinary product, it is recommended to start with the brand-name cyclosporine, Atopica.
Comfortis
Spinosad (Comfortis [Elanco]) is a novel insecticide produced from a family of natural products
derived from fermentation of the actinomycete, Saccharopolyspora spinosa, that has been
marketed for oral use in dogs. Separate randomized blinded studies were undertaken to
determine the minimum effective dose of spinosad given orally for the treatment of
experimentally induced flea infestations on dogs, and to assess any potential impacts of feeding
canned or dry food at the time of dosing. It was found that only the 30 and 40 mg/kg doses
maintained high efficacy (97.2%-100%) until 30 days after treatment, and since there was no
significant difference between the higher spinosad rates, 30 mg/kg was selected as the optimal
minimum effective dose in the United States. The authors concluded that repeated monthly oral
treatments with spinosad at 30 mg/kg provide sustained control of C. felis on dogs
independently from events in either study, indicating that spinosad has potential to be used
monthly as a safe and effective flea adulticide, providing sustained activity that matched that of
currently used topical products
The major benefits of spinosad especially for dermatology cases is the fact that topical therapy
will not have any adverse affects on the level of flea control. Many of our allergic skin disease
cases will require routine bathing and this will have adverse effects on all topical therapy used
for flea control. In addition, in Southern California, swimming in the ocean can also have
adverse affects of the longevity of topical flea control so this variable is avoided with the use of
the oral spinosad.
Dermoscent Spot on Therapy
Dermoscent Essential 6 Spot-on (Laboratoire de Dermo-Cosmétique Animale) contains a
combination of fatty acids and emollients that restores hydrolipidic film on the skin, maintains
hydration, controls transepidermal water loss (TEWL) and maintains epidermal barrier function.
It also helps diminish inflammation by having antioxidant and anti–free radical effects. This
product contains natural plant ingredients including hempseed and neemseed oils for a high
concentration of EFAs with an omega-6/omega-3 ratio of 4:1. In addition, other essential oils
(rosemary, lavender, melaleuca, cedar, oregano, clove, camphor, wintergreen, peppermint,
curcuma), along with vitamin E, are included to replenish the hydrolipidic film, hydrate the skin,
and control odor. Anecdotal reports of this product helping with coat quality and controlling
pruritus in dogs with AD exist. One open trial looked at seven dogs with atopic dermatitis and
five normal dogs that were treated with a spot-on containing essential oils and unsaturated fatty
acids once weekly for 8 weeks. Seven more atopic dogs received a daily spray containing
similar ingredients. In all dogs, TEWL was measured with a closed-chamber device before and
after treatment. The mean Canine Atopic Dermatitis Extent and Severity Index (CADESI) scores
in atopic dogs decreased with the spot-on from 25.1 to 15.3, and with the spray from 29 to 6.
Similarly, the pruritus scores decreased from 3.1 to 2.1 with the spot-on and from 2.3 to 1.3 with
the spray. There was a significant difference between healthy and atopic dogs’ TEWL values on
the abdomen and back. TEWL decreased significantly on the back after treatment with the
spray on the abdomen, the decrease was not quite statistically significant. Adverse effects were
not observed. These preliminary results indicate that topical fatty acids and essential oils may
be a useful treatment option for canine AD.
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CYTOLOGY AND SLIDE PREPARATION FOR EVERYDAY LUMPS AND BUMPS
Mona Rosenberg, DVM DipACVIM (Oncology)
Julie Bulman-Fleming, DVM, DipACVIM (Oncology)
Sara Fiocchi, DVM DipACVIM (Oncology)
David Bommarito, DVM, MS, DipACVR (Radiation Oncology), DipACVIM (Oncology)
Cytology is an attractive diagnostic technique since it is minimally invasive, does not
require anesthesia or sedation in most cases, has low morbidity, low cost and typically
yields results within 24-48 hours. Agreement between cytologic and histologic samples
has been reported as greater than 90%. Cytology has high specificity and positive
predictive values (98 and 99% respectively), which indicates that when a cytological
diagnosis is obtained, these results are correct. The sensitivity is slightly lower at 89%,
meaning that some samples do not yield a diagnosis. The negative predictive value is
69%.
An online survey asked 870 clinical veterinarians how they use cytology. More than
70% said they use cytology as a screening test, as a rule-out for specific disease or to
obtain a definitive diagnosis. 34% reported using cytology to stage disease, a practice
usually left for referral clinicians as reported in the March 2008 issue of JAVMA.1
Notable pathologist John M. Bjorneby, DVM, PhD Diplomate ACVP states that
“cytopathology is a useful and accurate tool to evaluate cutaneous and internal lesions
in conjunction with the clinical signs and history, laboratory results, and sonographic
findings.” However, there can be limitations to this usefulness if the sample quality is not
adequate. Sample quality is the most common reason cited by pathologists for a nondiagnostic sample. Good Sample Quality + Clear Communication = Definitive
Diagnosis, per Dr. Bjorneby.
Is there an easy and cost effective way to ensure sample quality? Good news, yes
there is.
The following are tried and true methods for avoiding poor sample quality.
To avoid drying artifact:
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Do not allow slides to dry on their own. Rapid air drying is the key to good
sample quality.
A blow drier on low to medium heat is very useful.
Slides can be dried by waving through the air, although many a slide has been
broken this way.
If a blow dryer is not handy, a small fan can be used. The tiny, hand held
personal fans work well.
Fluids submitted via a lavender top tube can be prepared at the lab and will avoid
all of the above.
To ensure cell integrity:
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Formalin fumes can damage the cell by fixing the cell membrane and thus
reducing the ability of the stain to penetrate causing loss of detail.2 Submit
cytology and histopathology samples separately.
Ultrasound gel should be cleaned off prior to aspirating as it can cause cell lysis
and/or swelling.
Apply sample to only one side of the slide, preferably the frosted side.
When smearing, do not apply too much pressure as this can cause nuclear
streaming.
Heat fixation should not be used for this type of cytology.
Other useful tips:
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Submitting unstained, properly dried slides is helpful, especially in the event that
a special stain is requested or will be at a later date.
Submitting only one slide is not recommended. The slide may be broken or may
not yield enough of a sample for a definitive diagnosis.
Peripheral blood contamination on the slide or hemodilution may inhibit the
pathologist’s ability to accurately read the slide.
Spreading the sample thinly and evenly across the surface of the slide is
essential to a definitive diagnosis. This allows the pathologist to accurately
assess each cell individually.
From a practical standpoint, in-clinic cytology may be used to ensure that a
representative sample was obtained. Evaluating the slide prior to submission limits
frustration for both the doctor and the client, shortens time to appropriate treatment and
is both time and cost effective. View the sample under 10x powers to ensure the sample
is cellular, contains a lymphoid population if sampling a lymph node, and that cells are
intact. Hemodilution, accidental salivary gland aspiration, crush artifact/DNA streaming
and aspiration of perinodal fat are the most common causes for non-diagnostic
samples.
While the majority of cytological diagnoses can wait to be made by a pathologist,
recognizing mast cell tumors, skin abscesses, lipomas, cysts, suppurative lymphadenitis
and large cell (lymphoblastic) lymphoma on cytology may expedite or negate the need
for treatment.
If cytology is equivocal or does not match your clinical suspicions, histopathology is
recommended. Biopsies can be excisional (intending to remove completely), wedge (if
needed, a wider surgical margin can be obtained) or needle core samples. Many pets
tolerate these procedures with local anesthetic with or without a sedative.
References:
Portions of this information were provided courtesy of John M. Bjorneby, DVM, PhD
Diplomate ACVP (Clinical Pathology)
1
Use of cytology as a diagnostic method in veterinary practice and assessment of
communication between veterinary practitioners and veterinary clinical pathologists. M.
M.
Christopher, et al, JAVMA, Vol 232, No. 5, March 2008
2
http://www.cytopath.co.uk/advicecytology.html
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Strange “Neuro” Cases
Stephen Hanson, DVM, MS, Dip. ACVIM (Neurology)
Stacy Dillard, DVM, Dip. ACVIM (Neurology)
Veterinary Neurology Center
Tustin, CA
In this presentation, we will share some cases we find particularly interesting. Some of these are
examples of unusual neurological conditions and some are only masquerading as neurological disease.
Idiopathic Head Bobbing
Idiopathic head bobbing is a condition of dogs that involves episodes of rhythmic up-and-down (“yes”),
side-to-side (“no”) or bobble type movements. The episodes occur at rest, and do not involve loss of
consciousness. In fact, a dog with head bobbing can oftentimes be “distracted” out of the episode by
showing them something exciting, like a treat or toy. Idiopathic head bobbing can occur in any breed of
dog, but English bulldogs, Doberman pinchers and boxers are over-represented. Dogs with idiopathic
head bobbing usually start the abnormal motor activity at a young age. The frequency of episodes tends
to wax and wane, but the episodes tend to stop occurring as a dog ages.
Idiopathic head bobbing is not a rare condition – You Tube videos of this abound. But, it has received
very little attention in the literature, probably because the condition is poorly understood. It is thought
to be similar to a condition in people called “essential tremor,” which likely involves malfunction of the
stretch reflex mechanism. Idiopathic head bobbing is benign and does not require treatment. Since it
occurs at rest, it does not interfere with normal activities. Furthermore, it does not progress to more
serious problems, such as seizures.
Conditions that can appear similar to idiopathic head bobbing are focal seizures and cerebellarassociated tremors. Focal seizures often involve some impairment of consciousness, and the animal
generally cannot be distracted out of them. They frequently progress to generalized seizures.
Cerebellar tremors are typically exacerbated by movement, so they worsen with activity.
Feline Hyperesthesia Syndrome
Feline Hyperesthesia Syndrome (FHS) manifests as episodes of agitated behavior, often associated with
pupil dilation, crawling movements of the skin, aggressive licking or biting at the flank, back and hind
limbs and abnormal vocalization. Typically these cats have normal brain MRIs, normal CSF and do not
respond consistently to anticonvulsant therapy. Some reports suggest the signs may be caused by a
type of myopathy called inclusion body myositis, although histopathological evidence of this is not
evident in every case. Additionally, it is unclear why a cat with myositis would have such severe episodic
signs.
Other sources of pain and agitation should be ruled out in cats with signs of FHS. Also, since a post-ictal
state can involve agitation resembling what is seen with FHS, owners should watch for generalized
seizure activity, which would indicate a different pathological process. Amitripylene and clomipramine
are helpful in controlling the episodes FHS, although they may still occur in a less frequent and severe
form.
Fibrotic Myopathy
Fibrotic Myopathy is an idiopathic condition that causes a very characteristic lameness. It affects most
commonly the gracillis muscle, but has been reported in semitendinosus, supraspinatous, quadriceps,
infraspinatous, iliopsoas and tensor fascia lata muscle. Dense collagenous connective tissue, as seen on
muscle biopsy, creates a fibrous band that can often be palpated. This fibrous band in the
gracilis/semitendinosus muscle produces a tethering effect, preventing full extension of the limb,
resulting in internal rotation of the stifle and external rotation of the hock with limb advancement and
the characteristic flipping or jerking of the foot. This disorder is seen overwhelmingly in German
Shepherds. The age onset is from 8 months to 9 years and typically is a progressive over weeks.
Medical management has been ineffective and surgery initially dramatically improves the gait; however,
the results are transient and signs recur within months, making long-term success poor. Most dogs
appear unaffected by the lameness and continue to be active. Historically, this disorder was not
considered painful, however one study found pain with hip abduction and palpation of the fibrotic area
in affected dogs, so pain control may be indicated in some dogs.
Aortic Thromboembolism
Aortic thromoboembolic (AT) disease is vastly different in the dog than the cat and therefore may be
under diagnosed in dogs. Though dogs can present acutely paraplegic just like in the cat, a chronic
progressive history (weeks to months) is more common. Unlike in cats, a high percentage of dogs with
AT do not have structural heart disease. AT can be associated hypercoagulable diseases such as protein
losing nephropathy/enteropathy, hyperadrenocortism, hypothyroidism, as well as diseases that affect
the endothelial lining (neoplasia, trauma, hypertension, infection, etc.) Some dogs have no
identifiable concurrent illness at the time of diagnosis of AT. Clinical signs in dogs with AT can vary,
including exercise intolerance, monoparesis, paraparesis and paraplegia. The more severely affected
dogs tend to be those with an acute onset whereas the clinical signs are milder in chronic disease.
Because of this variable presentation both in history and clinical features, a through physical and
neurological examination is important. Common clinical features include: dysfunction in ambulation
(varying degrees), pain with palpation of the pelvic limbs, decreased segmental spinal reflexes (patellar
reflex is reduced or absent) and flaccid paresis. There should be normal tone and function to the tail
and perineum. Femoral pulses can be present or absent, though if present the quality is typically
reduced. Definitive diagnosis is most commonly made by ultrasound however MRI features have been
described. Treatment consists of administration of warfarin (or other anticoagulant) and treating the
underlying cause. Dogs have better long-term survival rates than in the cat, and depending on severity
of signs and underlying cause of AT, aggressive treatment may be beneficial.
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Sarah Beaman, DVM
AVSG After Hours
Chest Tube Placement
In general, an animal presenting with pleural space disease should have radiographs to confirm pleural
space disease. Radiographs allow one to determine which side, if not both, the disease is present in and
if the problem is air, fluid or a mass.
Thoracocentesis should be performed:
1. For stabilization.
2. To help determine if a chest tube is indicated.
3. If there is fluid - to determine the type of fluid and its composition.
The general indications for a chest tube are:
1. Air or fluid that accumulates quickly after a productive thoracocentesis.
 If greater than three taps in a 24 hour period are needed, a chest tube should be
considered.
 If the patient is not able to be stabilized with a thoracocentesis, a chest tube is needed.
 Nota bene: if the volumes of air or fluid are considerably decreasing with each tap, a chest
tube may not be needed.
2. Pyothorax
3. Post-operative thoracotomy
Types of tubes
Chest tube diameter should be the size of the diameter of the mainstem bronchus.
1. Argyle chest tube 8fr (cats/small dogs) to 32fr (large dogs)
2. Red rubber chest tubes: may need to make more holes
3. Mila over-the-wire: early reports are good for removing smaller volumes of air and they may be
placed with sedation. They are unlikely to be helpful with thick fluid.
Placement
Typically done under general anesthesia.
May use a local with a heavily sedated, debilitated patient.
Materials
Have materials out before placing:
Small surgical pack (blade, blade handle, thumb forceps, needle driver, hemostats,
suture scissors)
Sterile chest tube
C clamp
Christmas tree adaptor
3-way stopcock
Procedure
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Sterile technique – clip, prep, drape, sterile gloves
Clip a wide margin
Chest tube should enter at the 8th ICS space
Tunnel under the skin from the 10th ICS space
(a) May pull skin cranially to aid in tunneling after incising at the 10th ICS space
(b) Incise halfway between spine and sternum.
(c) Before inserting tube into the 8th ICS space:
Measure the tube cranially before placement (from skin incision to the area caudal to the
thoracic limb).
Hemostat method (Kelly, Carmalt)
(a) Remove the trocar. Grasp the end of the tube and bluntly dissect through the chest
wall.
(b) Dissect through into the chest cavity, leave the hemostats and guide the tube
through with the trocar. Remove the trocar after advancing the tube into the chest.
Trocar method
(a) Partially incise the intercostal muscles.
(b) Use firm steady pressure to advance the trocar into the chest cavity.
Once the chest is open, breathing will need to be controlled.
Clamp the tube after entering the chest cavity.
(a) Clamping with hemostats may damage the chest tube-use a C clamp.
Feed cranially and ventrally to the point previously measured.
Secure the tube to the skin with a Roman Sandal or Chinese Finger Trap.
Suction the tube, clamp, place the Christmas tree adapter and 3 way stop cock.
Post placement radiographs
Confirm the tube placement, position and effectiveness.
Tube care
E collar and light wrap with gauze at the stoma
Stockinette wrap with gauze at the stoma
Removal
Continuous suction- when negative change to intermittent suction.
Intermittent suction – q 1-2 hours until negative 2-3 times, then q 2-4 hours, etc.
When negative q 24 hours, okay to pull.
With pleural fluid, the body produces 2ml/kg/24 hours, so the tube can be pulled if the amount
suctioned is comparable.
If infectious fluid – check fluid before removing and follow fluid guidelines.
Close the skin incision with sutures or staples.
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Immune Mediated Polyarthritis
Andrea McDooling, BVSc, DACVIM (SAIM)
Ashley Cruse, DVM, DACVIM (SAIM)
NOTES AVAILABLE ON-SITE
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