Volume 18 (2) October 2008
The Official Journal of the Federation of
European Companion Animal Veterinary
Associations (FECAVA).
EDITOR
Dr. Keith Davies
43, Hill Top Road - Newmillerdam
GB-WF2 6PZ Wakefield
Tel.: (44) 1924 250486 (UK)
(33) 4 68 39 50 29 (F)
Fax: (44) 1924 259572
E-mail: kdaviesejcap@compuserve.com
PRODUCTION COMMITTEE
Dr Andrew Byrne, FECAVA President
Dr. Keith DAVIES, Editor
Astrid M. BJERKÅS, Sub-Editor
Dr. Joaquin ARAGONES
Dr. Peter STERCHI
Dr. Denis NOVAK
Dr. Tiina TOOMET
Dr. Johan VAN TILBURG
Dr. Monique MEGENS
Dr Ellen BJERKÅS
EDITORIAL BOARD (FOR NEW WORK)
Dermatology
Didier-Noël CARLOTTI (F)
Cardiology
Anna TIDHOLM (S)
Internal Medicine
Åke HEDHAMMAR (S)
Orthopaedics
Aldo VEZZONI (I)
Surgery
Simon ORR (GB)
Imaging
Ingrid GIELEN (B)
Eiliv SVALASTOGA (DK)
Reproduction
Stefano ROMAGNOLI (I)
Dentistry
Peter FAHRENKRUG (D)
Ophthalmology
Ellen BJERKÅS (N)
Neurology
André JAGGY (CH)
Endocrinology
Mike HERRTAGE (GB)
Oncology
Jane DOBSON (GB)
New Material should be sent to:
Prof. Ellen BJERKÅS,
Norwegian School of Veterinary Science,
PO Box 8146-Dep, N- 0033, Oslo.
E-mail: ellen.bjerkas@veths.no
ADVERTISEMENT BOOKINGS
Sould be sent to: The Editor (see above)
CIRCULATION
All members of the Associations belonging to
the Federation of European Companion Animal
Veterinary Associations receive the European
Journal of Companion Animal Practice as a part of
their membership subscription (26,000 copies).
PURCHASE OF COPIES
For others interested in purchasing copies the
price is 52 € per Volume (2 issues). Payment is only
accepted by electronic transfer in euros.
Orders should be sent to:
FECAVA HQ, rue Defacqz 1, B-1000 Brussels
EDITORS NOTE
The language of EJCAP is English (UK). Where
reprint papers have been translated, or where
other versions of English were originally used, these
have been translated to English (UK).
THANKS
The production Committee of EJCAP thanks:
Dr. Bob Gibbons
Dr. John Houlton
Dr. Tim Hutchinson
who have spent time correcting the translations.
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DISCLAIMER
“The Federation of European Companion
Animal Veterinary Associations and the
Production Committee of the European Journal
of Companion Animal Practice accept no
responsibility for any omissions and/or errors in
information printed in this journal.We specifically
draw readers attention to the need to follow
instructions of manufacturers products. In any
specific situation readers are strongly advised not
merely to rely on the material contained in the
journal. Any views and opinions expressed are
those of the writer and not the Federation or the
Production Committee.”
The European Journal of
Companion Animal Practice (EJCAP)
Contents
The Federation of European Companion Animal
Veterinary Associations (FECAVA)
Editorial
News
GENERAL
Non-domesticated animals kept for companionship: an overview of
the regulatory requirements in Italy to address animal welfare and
human safety concerns
A. Passantino
Clinical Cytology of Companion Animals:Part I Introduction
E. Teske
CARDIOLOGY
Blood Pressure in Small Animals - Part I:
Hypertension and hypotension and an update on technology
A.P. Carr, T. Duke
Case report : mitral valve disease in a large breed dog
E. Bomassi
106
109
113
119
127
135
145
ORTHOPAEDICS
Interobserver agreement in the diagnosis of canine hip dysplasia using
the standard ventrodorsal hip-extended radiographic method
G. Verhoeven, F. Coopman, L. Duchateau, J. H. Saunders, B. Van Rijssen,
H. Van Bree
149
Mandibular fracture in a Lhasa Apso with renal secondary
hyperparathyroidism
P. Roux
157
ENDOCRINOLOGY
Central diabetes insipidus and secondary hypothyroidism associated
with a pituitary macroadenoma in a dog
T. Tejada, V. Lario, J. López-Grado, D. Borras, A. Font
161
DIAGNOSTIC IMAGING
Magnetic resonance imaging features of orbital inflammation with
intracranial extension in four dogs
S. Kneissl, M. Konar, A. Fuchs-Baumgartinger, B. Nell
167
Sonographically detected change of splenic diameter after
medetomidine administration in dogs
M. Pruss, A. Tidholm
173
Magnetic resonance imaging findings in dogs with suspected ischemic
myelopathy due to fibrocartilaginous embolism
V. M. Stein, F. Wagner, C. Bull, A. Gerdwilker, F. Seehusen, W. Baumgärtner,
A. Tipold
176
URINOGENITAL SYSTEM
Urethral sphincter mechanism incompetence in spayed bitches:
new insights into the pathophysiology and options for treatment
I. Reichler, M. Hubler, S. Arnold
PRACTICE MANAGEMENT
The Helsingborg Referral Animal Hospital : A Swedish ‘Foundation’
Practice
A. Vilén
Suicide and the veterinary profession
R.J. Mellanby
Book Reviews
Calendar of main European national meetings and other continuing
education opportunities
Secretariat or address to contact for information
105
187
195
203
207
210
211
The Federation of European Companion Animal Veterinary Associations (FECAVA)
FECAVA Headquarter’s address:
C/O Federation of Veterinarians of Europe
rue Defacqz, 1 B-1000 Brussels
Tel: +32 2 538 29 63 – Fax: +32 2 537 28 28
FECAVA Website: www.fecava.org
Participating Associations:
SKSAVA Slovak Small Animal Veterinary Association
Director: Dr. Igor KRAMPL
SASAP Serbia Association of Small Animal Practitioners
Director: Dr. Denis NOVAK
SSAVA Swedish Small Animal Veterinary Association
Director: Dr Alexandra VILÉN
SVK/ASMPA Schweizerische Vereinigung für Kleintiermedizin/Association
Suisse pour la Médecine des Petits Animaux
Director: Dr. Peter STERCHI
SZVMZ Slovensko Zdruzenje Veterinariev Za Male Zivali
Director: Dr. Bojan ZORKO
TSAVA Turkish Small Animal Veterinary Association
Director: Dr. Akif DEMIREL
USAVA Ukrainian Small Animal Veterinary Association
Director: Dr. Vladimir CHARKIN
VICAS Veterinary Ireland Companion Animal Society
Director: Dr. Peter A. MURPHY
VÖK
Vereinigung Österreichischer Kleintiermediziner
Director: Dr. Silvia LEUGNER
AFVAC Association Française des Vétérinaires pour Animaux de
Compagnie
Director: Dr. Jean-François ROUSSELOT
AIVPA Associazione Italiana Veterinari Piccoli Animali
Director: Dr. Giuseppe TRANCHESE
APMVEAC Associação Portuguesa de Médicos Veterinários Especialistas
em Animais de Companhia
Director: Dr. José H. DUARTE CORREIA
AVEPA Associación de Veterinarios Españoles Especialistas Pequeños
Animales
Director: Dr. Xavier MANTECA
BASAV Bulgarian Association of Small Animal Veterinarians
Director: Dr. Boyko GEORGIEV
BHSAVA Bosnia and Herzegovina Small Animal Veterinary Association
Director: Dr. Josip KRASNI
BSAVA British Small Animal Veterinary Association
Director: Dr. Ian MASON
CSAVA Czech Small Animal Veterinary Association
Director: Dr. Jiri BERANEK
CSAVS Croatian Small Animal Veterinary Section
Director: Dr. Davorin LUKMAN
DSAVA Danish Small Animal Veterinary Association
Director: Dr. Hanne WERNER
ESAVA Estonian Small Animal Veterinary Association
Director: Dr. Tiina TOOMET
FAVP
Finnish Association of Veterinary Practitioners
Director: Dr. Kaj SITTNIKOW
GSAVA German Small Animal Veterinary Association
Director: Dr.Dr. Peter FAHRENKRUG
HSAVA Hungarian Small Animal Veterinary Association
Director: Dr. Ferenc BIRÓ
HVMS Hellenic Veterinary Medical Society
Director: Dr. Katerina LOUKAKI
LAK
Letzebuerger Associatioun vun de Klengdeiere - Pracktiker
Director: Dr. Katia DI NICOLO
LSAPS Latvian Small Animal Practitioners Section of The Latvian
Association of Veterinarians
Director: Dr. Lita KONOPORE
LSAVA Lithuanian Small Animal Veterinary Association
Director: Dr. Saulius LAURUSEVICIUS
MASAP Montenegro Association of Small Animal Practitioners
Director: Dr. Predrag STOJOVIC
MSAVA Macedonion (Fyrom) Small Animal Veterinary Association
Director: Dr. Marin VELICKOVSKI
MVA
Malta Veterinary Association
Director: Dr. L. VELLA
NACAM Netherlands Association for Companion Animal Medicine
Director: Dr. Monique MEGENS
NSAVA Norwegian Small Animal Veterinary Association
Director: Dr. Kjetil DAHL
PSAVA Polish Small Animal Veterinary Association
Director: Dr. Roman ALEKSIEWICZ
PVA
Pancyprian Veterinary Association
Director: Dr. Yiannis STYLIANOU
RSAVA Russian Small Animal Veterinary Association
Director: Dr. S. SEREDA
SAVAB Small Animal Veterinary Association of Belgium
Director: Dr. J. van TILBURG
Associate Associations:
ECVD
European College of Veterinary Dermatology
Contact: Dr. Dominique HERIPRET
ECVS
European College of Veterinary Surgeons
Contact: Monika GUTSCHER
ESAVS European School for Advanced Veterinary Studies (A part of the
European Association for Veterinary Specialisation (EAVS))
Contact: Dr. Hans KOCH
ESVC
European Society of Veterinary Cardiology
Contact: Dr. Nicole VAN ISRAËL
ESFM
European Society of Feline Medicine
Contact: Claire BESSANT
ESVCE European Society of Veterinary Clinical Ethology
Contact: Dr. Sarah HEATH
ESVD
European Society of Veterinary Dermatology
Contact: Dr. Aiden FOSTER
ESVIM The European Society of Veterinary Internal Medicine
Contact: Dr. Rory BELL
ESVN
European Society of Veterinary Neurology
Contact: Dr. Jacques PENDERIS
ESVOT European Society of Veterinary Orthopaedics & Traumatology
Contact: Dr. Aldo VEZZONI
EVDS
European Veterinary Dental Society
President: Dr. Olivier GAUTHIER
EVSSAR European Veterinary Society for Small Animal Reproduction
Contact: Dr. Gaia Cecilia LUVONI
FECAVA Officers:
Dr. Andrew BYRNE
Dr Johan van TILBURG
Dr. Simon ORR
Dr. Jerzy GAWOR
Eire
Belgium
UK
Poland
President
Vice-President
Secretary
Treasurer
Advisor to the board:
Dr. Dr. Ellen BJERKÅS
Norway
Senior Vice-President
Dr. Keith DAVIES
106
EJCAP Editor
Editorial
Pets in Society – can FECAVA help promote animal based projects to
improve recovery rates in sick children?
A group of psychologists posed the question “what is love” in order to explore the ways in which children of 4-8
years of age expressed love. Anna, a five year old girl, was shy and hesitated to answer such a question. Suddenly
however her face brightened up and she said: ‘Love is when I come home and my dog jumps on me with joy,
although I have left him alone the whole day’.
Anna with her innocent answer described an obvious fact, which many researchers have tried to investigate by
asking the question ‘Do pets have a social contribution or they are just another hobby?’
Scientific research repeatedly shows that contact with any species of animal contributes to an
improvement of the social behavior of children, to their balanced development, to the improvement of
their apprehension and to their cognitive abilities. Their capability to understand the function of their
surrounding environment is also improved.
The modern way of life in big cities, the structure of the family and hard social conditions all create an
environment in which children often have difficulty to adjust. The quality of their life is often not ideal and very
often intellectual and emotional problems can arise.
The situation can become even more difficult when children suffer from chronic health problems such as cancer,
heart diseases, diabetes, musculoskeletal conditions and psychiatric disorders. They experience not only the
symptoms of their disease but other consequences too: they have to stay in the hospital, away from their family
for long periods of time; they have to tolerate numerous diagnostic procedures and treatments, some of which are
painful and give rise to side effects.
The quality of life of these children is poor and scientists are always searching for ways to reduce the stress that
these children are experiencing, because they have observed that, when stress is reduced, children respond better to
their treatment and present a better therapeutic prognosis.
Researchers are now trying to investigate the possible influence that pets have during the hospitalisation period
of children who are suffering from cancer. Research to date has showed a very positive influence. There is a
reduction of anxiety and frustration and the secretion of dopamine, cortisole, oxytocin, prolactin, endorphins and
phenylethylamine are lowered.
Other research concludes that the presence of pets in pædiatric hospitals has a positive effects, not only on the
children, but also on the adults who accompany them.
The majority of research on the influence of animals in the development of children in general, and especially on
children who suffer from chronic health problems, has been conducted in the USA, Canada, and Australia but only
rarely in European countries.
FECAVA has demonstrated a high level of social sensitivity by supporting public awareness projects such as “The
Blue Dog”. It would be very worthwhile if FECAVA could coordinate and support “Animal Assisted Therapy”
projects in different European countries. The aim of these projects would be to improve the quality of life of children
in as many pædiatric hospitals and other children’s institutions as possible. Through such a project we would have
an opportunity to emphasise another important role of pets in our society particularly in the lives children..
The conclusions drawn from these projects would hopefully give veterinarians, who work with companion
animals, useful scientific information about the role of pets in the lives of children. It would enable them to be
proactive in cooperating with pædiatricians, psychologists, teachers and parents.
Let’s take action!
Katerina Loukaki, DVM,
General Secretary of HVMS, Director of FECAVA
109
FECAVA NEWS
EJCAP - Vol. 18 - Issue 2 October 2008
FECAVA NEWS
FECAVA supports continuing education courses
Every year FECAVA gives financial
support to some of its member
associations in order to help them
organise high quality CE (continuing
education) opportunities for their
individual members.
In 2008 the following countries will
benefit from the FECAVA CE programme:
Bulgaria, Estonia, Lithuania, Latvia,
Slovenia, Serbia, Montenegro, Poland and
the Former Republic of Macedonia. Each
association will receive € 1900 from
FECAVA.
From the time FECAVA came into being in
1990, promoting Continuing Education has
been one of the key aims of the Federation.
Every year FECAVA supports CE courses organised by some of its member associations.
This picture was taken at the FECAVA Dermatology CE course in Eretria close to Athens,
Greece some years ago.
In the early years, FECAVA CE courses
were organised from time to time in
co-operation with member countries. At
the Council meeting in April 2000, it was
agreed that FECAVA should also assist
CE in deserving countries in a slightly
different way, by sponsoring a speaker at
an existing national congresses
This strategy was so successful that the
FECAVA CE Courses became less and less
important and it was finally agreed at the
2006 Council meeting in Prague that we
should no longer sponsor complete
courses.
FECAVA is now seeing that some of the
newer European countries no longer
require these grants as their meetings are
self-funding and very successful – a very
satisfying indication of the impact of the
initiative. However, even in the present
challenging economic climate, FECAVA
remains committed to helping member
associations supply high quality CE to its
individual members.
Astrid Bjerkås
Executive Assistant to FECAVA
The Danish Small Animal
Veterinary Association
celebrates its 50th
anniversary
On behalf of FECAVA I would like to
send a warm birthday greeting to
everyone in the Danish Small Animal
Veterinary Association (DSAVA) on the
occasion of their 50th anniversary. This is
indeed a very important moment for an
association and I am sure it will be full of
many special memories both of
challenges and achievements.
DSAVA is one of the founding members
of FECAVA and has always been a very
active contributor and solid supporter of
FECAVA activities. Eiliv Svalastoga
played an important role in the
foundation of FECAVA. In more recent
years I had the pleasure of serving with
Jørgen Mikelsen who was a great friend
of FECAVA and who represented DSAVA
for a decade both as the Danish director
and also as a member of the FECAVA
financial advisory committee. This year
Jørgen retired from the FECAVA Council
and has passed on the mantle to Hanne
Werner.
The DSAVA is recognized throughout
Europe as a strong and highly organized
association that promotes the very
highest standards of veterinary practice.
DSAVA together with the Danish
Veterinary Nurses Association and the
Kolding Institute have been very active in
the development the veterinary nursing
education and accreditation of nursing
schools in Europe. This is just one
example of the vision and proactive
culture of the DSAVA.
May we in FECAVA offer DSAVA our
congratulations and our best wishes for
the next 50 years!
113
Andrew Byrne the FECAVA President
congratulates the Danish Small Animal
Veterinary Association.
FECAVA NEWS
Ireland pulls it off with a Triple Gold!
Scientific, social and ceremonial- The Dublin FECAVA/WSAVA/ VICAS Congress has it all !
When the bid made by VICAS (The
Veterinary Ireland Companion Animal
Society) to host a FECAVA Eurocongress
/WSAVA Congress was accepted,some
were sceptical as to how so small an
Association (400 members) could possibly
put on such a prestigious event. After all,
most European and World congresses
rely on home veterinarians for 85% of the
attending delegates. We were all
astounded on arriving at the Opening
Ceremony to see 2000 people, packing a
large Hall, and to hear that the number of
paying delegates had already exceeded
2500!
David Lloyd receives the FECAVA Prize for his paper in EJCAP FECAVA Dealing with
MRSA in companion animal practice’ from FECAVA Keith Davies, Editor EJCAP.
Ciara Feeney, President of Veterinary Ireland
seamlessly MC’s the Opening Ceremony.
The Opening Ceremony set the tone for
the Congress in many ways, and it was
not long before those attending realised
what a wise choice they had made in
deciding to come to Dublin to what
everyone agreed was one the most
memorable Congresses for many years.
The ceremony proceedings were
orchestrated by Ciara Feeney, President
of Veterinary Ireland. It was so refreshing
to have ‘one of us’ as MC rather than a
professional outsider.
The electric Ceili then had the audience enthralled with their music,
song and dance.
Nicola Neumann, the Congress
Chairperson set things off to a good start,
welcoming delegates and declaring the
Congress open. She paid tribute to the
many people who had ensured the
success of the Congress. I found it very
appropriate that Des Thompson, a Vet
from the north of Ireland was mentioned.
The Leprechaun’s hat, carried all over
Europe and the World by Des when
promoting the Congress was thrown in to
the audience, endowing the person who
Carl Osborne receives the WSAVA/ Hills Excellence in Veterinary
Healthcare Award.
114
EJCAP - Vol. 18 - Issue 2 October 2008
The presentation of the WSAVA/ Hills
Excellence in Veterinary Healthcare Award
to Dr Carl Osborne was very special. Carl
climbed onto the podium clearly with a
disability, straightway explaining this with
words we will all remember. ‘You can see,
I’ve got Parkinson’s Disease but
Parkinson’s disease hasn’t got me’. He went
on to outline his lifelong and continuing
dedication to his work. ‘What we do for
ourselves dies with us, but what we do for
others lives on’. As you can imagine this
award received a prolonged standing
ovation. It was a moment few of us will
forget.
The evening continued in the sunny
outdoor Arena where we enjoyed canapés
and wine whilst watching a display of
Irish dog breeds, sheepdog trials,
equestrian displays and a most
interesting and unusual duck herding
demonstration.
All this was only the start of a congress
packed with an excellent 8 stream
scientific programme and exciting social
events. The scientific programme
included the FECAVA Lectures and the
FECAVA Symposium on Suicide in the
profession. More of these two items will
be featured as papers in EJCAP (the first
in this issue p. 202).
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115
CAVA
FE
The Presidents of FECAVA, WSAVA and VICAS hosted a
spectacular Gala Dinner at the University college, Dublin Campus.
CAVA
,ECTURE ROOMS
The 8 stream scientific programme was second to none.
FE
The Presidents of FECAVA and WSAVA
Drs Andrew Byrne and Brian Romberg
addressed the meeting followed by the
presentation of the FECAVA Award for
the best paper in EJCAP. This was
presented to Dr David Lloyd for his paper
‘Dealing with MRSA in companion
animal practice’.
The ‘Electric Ceili’ then had the audience
enthralled for 20 minutes with their
music, song and dance. One could have
been forgiven for thinking the
presentation of the WSAVA Awards
would be an anticlimax. Not so, awards
to Dr. David Bennett (The WSAVA/Hills
Award for Pet Mobility), Dr. Marian
Horzinek (WSAVA/Intervet International
Award for Service to the Profession), Dr.
Peter F Moore (WSAVA/WALTHAM
Scientific Achievement Award) each
proved to have been given for work of an
outstanding nature .
CAVA
FE
caught it with a special share of good
luck. A song from Belfast, performed later
by the ‘Electric Ceili band’, further
emphasised the unity of the profession in
the whole of Ireland.
1200 delegates enjoyed a Grand Ceili and party in the Historic
Trinity College.
CAVA
FE
A most interesting and unusual duck herding demonstration.
FECAVA NEWS
FECAVA Congress 2011 to
be in Istanbul
At the FECAVA Council meeting in Paris
in April, it was decided that the Turkish
Small Animal Veterinary Association
will host the 17th FECAVA European
Congress in 2011. The Congress will take
place in Istanbul.
But don’t forget the 2010 FECAVA Congress
to be held in Geneva June 2nd -5th
Have you read the EJCAP special issue
on ophthalmology?
The European Journal of Companion
Animal Practice (EJCAP) has recently
published a special issue on ophthalmology EJCAP 17(3). The articles were written
by some of the leading ophthalmologists
in Europe, and are targeted at the general
practitioner as well as the specialist.
Among the papers, you will find a
step-by-step introduction to how to
examine the canine and the feline eye.
The EJCAP special issues are online
issues only. Log on to www.fecava.org
and download the articles free of charge.
The topic of the EJCAP special issue in
2008 will be Zoonosis.(EJCAP 18(3) In
2009 it will be Dermatology. (EJCAP 19(3).
These issues are published at the end of
each year.
Astrid Bjerkås
Sub Editor of EJCAP
responsible for the special issues
Log on to www.fecava.org and download the
articles free of charge if you still have
not read the EJCAP special issue on
ophthalmology. (Photo: Courtesy of Pixelio.de)
UEVP NEWS
The Economic impact of companion animals in Belgium
The results of a study commissioned by the
UEVP and undertaken by the students of the
Solvay School of Commerce, Université Libre
de Bruxelles
In 2004 it was estimated that there was in
Belgium a pet population of 1.064 million
dogs, 1.9 million cats, 3 million birds, 4.5
million fish and 1 million other pets
(guinea pigs, hamsters, mice, etc.). In
reality, we now know that the number of
dogs in Belgium was in fact 1.500 million.
This study relates to the cash flow
estimated on the basis of national
household expenditure and turnover of
the studied economic sector’s main
companies. Several facts and figures
regarding employment creation are
presented.
Different sectors have been analysed and
the results are as follows:
Breeding
It is estimated that there is a turnover of
€ 37.20M in this sector .This takes into
account only declared income and it is
very likely that many amateurs do not
declare their income.
Pet Food production:
The majority of pet food consumed in
Belgium is imported from France and
Holland. In spite of this, it is estimated
that food produced in Belgium costs €
62.85M . With regard to the distribution
of pet food, the turnover amounts to a
total of € 458.72M, of which €194.10M is
for dogs, €198.10M for cats and €66.52M
for the other species.
Accessories for pets
This also represent a significant activity
sector generating € 93.68M is It should be
noted that this sector is undergoing very
116
strong growth at over 15% per year.
Veterinary drugs
It is estimated that € 60M is spent on
drugs for pet use. 300 people in Belgium
are employed in this sector.
Equipment, it has not been possible to
obtain a sufficiently precise estimate of
turnover in this sector.
Veterinary care for pets
This generated € 190M in 2004 and
employed 1,220 veterinarians caring only
for pets and an additional 800 with a
mixed activity. This figure has been
increasing sharply, and the estimates for
2006 were € 250M.
Other services
Other services such as grooming, dog
training, insurance, shows, cremation
EJCAP - Vol. 18 - Issue 2 October 2008
services, animal boarding etc. have also
been estimated. Collectively these
generate a turnover of over € 50M.
Summary
In total, activities linked to pets
generated a turnover of € 1,473M in 2004
and employed over 8,000 people.
Globally, activities linked to pets are
thought to be to be undergoing significant
growth. It would certainly be interesting to
undertake similar studies in different
European countries, as this type of activity
undoubtedly plays quite a significant role
on an economic and social level. It would
therefore be useful to find out more from
both the national and European authorities.
Marc Buchet Treasurer UEVP
Turnover (M€)
Companies
Employees
Breeding
41,33
390
743,5
Food production
62,85
88
400
Food distribution
538,85
3226
2608
Pet Accessories
119,84
899
602
Veterinary medicines &
material
60
30
300
Veterinary care
190
2000
2500
Miscellaneous services
More than 40
More than 1700
More than 2000
No relevant data
No relevant data
No relevant data
Other activities
More than 7
No data
More than 50
Total
More than 1.050
More than 7.500
More than 8.000
Insurance
Hill’s Pet Nutrition
and WSAVA Celebrate
Sponsorship Partnership
Diagnosis of Canine and Feline Liver
Disease), and the WSAVA News Bulletin
on www.wsava.org.
Recently, Hill’s Pet Nutrition and the
WSAVA celebrated a new financial pledge
as part of their joint partnership towards
providing better veterinary health care
across the globe. Hill’s has agreed to
provide a long-term grant of more than
$1.8 million (approx €1.2 million)to aid
WSAVA in areas such as the WSAVA
Congress, WSAVA Global Continuing
Education, WSAVA Disease
Standardization Groups (which included
the recently published book titled
Standards for Clinical and Histological
In addition to this new financial
initiative, Hill’s is pleased to continue to
provide support for other award
programmes like:
• WSAVA/Hill’s Excellence in
Veterinary Health Care Award
• WSAVA/Hill’s Pet Mobility Award
WSAVA GI Standardization
Group Updates
This hard-working WSAVA
Standardization Group has seen three
Pictured during the sponsorship celebrations are (from left to right): Dr. David Wadsworth,
WSAVA President Elect; Neil Thompson, President, Hill’s Pet Nutrition, The Americas;
Dr. Hein Meyer, Director of Strategic Initiatives, Hill’s Pet Nutrition; Dr. Brian Romberg,
WSAVA President and Professor Jolle Kirpensteijn, WSAVA Vice President.
117
major accomplishments from its work:
• Histopathological Standards for the
Diagnosis of Gastrointestinal
Inflammation in Endoscopic Biopsy
Samples from the Dog and Cat: A
Report from the World Small Animal
Veterinary Association
Gastrointestinal Standardization
Group. J Comp Path 2008;138:S1-S44
• Standardized GI Endoscopy Reporting
Forms available at www.wsava.org
• Invitation by the ACVIM to develop of
a Consensus Statement on
Inflammatory Bowel Disease (IBD)
WSAVA Members in the
News
At the American Animal Hospital
Association conference in Tampa, Florida
in March of this year, two well-known
WSAVA members were recognized for
the ongoing contributions to the
veterinary profession:
Hill’s Animal Welfare and Humane Ethics
Award, Roger Clarke
Royal Canin Veterinary Diet Award, Larry
Dee
Congratulations to both for these
well-deserved accolades.
For more information on the WSAVA and
its many activities in global continuing
education – including the recently held
Dublin World Congress, global small
animal welfare, and many other
committee initiatives and projects, visit
us at www.wsava.org.
FECAVA NEWS
Fiftieth Jubilee Anniversary of DSAVA
I am proud to be the chairman of the
DSAVA this year, as we celebrate our
fiftieth jubilee year.
Many things have taken place during the
last fifty years.
Important things have been discussed,
and no doubt new subjects for discussion
will turn up in the future.
Practice standards
In Denmark, as other European countries,
many clinics attain a certificate of
proficiency. To gain this certificate clinics
need to demonstrate that they have
manuals describing their different working
routines such as handling of the clients,
staff, continuing education and so on.
In co-operation with DNV ( Danak
Nordic Veritas ) the DSAVA try to
encourage as many clinics and Veterinary
Hospitals as possible to gain the
proficiency certificate issued by DNV.
Nowadays, and increasingly in the
future, many of vets will specialise. This
will mean that some clinics will become
referral centres.
Almost every clinic in Denmark has its
own website.
The ‘Blue Dog’ project
The board of DSAVA have put a lot of
effort into this project. We think it is
essential to have the small animal vet as a
central figure in this campaign. The
project was particularly designed for
children at the from 3 to 6 years old, but it
enables vets to make lots of useful
contacts with different branches of
society.
The DSAVA intends to lead the way- And
where does this way lead?
• At the moment it seems that most
newly graduating veterinarians are
females. Is this acceptable or do we try
to change things?
• In the last decade there has been a lot
of attention given to pets. Should we
try to create a health service for our
pets like the health service available to
human beings? We are not sure that
the government would want to bear
the expenses of pet care, but we might
be able to promote insurance that up
to 95% of the pet owners would
welcome.
• A new type of health service for pets
could well result in the development
of specialised hospitals. The local vet
would be the person who has the first
contact to the owners, often then
referring them to specialist vets or
hospitals.
• We may even have “veterinary
dentists”, specially trained rather like
the human dentists.
• In the future there will certainly be a
lot of challenges .It is a pleasure to work
with the present excellent and active
DSAVA Board and I am confident that
we can meet the challenges ahead. My
best wishes to the DSAVA association
Jan Birch, President of the DSAVA
GENERAL
ORIGINAL WORK C
Non-domesticated animals kept for
companionship: an overview of the
regulatory requirements in Italy to
address animal welfare and human
safety concerns
A. Passantino (1)
SUMMARY
The keeping of non-domesticated species (NDSs) (i.e. fish, amphibians, reptiles, birds and small mammals) as
companion animals in Italy has recently increased. A analogous trend has been apparent also in many other developed
countries around the world.
Nevertheless, each species has its own welfare requirements and the challenges of keeping NDSs in high standards of
welfare may often be greater than those of keeping more traditional companion animals.
From the point of view of welfare, it is not possible to make a simple distinction based solely on whether or not an
animal is domesticated. In fact, it is well-known that there is likely to be variation among the wide range of species for
awareness of sensory inputs or cognitive states and thus in capacity to suffer.
From another point of view, NDSs kept as companion animals can be a source and/or carriers of infectious diseases
to humans.
The Author makes an overview on the keeping of NDSs as companion animals in an attempt to identify the possible
benefits and disadvantages, with particular regard to the issues of animal welfare and the regulations in Italy.
Key words: Non-domesticated animals, companionship, animal welfare, legislation, five freedoms.
Introduction
15,800,000 were fish and 1,400,000 other animals (turtles,
reptiles, amphibians, etc.) [3].
Some species have been bred for many generations in captivity;
others have not been kept as CAs until very recently; there are
significant importations of wild-caught marine fish, reptiles and
amphibians and birds.
Drawing a line between domesticated and non-domesticated
animals is very difficult. Generally, domestic animals (ferae
domitae) are defined as animals that are habituated to live in or
about the habitations of men, or that contribute to the support
of a family.There is a continuum in the degree of domestication
The companion animal industry has changed rapidly over the
last century and many of the species currently popular are very
recent introductions.
In particular, very large numbers of species of non-domesticated
animals (NDAs), or so-called exotic pets or companion animals
(CAs), are kept by private owners in Italy. A similar trend has
been apparent also in many other developed countries around
the world (see, for example, UK and USA) [1,2].
In 2002, EURISPES estimated that about 44,100,000 animals
were kept as pets in Italy, of which some 12,100,000 were birds,
(1) Department of Veterinary Public Health, Faculty of Veterinary Medicine, Polo Universitario Annunziata, I- 98168 MESSINA
E-mail: passanna@unime.it
119
Non-domesticated animals kept for companionship - A. Passantino
The species most commonly kept are parrots, iguanas, snakes,
tropical fish, a variety of turtle species and small mammals, e.g.
hamster, rabbit, ferret and guinea pig.
It is recognized that companion animal ownership can be beneficial
to owners, but the practice of keeping of NDAs for companionship
has been questioned, based on concern for their welfare.
The needs of some species are relatively easy to meet but
those of others present considerable challenges if high welfare
standards are to be achieved.
How an animal is viewed in the eyes of
the law
In recent years, human-animal relationships have represented
a crucial issue for governments, international institutions and
scientists. The European Union re-defines the legal position of
animals, so that they are considered not just as human property,
but rather as sentient beings [4].
In particular the recognition of animal dignity as sentient beings
is contained in the Protocol on Animal Protection and Welfare,
attached to the final act of the institutive Treaty of the European
Union, approved in Amsterdam in 1997, which demonstrates
how strongly the need for animal safeguard and welfare is
perceived by the EU Members.
In the past, the spirit of animal protection laws mainly defended
human interests. Conversely, more recent laws seem to display
a greater concern for animal rights. In this context, the scientific
attention to animal life has focused predominantly on animal
welfare, dealing with the psychological [5,6] and relational
features of animal well-being [7].
In contrast, despite the increased concerns about animal rights in
human society, the legal status of non-human beings still remains
an open question in many countries [8], where established legal
doctrine classifies animals as property [9,10,11,12].
The property status of animals is in direct conflict with the
notion that they are sentient and emotive beings.
This juridical “dichotomy” depends predominantly on reasons
which are more frequently “cultural”, rather than scientific or
philosophic.
In this context, Tischler (2002) stated that “ …For many people
in our society, the concept of legal rights for other animals is
quite “unthinkable”. That is because our relationship with the
majority of animals is one in which we exploit them: we eat
them, hunt them and use them in a variety of ways that are
harmful to the animals. ...Animals are not “things” and a legal
system which treats them as mere property is intrinsically flawed”
[13]. Furthermore, the juridical tradition does not acknowledge
qualities which are specific to humans are also specific to nonhuman beings, and frequently the expression “animal rights” is
considered a “metajuridical” concept.
In fact, once man used to place himself in a position of separation
with what was thought different from himself - animals first of
all. This was not necessarily an attitude of hatred or cruelty, but
it meant that the individuality of the various species was taken
into consideration only in utilitarian terms, even when such
usefulness was not really economic.
A good relationship often develops between domesticated and non
domesticated companion animals.
from species that have never bred under human stewardship to
those that have done so for thousands of generations.
With this review the author: 1) discusses the lack of specific
laws and/or regulations with regard to keeping NDAs as
companion animals in Italy; 2) gives some information on the
practice of keeping NDAs for companionship, and 3) suggest
recommendations intended to promote high standards of
welfare, where such a need has been identified. Because
of the very great number and diversity of species kept for
companionship, it has not been possible to undertake a detailed
review of the welfare implications for individual species.
A note on terminology
Before delving into the substantive issues, one caveat should be
made regarding the terminology used throughout this review.
The term CAs instead of wild could be used as the preferred
term to include all those animals kept by private individuals for
companionship or hobby and to reflect the changes in perception
of the relationships people have with NDAs. In fact, the word
‘wild’ can imply lack of tameness and this is not the meaning
we intend. Some species of ‘wild’ animals, especially if captivebred and reared by or in proximity to humans, can become very
tame. I also considered using the term ‘exotic species’ but strictly
this refers to non-indigenous species only, and the intention
was that this review should apply to both indigenous and nonindigenous species.
I recognise, however, that defining precisely what ‘nondomesticated’ means in the context of animals kept for
companionship is not straightforward, and any attempt to make
a clear distinction between domesticated and non-domesticated
animals is bound to be problematic.
Generally, criteria for choosing an ideal animal include the ease
and cost of keeping it to a high standard of welfare and, for many
potential owners, the time and technical commitments required
to achieve this. For many people, animals that need little space
are preferable to those that require a very large enclosure or a
lot of exercise. Some NDAs may meet these criteria better than
some domestic species.
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EJCAP - Vol. 18 - Issue 2 October 2008
Regulations relating to non-domesticated animals kept for companionship
A variety of laws regulate aspects of the importation, transport,
retailing and keeping of domestic animals; international treaties
regulate trade in certain animal species. In particular, the
Convention on International Trade in Endangered Species of
Wild Fauna and Flora (CITES, Secretariat 1973) [14] regulates
international trade in species of conservation concern, which are
or may be affected by trade. It does not regulate domestic trade
or require Parties to protect habitat.
The Parties assess a species’ vulnerability and determine in which
of three appendices to place the species. CITES prohibits all trade
for “primarily commercial purposes” in species in Appendix I,
which includes species that “are threatened with extinction and
are or may be affected by trade.” Because of the significant role
that trade has played in driving some species toward extinction,
the Parties have interpreted “primarily commercial purposes”
very broadly to include “any transaction that is not wholly noncommercial”. Because most trade in many species includes a
commercial component, an Appendix I listing effectively halts
all legal trade in that species.
For Appendix II species, those species that may become
threatened, trade is permitted provided the trade will not be
detrimental to the survival of the species. Species are listed in
Appendix III solely on the basis of a decision by the country of
origin, and this carries only minor trade restrictions.
Farmed wild animals and those kept in zoos or for research are
protected by specific legislation that has mechanisms for setting
and updating standards for welfare. In England there are e.g.
Welfare of Farmed Animals Regulations, 2000; Zoo Licensing
Act, 1981; Animals (Scientific Procedures) Act, 1986; in Italy
there are Decreto Legislativo (D.Lvo) no. 73 of 21 March 2005
and D.Lvo no. 192 of 04 April 2006, relating to the keeping of
wild animals in zoos.
The preamble to the Council of Europe’s Convention for the
Protection of Pet Animals (1987, ETS No. 125) sets out the
considerations that underpin its provisions. These include: “the
importance of pet animals in contributing to the quality of life
and their consequent value to society”, and “the keeping of
specimens of wild fauna should not be encouraged”.
The Convention therefore generally regards the practice of
keeping companion animals positively, but this attitude does not
extend to circumstances in which wild animals are kept.
In USA concerning keeping/private possession of NDAs the
regulations vary from state to state [15].
While some states have a complete ban on NDAs, other states
simply require permits for their possession, and some states
have no regulations whatsoever.
In Italy, for example, two ministerial decrees [16,17] bans the
keeping of some species (i.e. genere Varanus, Pithon reticulates,
cobras, Chelydra serpentine, Macroclemmis temminchi, all
species belonging to the family Crocodylidae, etc. - attachment
A) that are deemed dangerous and unsuitable as CAs. The
Decrees define “wild animal” broadly: the term wild animal shall
mean any mammal, amphibian, reptile or fowl of a species that
is wild by nature and that, because of its size, vicious nature or
other characteristics, is dangerous to human beings.
At local level some regions (i.e. Veneto, Piedmont, Marches,
Two loving friends: a dog and a black-tailed prairie dog (Cynomys
ludovicianus).
etc.) and cities (i.e. Milan, Alessandria) have adopted ordinances
(decisions made by municipal governments).
Specifically Region Veneto has implemented measures taken
to ensure that possession, breeding and trade for exotic animal
were respected (D.G.R. no. 3882 of 31 December, 2001) [18].
At present, there is no corresponding legislation in Italy that
provides a mechanism for establishing detailed standards for the
welfare of NDAs kept as CAs.
Consequently, specific recommendations concerning the welfare
of NDAs are lacking or limited.
In absence of common criteria and guidelines, it is possible to
make reference to the well-known “five freedoms” [19].
A non-domesticated animals welfare
and five freedoms
There are conditions of an animal’s life for which society, science
and the legislator can establish requisites of welfare, after having
identified physiological and ethological requirements.
The concept of welfare is particularly relevant in the relationship
between man and animals, where it is necessary to define the
best conditions for the environment, feeding and utilization of
animals. In fact, where captive environments do not adequately
meet animal’s needs, welfare will be compromised and diseases
may occur.
Knowledge of the requirements of even the commonly kept
species of domesticated animals is at present incomplete, and
it is therefore inevitable that there remain many gaps in our
knowledge of the needs of NDAs kept as CAs.
Reference should take account of five basic principles which
owners and managers should use to guide their animal
management practices.
In this context, the interpretation of the words shall, must and
should is as follows: shall means there is a statutory requirement;
must indicates a minimum standard; should denotes a strong
recommendation.
i) Freedom from thirst, hunger and malnutrition - by ensuring
ready access to fresh water (except for those animals for which
121
Non-domesticated animals kept for companionship - A. Passantino
access to fresh water would be harmful) and a diet appropriate
to maintain full health and vigour.
The satisfacton of needs for food and water are essential for
life.
Incorrect feeding is more often encountered than starvation,
as many lay owners have no idea what is a suitable feeding
regimen for NDAs.
Water is essential for all body functions. Whenever possible,
that is when not working, exercising or travelling, the animals
must have ready access to clean water at all times, particularly
in hot weather. The water should be potable and cool. The
food offered should be sufficient in amount and appropriately
balanced in nutrients to meet their physiological needs. NDAs
shall be fed to maintain their body weight within the normal
physiological range, no matter how much physical activity they
have. Ideal body weight depends on species, breed and age.
The veterinarian may be the only knowledgeable person to see
these animals, and it is his task to educate owners about suitable
feeding regimes.
New World primates, for example, need dietary sources of
vitamin D3; and many carnivorous birds and reptiles are likely to
need fresh whole mice or rats to eat.
ii) Freedom from physical and thermal discomfort means
provision of appropriate comfort and shelter - by providing an
appropriate environment (i.e. for foraging, resting, sleeping,
exercise, etc.), including shelter and a comfortable resting area.
Also important are ventilation, humidity, quality of water (in
ornamental fish) [20], sites for resting and/or hiding, structure
of the floor and of rocks, and branches for climbing activities.
Hygiene is also an important aspect because poor hygiene often
is directly related to problems.
Many species require very specialized housing; reptiles, for
example, need appropriate heat sources and lights that meet
their requirements for certain wavelengths of ultraviolet [21].
The above points are important because many health problems
in animals are related to management and feeding. Research
indicates that animals that are well treated and able to behave
naturally are healthier than animals treated badly. Continuous
physical stress on animals (e.g. from their housing conditions)
affects not just their behaviour but their physiology, and can
result in pre-pathological or even pathological states. Various
pathogens (microbes, viruses, parasites) that do not lead to
illness under good husbandry conditions can become more
aggressive, proliferating and causing disease in animals after
transport. Good management is a prerequisite for the better
performance of animals.
A large number of husbandry problems, e.g. in reptiles, lead
to pathophysiological situations. Simpson underlines that
inappropriate husbandry can result in an increasing incidence
of the diagnosis of hepatic lipidosis in some species of snake
[22]. Assessment of the husbandry problems of reptiles
involves detective work that can be achieved as a result of close
cooperation and exchange of information between the owner
and the pathologist [23] .
iii) Freedom from pain, injury and disease means prevention of,
or rapid diagnosis and treatment of injury, disease or parasite
infestation. Diseases and disordes often cause dullness,
discomfort and sometimes pain. CAs owners have a responsibility
to prevent, control and treat disorders when appropriate and to
maintain their animals in healthy condition.
Health and welfare are strongly correlated and should be checked
daily. This should include observing whether the animal is eating,
drinking, urinating, defecating and behaving normally.
Veterinary advice must be obtained if an animal shows significant
signs of ill health which persist for more than a few days, or of
severe distress which persist for more than a few hours.
The following signs may indicate ill-health:
− abnormal dullness, lethargy or abnormal excitement,
agitation
− loss of or increase in thirst or appetite
− a discharge from the eyes, nose, mouth, anus, vagina or
prepuce
− vomiting, diarrhoea
− straining as if to defecate or urinate
− sneezing or coughing or abnormal or increased rate of
breathing
− significant weight loss
− patchy or excessive hair/feather/scale/flake loss
− swelling of part of the body
− pale gums and inner eyelids
− persistent scratching or biting resulting in self mutilation.
iv) Freedom from fear and distress - by ensuring conditions
which avoid mental suffering;
v) Freedom to express most normal patterns of behaviour - by
providing sufficient space, proper facilities and appropriate
social grouping. This requires knowledge of the animal’s normal
behaviour, including social behaviour, in the environment in
which the species evolved [24]. Changes in behaviour are often
the first signs of disease and the main sign of distress.
The welfare of a sentient animal is good if it can sustain fitness
and avoid suffering; i.e. stay fit (physical welfare) and happy
(mental welfare). According to Webster (2001) “For a sentient
animal both criteria (physical and mental welfare) must be
met. Sentience implies an awareness of the nature of emotions
associated with pleasure and suffering. Many of these emotions
are associated with primitive sensations such as hunger, pain,
and anxiety” [25].
The “Five Freedoms” address both physical fitness and mental
suffering.
Good animal welfare depends upon owners and handlers being
competent. As well as providing the basic necessities of life for
their animals, owners should attempt to provide them with a
reasonable quality of life.
Many individual abuses of animal welfare can be ascribed to
ignorance or neglect.
Several authors [26,27] provide a checklist of questions for use
in assessing the suitability of a species as a companion animal.
They conclude that suitability of a species as CAs, can be
determined by placing it into one of four groups:
category 1 - species not suitable for private husbandry. Category
1 species are those that are unsuitable as companion animals
because of the serious welfare implications associated with
taking the animal into captivity, together with the risks to the
animal, owner, the community or the environment which may
arise as a result of it being kept in captivity. In this category
may be included dangerous species as venomous snakes,
species whose requirements (e.g. for normal social behaviour)
cannot reasonably be met in captivity. Royal python would be
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EJCAP - Vol. 18 - Issue 2 October 2008
‘The green iguana may be an example, because it requires a
specialised, temperature and humidity controlled environment in
some climates.’
Relationship between man and an European goldfinch.
an unsuitable animal for someone looking for companionship,
since these animals are nocturnal and they do not respond well
to handling.
Category 2 - species suitable only for qualified keepers.
The green iguana may be an example, because it requires a
specialized, temperature and humidity controlled environment
in some climates [28].
Category 3 - species conditionally suitable for knowledgeable
private individuals;
or category 4 - deficient data. In this category might be assigned
species where there is insufficient knowledge (e.g. regarding
procurement, transportation, environmental impact or the
animal’s needs) to allow a confident assessment of its suitability
as a companion animal.
would affect wildlife. There is no legal requirement, for example,
for quarantine or for detailed disease screening of imported
reptiles or amphibians [29].
The list of infections that can be carried, and transmitted to
humans, by the wide range of NDAs is long, and some can
cause severe disease.
The risk of zoonotic diseases (those that can be transmitted
from NDAs to humans) is of special importance because of
the fact that they are non-native. While the diseases may be
somewhat harmless in their natural context, their introduction
into populations (people and animals) that have not evolved to
be resistant poses special dangers.
Macaque monkeys, which are increasingly kept as pets,
frequently carry Cercopithecine herpesvirus 1, also known as B
virus [30]. The virus is mostly harmless in monkeys but can be
fatal in humans [31].
Scientists warn that the increase in the trade in non-human
primates, including macaques, could create “an emerging
infectious disease threat in the United States” [30].
The outbreak of monkeypox in prairie dogs (and subsequently
in humans) was traced back to giant Gambian rats imported
from Africa. While the disease was balanced in its original
environment, its introduction into a new context caused it to
spread among unprepared species.
Having the same close contact with pet reptiles and turtles as
with cats and dogs, or even just keeping them in the private
home, increases the risk for transmission of Salmonella bacteria
from animals to humans [32,33,34,35,36,37]. Generally reptiles
carry salmonella [38], which can be transferred to humans
through faeces. Additionally, since many NDAs live in dirty and
stressful conditions, they are more likely to contract and transmit
diseases like salmonella. Baby turtles, considered cuter and more
pet-worthy, are more likely to have salmonella bacteria than
adult turtles [39].
The ways humans interact with their CAs also poses special
disease problems in the context of exotics. Specifically, kissing
or hugging bacteria-covered animals can easily transmit
pathogens through the mouth, or through scratches by sharpclawed animals. The hygiene practices required for NDAs are
much stricter than those associated with domestic animals like
Reasons for banning the private possession of non-domesticated animals
States should adopt a precautionary principle regarding which
animals to ban, whereby lots of NDAs are presumptively
unsuitable for private ownership or possession.
The ban is intended to protect wild animals from unnecessary or
undesirable interference and from improper treatment, as well
as to protect the public health, welfare and safety.
The reasons to institute and enforce a ban on possessing NDAs as
“pets” is also because of concerns about public health (referred
to the epidemiological risks of exotic pet ownership), and public
safety (referred to the risks of attacks and trauma associated
with such ownership).
It is important to consider that NDAs kept as CAs can be a source
of infectious agents harmful to humans. In particular, imported
NDAs are potential sources of infectious diseases that might
affect humans, domesticated animals, or captive or free-living
wild animals. A variety of pieces of animal health legislation exist
to reduce the risk of introduction of infections. However, the
main focus of this legislation has been the prevention of diseases
that threaten the health of humans or animals of economic
importance (agricultural animals). It has not been constructed
with a view to providing a solid defence against infections that
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Non-domesticated animals kept for companionship - A. Passantino
cats and dogs, and many owners fail to understand the extra
precautions necessary to avoid diseases [40].
Public safety concerns generally have to do with the
unpredictability of NDAs. Really, such animals can become
agitated in unfamiliar circumstances; some owners take their
animals into inappropriate public places and situations, such as
schools, parks, and shopping malls. Because of these animals’
potential to kill or severely injure both people and other animals,
an untrained person should not keep them as pets. Doing
so poses serious risks to family, friends, neighbours, and the
general public.
For instance, reptiles, including all types of snakes and lizards,
pose safety risks to humans as well. There have been many
reported incidents of escapes, strangulations, and bites from
“pet” reptiles. Snakes are the most common “pet” reptiles
and have the potential to inflict serious injury through a bite or
constriction.
Non-domesticated felines, such as lions, tigers, leopards,
etc., are cute and cuddly when they are young but have the
potential to seriously injure or kill people and other animals as
they mature. Adult exotic felines weigh anywhere between 300
to 500 pounds depending on the species, and are incapable
of being “domesticated.” Even an animal that appears to be
friendly and loving can attack unsuspecting individuals.
be subject to some conditions that will specify that:
a) only the person named on the licence shall be entitled
to keep the animal;
b) the animal shall only be kept on the premises named on
the licence;
c) the licensee must hold a current insurance policy which
insures against liability for damage caused by the
animal;
d) only the species and number of animals listed on the
licence may be kept.
Registration applications should require a number of supporting
documents, intended to assure public safety and animal
welfare. For example, applicants should submit a detailed
description of the animal including species, sex, age, if known,
and any distinguishing marks or colours that would aid in the
identification of the animal (see table 1).
ii) Where the owner violates the above regulations, the offending
owner could face a variety of punishments; she/he could
be fined, imprisoned or deprived of the animal. The animal
itself may be confiscated or sent to a safer environment. Of
course, where the owner has abused the animal or kept it
in inhumane conditions, the owner should also face charges
under separate animal cruelty laws. For example, in Italy see
Law no. 189 of July 20, 2004, published in Official Journal
no. 178 of 31 July 2004, relating to the prevention of cruelty
to animals (abandoning animals, injury, ill-treatment, death,
neglect, etc.)
iii) Pet stores, veterinarians, and other appropriate sources
should provide better information on how to avoid the risks
of transmission of infections to all prospective buyers of NDAs
[41].
In conclusion, the Author recommends that:
i) the owners of NDAs should be expected to keep up to date
with developments in knowledge about the biology and
husbandry requirements of the species that they keep. A high
standard of welfare is dependent on an animal’s physical and
behavioural needs being adequately met at all stages of its
life. If these requirements are known and are satisfactorily
met, there is no reason to suppose that the welfare of a
NDA will be better or worse than that of a domesticated
animal whose needs are similarly known and provided for.
Appropriate standards should be developed which set out
the husbandry requirements for keeping NDAs. These should
be developed for each species, recognizing their specific
needs. On the basis of these considerations, the Government
should review the regulation of NDAs with a view to clarifying
present uncertainties and ensuring adequate standards of
animal welfare.
ii) The Government and devolved administrations pursue the
development of new animal welfare legislation that would
make provision to establish and update standards for the
keeping of NDAs in the light of advances in understanding of
welfare needs.
iii) Legislation should be developed to regulate keeping and
selling of NDAs as CAs in order to help ensure the maintenance
of high standards and consistency across regions.
iv) The Government should commission a review of the disease
risks posed to the native wild fauna and the adequacy of
current biosecurity arrangements.
Conclusion and recommendations
In the absence of specific laws and regulations concerning the
keeping of NDAs for companionship, the Author proposes the
following points:
i) Licensing schemes should be created to regulate NDAs by
giving the authority to state agencies to issue permits for
animals deemed sufficiently safe. The licensing scheme
could regulate the possession of animals, creating limits to
the quantity of animals an individual may have or setting
standards for importation and animal care. These permit
schemes can ensure at least some degree of public safety
and animal welfare.
Except in exceptional circumstances, the person making the
application must be the person who owns and possesses
or proposes to own and possess the animal to which the
application applies.
Before granting a licence the Licensing Inspector must be
satisfied that:
1) it is not contrary to the public interest to do so on the
grounds of safety, nuisance or other grounds;
2) the applicant is a suitable person to hold a licence to keep
the animals listed on the application;
3) the animal(s) will be kept in accommodation that prevents
its escape and is suitable in respect of construction, size,
temperature, drainage and cleanliness;
4) the animal(s) accommodation is such that it can take
adequate exercise;
5) the animal(s) will be supplied with adequate and suitable
food, drink and bedding material and be visited at suitable
intervals;
6) all reasonable precautions are taken to prevent the spread
of infectious diseases.
7) where the local authority issues a licence, that licence will
124
EJCAP - Vol. 18 - Issue 2 October 2008
Legislation and control systems are important but the above
- the need for training of NDAs for any commercial or
objectives can be achieved better through a correct formulation
competitive purpose to be carried out by persons with
of the man-animal relationship, in particular:
adequate knowledge and ability;
1) for correct keeping of NDAs:
- the need to discourage:
a) Any person who keeps a NDA shall be responsible for
• gifts of NDAs to persons under the age of eighteen
its health and welfare.
without the express consent of their parents or other
b) All owners or keepers shall have their animals examined
persons exercising parental responsibilities;
by a veterinarian every time their state of health renders
• gifts of NDAs as prizes, awards or bonuses;
it necessary and the owners and keepers follow the
• unplanned breeding of NDAs;
veterinarian’s prescriptions.
- the possible negative consequences for the health and wellc) Any person who keeps a NDA or who is looking after
being of NDAs if they were to be acquired or introduced as
it shall provide accommodation, care and attention
pet animals;
which take into account the ethological needs of the
- the risks of irresponsible acquisition of NDAs leading to
animal in accordance with its species and breed.
an increase in the number of unwanted and abandoned
d) All owners or keepers of animals shall guarantee the
animals.
animals constant appropriate living conditions.
In giving this information the companion animal veterinarians
e) Any person who keeps a NDA or who has agreed
have an important role.
to look after it, shall take all reasonable measures
to prevent its escape and shall
guarantee the protection of third
parties from aggression.
2) to encourage the development of
Table 1 - APPLICATION FOR LICENCE TO KEEP NON-DOMESTICATED ANIMAL(S)
education programmes for NDAs and
Please tick appropriate box:
New
Renewal
If Renewal state Licence No:
owners where the participants receive
To:
Mayor of ………………and Local Veterinary Authority
information about the NDA’s normal
NAME OF APPLICANT
behaviour and the principal diseases
and obtain basic knowledge about
ADDRESS:
keeping and caring for animals:
TELEPHONE NO:
POST CODE:
a) Information and education proADDRESS OF PREMISES WHERE
ANIMAL(S) IS/ARE TO BE KEPT
grammes for owner/keeper of NDAs.
SPECIES OF ANIMAL(S) TO BE KEPT (1)
Correct information can be given,
IDENTIFICATION OF ANIMAL(S):
for example, in informative, practical
MICROCHIP NUMBER/TATOO NUMBER
LOCATION OF MICROCHIP
and concise brochures, containing
DATE OF MICROCHIPPING/TATOOING
NUMBERS TO BE KEPT:
Male:
Female:
TOTAL:
mainly the following information:
1.
IS IT INTENDED TO BREED OR ATTEMPT TO BREED FROM THESE ANIMALS?
YES/NO
- normal behaviour of the NDAs;
IS IT INTENDED TO KEEP THESE ANIMALS?
YES/NO
2.
DESCRIPTION AND DIMENSIONS OF ACCOMMODATION TO BE USED:
- correct behaviour towards NDAs;
- behaviour in the presence of children;
- how to recognise and react in the case
3.
DESCRIPTION OF TYPE OF FOOD TO BE SUPPLIED AND SOURCE:
of aggressive behaviour of the animal;
- how aggression can be prevented;
4.
DETAILS OF INSURANCE POLICY HELD TO COVER LIABILITY FOR DAMAGE CAUSED BY ANIMAL(S) (2)
- responsibility of the owner/keeper
Company: _____________________________________________________________________________
b) Information and education proPolicy No: ______________________ Expiry Date: ____________________ Amount: _______________
grammes among individuals concerned with the keeping, breeding,
I HEREBY DECLARE that I am over 18 years of age and not disqualified by being convicted of any offence at any
training and/or trading of NDAs, for
time under the Protection of Animals Acts.
I APPLY for a Licence under the Decreti Ministeriali (1996 and 2001) in respect of which I enclose the
any commercial purpose. In these
fee of (3)
programmes, attention shall be
This application must be accompanied by the appropriate fee.
drawn in particular to the following
Dated: _________________________
Signed: __________________________________
subjects:
*If signing on behalf of a Company or partnership, *__________________________________
state in what capacity
(1) Give scientific name if possible
(2) This Policy must be produced to an inspecting officer if required
(3) The fee is such sum as, in the authority’s opinion, is sufficient to meet the direct and indirect costs which they may incur as a result of
this application
‘DATA HELD BY THE AUTHORITY WILL BE USED FOR CROSS SYSTEM AND CROSS AUTHORITY
COMPARISON PURPOSES FOR THE PREVENTION AND DETECTION OF FRAUD’
FOR OFFICIAL USE ONLY
Receipt No:
Date:
125
Non-domesticated animals kept for companionship - A. Passantino
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126
GENERAL
COMMISSIONED PAPER
Clinical Cytology of Companion
Animals:
Part I Introduction
E. Teske (1)
SUMMARY
In veterinary medicine, interest in the technique of cytological examination of smears obtained by fine needle
aspiration biopsy (FNAB) is a rather recent phenomenon. One might assume from this that it is a recently developed
method, but nothing could be farther from the truth. As early as 1851, the Swiss pathologist H. Lebert described the
method of diagnostic aspiration in his book “Traité des Maladies cancéreuses et des Affections curables confondues
avec le Cancer: (“.. and an explorative aspiration can remove all doubt. If it is a purulent or serous cyst, a stream of fluid can come
out of the needle; when cancerous tissue is punctured, the needle will be surrounded by more solid structures and is less moveable. If
some material is obtained it is a thin substance which when examined macroscopically, and if necessary microscopically, appears to
be cancer.”) A few years earlier (1838) the Berlin physiologist Johannes Müller first described cytological criteria for the
differentiation of benign and malignant tumours. Now, one and a half centuries later, this technique has also become
popular in veterinary medicine.
Advantages and disadvantages of
FNAB
clinical examinations. The smears do not have to be processed
immediately but can be left until later. With FNAB one can
obtain multiple aspirates from a lesion, which is advantageous
in the follow-up of patients during the course of treatment. The
risk of metastases being caused by FNAB is so small as to be
negligible.
Cytological examination of smears obtained by FNAB has several
disadvantages relative to examination of histological biopsies,
but there are also various advantages. When deciding whether
to obtain a surgical biopsy for histological examination or an
aspiration biopsy, these should be considered carefully.
The positive predictive value of cytology is higher than the
negative predictive value. In other words, the absence of
malignant cells in a cytological preparation is less reliable
than the presence of cancer cells. The aspiration needle can
unfortunately be inserted beside the tumour rather than in it, or
in a necrotic or inflamed portion of the tumour, or the tumour
can consist of cells that are not easily aspirated. All of these
can lead to a false tumour-negative result. Another limitation
of FNAB is the lack of opportunity to study the histological
structure of the lesions.
The attractiveness of the FNAB rests on its advantages. It is a
method that is easy to learn. It is inexpensive and quick, and
the results can be known within half an hour. FNAB can also be
performed without anesthesia, which makes it possible during
Indications for performing FNAB
On the basis of cytological examination of biopsies obtained by
FNAB, it is usually possible to differentiate between inflammatory
tissue and tumour, between acute and chronic inflammation,
and between benign and malignant tumours. The aetiologic
agents of different infectious causes of inflammation are
recognisable (bacteria, fungi, and parasites such as Toxoplasma
and Leishmania), and also many tumours can be classified.
Cutaneous and subcutaneous masses that cannot be diagnosed
by physical examination provide an excellent indication for
aspiration biopsy. With FNAB, most skin tumours can not only
be distinguished but also classified (e.g., mast cell tumour,
histiocytoma, squamous cell carcinoma, basal cell carcinoma,
and melanoma). In contrast, in the case of mesenchymal
(1) Department Clinical Sciences Companion Animals, Veterinary Faculty, Utrecht University
PO Box 80.154, NL- 3508 TD Utrecht. E-mail: e.teske@uu.nl
127
Clinical Cytology of Companion Animals: Part I Introduction - E. Teske
proliferation, it is often difficult to determine whether the
process is tumourous or reactive. Chronic inflammatory tissue,
the presence of malignancy and the type of tumour (fibroma/
fibrosarcoma, haemanigioma/haemangiosarcoma) is often
uncertain. In many cases one can come no further than the
diagnosis of ‘mesenchymal proliferation’. Mammary tumours
also, especially for the inexperienced cytologist, can present
problems as stimulated mammary tissue often contains atypical
cells. In contrast, various lymph node abnormalities (including
metastases) are easily diagnosed. For someone experienced in
biopsy techniques, there are still more indications for FNAB:
prostatice changes, interstitial changes in the lungs, clinical
suspicion of abnormalities in the liver or spleen. For these
indications there is, however, a greater risk of complications.
Percutaneous lung biopsies in particular should not be attempted
unless one is capable of handling the eventual complications.
Syringe holders are recommended for use in aspiration biopsy
in human patients. Usually a 20-ml syringe must be used, which
in our experience is much less convenient. The distance from
the patient is too great which, in the case of restless veterinary
patients, can be a disadvantage. A small syringe has the
disadvantage that its plunger must be pulled back farther to
obtain sufficient vacuum. A 10-ml syringe seems to be a good
compromise. Recently, in veterinary medicine a special biopsy
instrument (Cybio®) a has been developed, which is easy to use
and gives good results (Fig. 2). Some advise the use of only a
fine-needle, the fine-needle capillary sampling technique, which
is easier to manoeuver and may create less blood contamination.
Especially in haematopoietic and epithelial tissues this may be an
effective method, in mesenchymal tissues, however, the yield is
often less than with FNAB.
It is a mistake to think that thicker needles can obtain better
aspirates. With thick needles large clumps of tissue are
aspirated. These are difficult to streak out, are easily damaged,
and are difficult to stain and examine. In addition, blood is
more easily aspirated with a thick needle. Experience has shown
that 22-gauge needles give the best results. Only if no material
is obtained with these needles is trying with a slightly larger
needle worthwhile.
Anaesthesia is seldom necessary for performing FNAB. Although
aspiration from the extremities and the head is occasionally
painful, even in these locations it is seldom necessary to use any
form of anaesthesia. The patient must be adequately restrained
by the owner or assistant(s). After the hair has been clipped and
the skin disinfected, the mass to be aspirated is fixed with one
hand and, with the syringe held in the other hand, the needle is
introduced. A vacuum of 1-2 ml is usually sufficient to aspirate
material. The needle, without being withdrawn from the mass,
is moved in various directions in order to obtain as representative
a biopsy as possible. Often little or no material is visible in the
cone of the needle. If blood suddenly enters, it is better to take
a new syringe and needle and start again, as too much blood
greatly hinders the evaluation of the preparation. Before the
needle is completely withdrawn from the tissue, the vacuum
must be released by allowing the plunger to return to a resting
position otherwise the aspirated material will be drawn into the
syringe and will be very difficult to retrieve. Then the needle is
loosened, some air is sucked into the syringe, the needle is again
placed firmly on the syringe, and the contents of the needle are
expelled onto a glass microscope slide.
Various methods have been described for streaking out the
biopsied material. A second object glass can be laid on top of
the first and, with a turning motion, the two glasses can be
pulled apart. Spreading the material with a needle or a scalpel
blade is also used. Often, however, many cells are destroyed
by these methods. This can be avoided if one uses the method
which is also applied for streaking out a drop of blood. For this
purpose a second slide, held at an angle of 45º to the first, is
backed up against the material and then streaked out with a
flowing movement so that the material along the back edge of
the slide is taken along. For mucous material one should streak
out more slowly than for more watery material.
It is advisable to take multiple aspirates from each tumour.
If the tumour is large, take an aspirate from both the centre
and from the edge. This increases the chances of obtaining a
Technique of FNAB
The material needed for performing FNAB is extremely simple: a
few glass microscope slides with a matt surface at one end, a 10
ml disposable syringe, and a thin (22 gauge) needle (Fig. 1).
It is important to use microscope slides that have a matt surface
at one end so that they may be labeled using a lead pencil.
Particularly when multiple biopsies are taken, a mix up of the
slides can be very unfortunate (for both the clinician and the
patient). The risk of mixing slides will be even greater if you
don’t do the microscopic examination yourself but send the
preparations to someone else. The best way to label the slides
is with a lead pencil, because in contrast to ink, this will not be
dissolved in the alcohol used during staining.
Fig. 1 Minimal material needed for performing FNAB: a few object
glasses with a matt surface at one end, a 10 ml disposable syringe
and a thin (22 gauge) needle.
Fig. 2 Special FNA biopsy instrument (Cybio®) developed for
veterinary medicine.
128
EJCAP - Vol. 18 - Issue 2 October 2008
representative sample. At the edge of the tumour, the certainty
of obtaining cells is smaller, but a correctly obtained aspirate
is then more representative because a rapidly growing tumour
becomes necrotic near the centre. This also applies to lymph
nodes invaded by tumour. In generalized lymphadenopathy it
is reasonable to biopsy multiple nodes, since the lymph node is
sometimes so necrotic that a good interpretation of the biopsy
is not possible. In addition, it appears that the mandibular lymph
node is less suitable for cytological examination because it is
usually reactive, as a result of minor inflammatory processes
within the oral cavity. Because of this, the true cause of the
lymphadenopathy can be masked.
from the sample. With a sterile scalpel, the surface of the tissue
is scraped until some material is on the blade surface. The blade
material is then spread onto a slide.
ii Swab method
Lesions such as those in the ear and nose, but also (muco)
cutaneous lesions, can be sampled with a cotton swab. The
material should then be smeared immediately onto a glass slide,
before the material dries.
iii Direct smears
From superficial lesions or skin lesions exhibiting vesicules,
pustules, etc., cytological smears may easily be obtained by
scraping the lesion with a scalpel blade and then smearing the
material onto a slide. However, in case of vesicules or pustules,
it is better to open the lesion with a sterile scalpel blade or
hypodermic needle, collecting material from within the lesion,
or by making imprint smears from underneath the roof of the
vesicule or pustule.
Exfoliative Cytology
Apart from FNAB of lumps or organ tissues, cytological smears
of superficial lesions can also be obtained by one of the following
methods.
i Impression smears
Impression smears may be obtained from skin lesions such as
ulcers, exudative dermatitis and from surgically excised material.
Impression smears from skin lesions can be made by pressing
the slide firmly against the lesion. One option is to freshen the
lesion by scraping the surface with a scalpel blade. Impression
smears from surgically excised material can be best made by
first cutting a fresh surface, removing the surface blood with
a gauze, and then pushing the slide against the lesion. It is
always best to make several impression smears. If the imprints
are poorly cellular, another technique can be used to get cells
Handling of the smear
After the smear of the biopsy has been made, the method of
staining determines how the preparation must be processed. For
Papanicolaou staining, the smear has to be fixed immediately
(by means of a fixative spray or by placing the slide into alcohol).
For the so-called Romanowsky stains (Giemsa, May-Grünwald
Giemsa, Hemacolor®, DifQuick®), good fixation by drying in air is
necessary before staining (Fig. 3). The air-dried preparations can
then be kept for a long time before staining. For Romanowsky
Table 1
Staining method
Papanicolaou
No. of dishes
Staining time
24
35 min
May-Grünwald Giemsa
3
22 min
Hemacolor® (Merck)
3
0.5 min
Table 2
Papanicolaou method
1. alcohol 70%
20 sec
13. alcohol 80%
20 sec
2. alcohol 50%
20 sec
14. alcohol 96%
20 sec
3. distilled water
20 sec
15. Orange G
3 min
4. Harris hematoxylin
6 min
16. alcohol 96%
20 sec
5. distilled water
20 sec
17. alcohol 96%
20 sec
6. 0.25% HCl
3 dips
18. EA 50
5 min
7. tap water
20 sec
19. alcohol 96%
20 sec
8. lithium carbonate
1 min
20. alcohol 96%
20 sec
9. tap water
20 sec
21. alcohol 96%
20 sec
10. distilled water
20 sec
22. alcohol 100%
20 sec
11. alcohol 50%
20 sec
23. xylol
5 dips
12. alcohol 70%
20 sec
24. xylol
15 min
129
Clinical Cytology of Companion Animals: Part I Introduction - E. Teske
Hemacolor®
Solution 1:
5x 1 sec
Solution 2:
3x 1 sec
Solution 3:
6x 1 sec
Wash off with buffer solution pH 7.2
Table 4
preparations. It should be realized, however, that for good
diagnosis, the quality of the preparation is of vital importance.
“In cytology the specimen is everything: Garbage in - Garbage
out.” (V. Perman, 1984). Good biopsy technique, good fixation
of the smears, and a good staining technique are essential. In
addition, a proper use of a good microscope is of course of the
essence!
Apart from the possibility of poor biopsy quality, cytology has
another limiting factor as mentioned earlier: a negative (e.g.,
tumour-negative) report is less reliable than a positive report.
Severe inflammation in a tumour, necrosis of tissue within a
tumour, or inadequate biopsies can result in a “false negative”
report. One should always take this limitation into account. As
with all diagnostic techniques, it is also advisable to consider the
probability of the cytological diagnosis in terms of the probability
of the clinical diagnosis, and not to see it as an independent
certainty.
The examination of a preparation goes through three phases.
The first is determining the tissue of origin, the second is
differentiating between inflammation, hyperplasia/benign
tumour and malignant tumour, and the third is classifying the
inflammatory process or the tumour.
Fig. 3 Hemacolor quick stain: alcohol fixation, red stain, blue stain
and buffer.
staining, fixing with spray, alcohol, heating, or formalin is not
allowed. In addition, the smear must not be covered with glass
cover-slip!
As shown below, various staining techniques are possible (Table
1). The Papanicolaou stain (Table 2) is very laborious and timeconsuming. Its advantage is that it provides good detail of
nuclear structure. The degree of keratinisation of cells is also
brought out well. In contrast, there is often little or no staining
of cytoplasmic granules. Both according to the literature and
in our own experience, the Romanowsky stains (Tables 3 and
4) are more suitable for veterinary applications. These stains
are suitable for demonstrating cytoplasmic inclusions and
microorganisms. In addition to these general stains, various
special stains are possible. An example of these is the rubeanic
acid stain for demonstrating copper (e.g., in liver cells). For these
stains various handbooks should be consulted.
Tissue of origin
Basic Principles for the Interpretation
of Cytological Preparations
Because the cytological characteristics of hyperplasia, inflammation, and malignancy can differ in different tissues, it is important
to first determine the most frequently occurring type of cell in
the cytological preparation. The following three tissues can be
distinguished.
An experienced cytologist examining cytological preparations
can sometimes make a diagnosis in a couple of seconds. With
his experience he makes use of pattern recognition. With
difficult preparations, however, a more systematic approach will
lead to results sooner. This is certainly true for the inexperienced
cytologist. In this paper a guideline is given for examining
cytological preparations obtained by aspiration biopsy or
exfoliative cytology. It is not possible in just one paper to give a
complete overview of all cytological diagnoses. Those wishing
to become better qualified in cytology after reading this text can
pursue the subject in the references that are provided.
This paper is only concerned with the examination of cytological
I. Haematopoietic tissue
These are cells originating from blood, bone marrow, lymph
glands, spleen, and thymus. Mast cells, histiocytes, and macrophages also belong to this category. Cells of haematpoietic
origin are individual cells, mostly round in shape, and have a
distinct cytoplasmic membrane (Fig. 4). The smears are usually
rich in cells. Preparations that have not been streaked out can
incorrectly suggest a tissue organization, but this will be seen to
disappear along the edges of the smear. The cell sizes can vary
from small to medium. Usually they contain little cytoplasm.
Table 3
May-Grünwald Giemsa method
Solution 1: methyl alcohol 90%
5 min
Solution 2: May-Grünwald stain 1 part, phosphate buffer pH 6.98 1 part
4 min
Solution 3: Giemsa stain 1 part, phosphate buffer pH 6.98 9 parts
15 min
130
EJCAP - Vol. 18 - Issue 2 October 2008
Fig. 4 Haematopoietic tissue: many individual round cells with
a few erythrocytes in the background (bone marrow of dog with
myeloid leukemia).
Fig. 7 Two fibroblasts in a mesenchymal proliferation (dog with a
fibroma on the foreleg).
II. Epithelial glandular tissue
Cells of this type of tissue have the tendency to be connected to
each other. They can form two- or three-dimensional clusters,
but also monolayers (Fig. 5), acini (Fig. 6) or duct structures.
Sometimes there is a stromal component present. Individual
cells may also be present. The cellularity is usually slightly less
than in preparations with haematopoietic cells. Benign epithelial
cells also have round nuclei. The cytoplasm is often abundant
and the cell borders are distinct. Sometimes, for example in
endocrine tumours, the cytoplasm is stripped from the nucleus
when the smear is streaked out and there are mostly naked
nuclei. The cell size may vary from small (basal cells) to very large
(squamous epithelial cells).
III. Mesenchymal tissue
Within this type are included the cells arising from connective
tissue, muscle, cartilage, and bone. Because of the strong
attachment between the cells it is difficulty to obtain material.
Smears of this type of tissue are thus also characterized by a
low cellularity and the cells are mostly separate from each
other, although groups of cells can also be found. The amount
of cytoplasm can vary markedly and the cell borders are often
rather vague. The shape of the nucleus can differ but is often oval
(Fig. 7). The cells can have characteristic morphologic forms, of
which the spindle-shaped cell is the best known. Synovial cells,
osteoblasts, and chondroblasts can have an egg-shaped outline,
in which the nucleus is eccentric and sometimes lies halfway
outside the outline of the cytoplasm. Fat cells can be very large
and can be recognised even at a low magnification. These cells
are generally connected together as a tissue, have distinct cell
margins, and have an oval nucleus that lies in the middle of the
light, transparent cytoplasm.
Fig. 5 Monolayer of epithelial cells (dog with epitheliosis of
mammary gland).
Benign pathologic processes
Inflammation
If primarily inflammatory cells are encountered in a preparation,
the process may be an acute or subacute inflammation or a
more chronic and sometimes granulomatous inflammation. But
it may also be a secondary inflammation in a neoplastic process.
It is therefore important, even in the presence of inflammatory
cells, to continue looking for other types of cells. It is then
sometimes difficult to differentiate between dysplastic, reactive,
and neoplastic cells.
Inflammatory processes can be differentiated on the basis
of their duration (acute versus chronic), type (purulent,
pyogranulomatous, granulomatous, and eosinophilic), and
aetiology (bacterial, parasitic, fungal, allergic, foreign-body
reaction, etc.).
In a purulent inflammation the majority of the cells are
neutrophilic polymorphonuclear leukocytes. They can account
for than 85% of the cells present in an acute inflammation
Fig. 6 Glandular epithelial tissue (dog with complex adenoma of
the mammary gland).
131
Clinical Cytology of Companion Animals: Part I Introduction - E. Teske
Fig. 8 Acute septic inflammation with several neutrophils with
intracellular bacteria and karyolysis.
Fig. 9 Aseptic exudative inflammation. Several non-toxic
neutrophils, pycnosis (on the left), karyorrhexis (in the middle),
and a few macrophages.
and decrease to 30-50% in a more chronic inflammation. In
a purulent inflammation there can also be macrophages.
Macrophages can be present in the inflammatory process within
a couple of hours and thus are no indication of chronicity. This
is in contrast to the presence of plasma cells and lymphocytes.
These cells only arrive at the site of the inflammation after 1-2
weeks. The inflammatory process can further be characterized
by the presence or absence of degenerative changes in the
inflammatory cells. Karyolysis is characterized by swelling of the
nucleus, less intense staining, and then disintegration of the
nucleus. This is especially seen in a severe inflammation with
the release of many toxic materials and proliferation of bacteria
(Fig. 8). If these characteristics are seen, a special effort must
be made to look for infectious agents. In contrast, pyknosis
and karyorrhexis are characteristics of a slower cell death (Fig.
9). Pyknosis causes the nucleus to shrink markedly and to lose
its chromatin pattern. The nucleus becomes a uniformly darkly
stained mass. If this pyknotic nucleus disintegrates, the process
is called karyorrhexis.
In granulomatous inflammation there are fewer polymorphonuclear cells than in purulent inflammation. In contrast,
there are more macrophages and epithelioid cells. The
macrophages usually show fewer signs of phagocytosis than in
a purulent inflammation. There can also be multinucleated giant
cells (Fig. 10). If the infection becomes chronic, lymphocytes and
plasma cells are encountered again. This type of inflammation
should lead the clinician to consider infection by fungi, infection
by actinomyces or similar bacteria, and reactions to a foreign
body.
Eosinophilic inflammation contains large numbers of
eosinophilic granulocytes. This type of inflammation occurs in
the eosinophilic granuloma in the cat, the lick granuloma in
the dog, and also in parasitic infections and allergic reactions.
Eosinophilic granulocytic infiltrates are also a characteristic
finding in many mast cell tumours.
Tissue regeneration
Many morphological changes related to an increased metabolic
status of the cell may be present e.g. basophilic cytoplasm (high
RNA- and protein content), prominent or multiple nucleoli,
and increased numbers of mitoses. Differentiating this from
malignancy may be difficult. Usually a normal maturation of the
cells can be found.
Scar tissue may be accompanied by young connective tissue
cells and blood capillaries. Some inflammatory cells may also
be found.
Fig. 10 Pyogranulomatous inflammation due to fungal infection.
A large multinucleated giant cell can be seen surrounded by
neutrophils, some macrophages and lymphocytes.
Fig. 11 Liver cell carcinoma in a dog. Note the change in
basophylia, the anisocytosis and change of nuclear/cytoplasm ratio.
132
EJCAP - Vol. 18 - Issue 2 October 2008
Fig. 12 Liver cell carcinoma in a dog. The nuclear malignancy
criteria are especially evident: anisokaryosis, prominent and
multiple nucleoli, some of them are angular and there is
anisonucleoliosis. In addition irregular nuclear membranes can be
seen.
Fig. 13: Mammary gland carcinoma in a dog. Apart from change
in basophilia and some microcytoplasmic vacuoles, there is
anisokaryosis, coarse chromatin pattern, abnormal nuclear forms,
multiple nucleoli with anisonucleoliosis.
Neoplastic processes
malignancy. Cluster formation means three-dimensional cell
growth without organized cell relationships. In contrast,
monolayers and the formation of acini and ducts indicate
better differentiation of the cell population. The occurrence of
a type of cell where it does not usually occur makes the lesion
immediately suspicious. A good example of this is the presence
of epithelial cells in a lymph node.
The cytoplasmic criteria of malignancy include strong basophilia
of the cytoplasm and even marked variability in basophilia of
immediately adjacent celss. This basophilia is related to the
amount of RNA and protein synthesis in the cytoplasm and is
thus a measure of the cell activity. Reactive cells can, however,
also be strongly basophilic. Anisocytosis (marked variation in
cell size) and macrocytosis (abnormally large cells) are more
often seen in malignant than in benign tumours (Fig. 11).
Other cytoplasmic criteria of malignancy are the occurrence of
abnormal cytoplasmic inclusions (especially cannibalism of other
cells), atypical vacuolization, a high nuclear/cytoplasmic (N/C)
In order to differentiate between malignant tumours and
benign tumours or hyperplasia, both general criteria and cellrelated (cytoplasmic and nuclear) criteria can be used. In the
following paragraphs the different criteria of malignancy will be
discussed. It must be realized that no single criterion is in itself
indicative of malignancy. The nuclear criteria weigh the most
heavily. In addition, the criteria are not identical for different
types of cells and locations. The malignancy criteria are most
often used for epithelial tumours. In mesenchymal tumours they
are less predictive, and the haematopoietic tumours are usually
diagnosed on different criteria.
With regard to the general criteria, the appearance of the
entire population of cells should be examined. The absence of
inflammatory cells, the presence of a uniform cell population
(i.e., one cell type) of pleomorphic cells (i.e., with variable shapes)
are indications of malignancy. A high cellularity and abnormal
cellular relationship (e.g., cluster forming) can also occur with
Table 5 Summary of cytoplasmic and nuclear characteristics of malignancy
Cytoplasmic
Nuclear
Anisocytosis
Anisokaryosis
Macrocytosis
Macrokaryosis
Basophilia
Multiple nuclei
Variable basophilia
Abnormal nuclear shapes
Abnormal cytoplasmic inclusions
Irreg. thickened nuclear membrane
Atypical vacuolization
Irreg. chromatin pattern
High N/C ratio
Hyperchromasia/anisochromasia
Variable N/C ratio
High mitotic index
Abnormal mitoses
Multiple nucleoli
Large nucleoli
Abnormally shaped nucleoli
Anisonucleoliosis
133
Clinical Cytology of Companion Animals: Part I Introduction - E. Teske
ratio (relatively little cytoplasm) and a marked variation in the
N/C ratio.
The most important criteria of malignancy are, however, the
nuclear criteria. Giant nuclei, anisokaryosis (difference in nuclear
size), multiple nuclei per cell (especially if they also differ in size
and are not 2n), abnormal nuclear shapes and marked variation
in shapes, irregular and thickened nuclear membranes (especially
easily seen in Papanicolaou staining), and an irregular, coarse
chromatin pattern are all nuclear characteristics that point to
malignancy (Fig. 12 and Fig. 13). An increased mitotic index and
especially abnormal mitotic forms are other nuclear criteria of
malignancy. The malignancy criteria of the nucleoli are multiple
nucleoli, abnormal large nucleoli, anisonucleosis and abnormally
shaped nucleoli. Some authors have proposed that the presence
of 3-4 of the above nuclear criteria of malignancy should be
considered indicative of malignancy, as this number of many
malignancy criteria should not occur in hyperplasia. In practice,
however, it can still be difficult to differentiate between a
malignant and a hyperplastic reaction, especially in mesenchymal
proliferations.
An overview of the most important of the above-mentioned
criteria of malignancy is given in Table 5.
Suggested Literature
ALLEN (S.W.), PRASSE (K.W.) - Cytologic diagnosis of neoplasia and
perioperative implementation. Comp Cont Ed Pract Vet, 1986, 8:
72.
BAKER (R.), LUMSDEN (J.H.) - Color Atlas of Cytology of the Dog and
Cat. Mosby Inc, St. Louis. 2000.
BOON (G.D.), REBAR (A.H.), DENICOLA (D.B.) - A cytologic comparison
of Romanowsky stains and Papanicolaou-type stains. I.
Introduction, methodology and cytology of normal tissues. Vet
Clin Pathol, 1982, 11: 22.
COWELL (R.L.), TYLER (R.D.), MEINKOTH (J.H.), DENICOLA (D.B.) Diagnostic Cytology and Hematology of the Dog and Cat. 3rd Ed.
Mosby Elsevier, St. Louis. 2008.
GRUNZ (H.), SPRIGGS (A.I.) - History of Clinical Cytology. A selection of
documents. 2nd ed. G-I-T Verlag Ernst Giebler, Darmstadt, West
Germany, 1983.
LOPES CARDOZO (P.) - Atlas of Clinical Cytology. Targa bv,
’s-Hertogenbosch, the Netherlands, 1975.
RASKIN (R.E.), MEYER (D.J.) - Atlas of Canine and Feline Cytology. WB
Saunders, Philadelphia, 2001.
REBAR (A.H.) - Diagnostic cytology in veterinary practice; current status
and interpretative principles. In: Kirk RW (ed), Current Veterinary
Therapy VII, WB Saunders Co, Philadelphia, 1980, pp 16-27.
TVEDTEN (H.) - Cytology of neoplastic and inflammatory masses. In:
Willard, Tvedten, Turnwald (eds), WB Saunders Co, Philadelphia,
1989, pp 327-348.
CARDIOLOGY
COMMISSIONED PAPER
Blood Pressure in Small Animals - Part I*:
Hypertension and hypotension and an
update on technology
A.P. Carr(1), T. Duke(1), B. Egner (2)
SUMMARY
The understanding of blood pressure and its disorders in companion animals as well the technology for blood
pressure measurement have evolved dramatically over the last 15 years. Much more as in human medicine, monitoring
this very important parameter plays a key role in diagnosing disease and the initiation and fine-tuning of therapy.
This parameter also offers valuable insight into the likelihood of hypertensive target organ damage or the risk of
hypoperfusion and organ compromise in association with hypotension. As a consequence, blood pressure monitoring
has become a more routine procedure in many veterinary clincis world wide.#
The role of blood pressure (BP) in
overall patient evaluation
blood pressure is vital for guaranteeing normal organ function.
Both hypertension and hypotension can limit life expectancy
and quality of life, especially if the abnormality persists for long
time periods or if the changes are dramatic. Baroreceptors,
chemoreceptors, and the central pressure control in the medulla
oblongata are the main components of the control system that
aims to secure adequate perfusion by maintaining normal blood
pressures. The main effector system is the Renin-AngiotensinAldosterone system. Additionally catecholamines, ANP,
Prostaglandins etc. play a vital role.
Kidney disease, diabetes mellitus, hyperthyroidism and
hyperadrenocorticism are the main causes of a pathologic rise
in blood pressure in small animal patients [1]. Pain (especially
acute pain), obesity and other uncommon diseases like a
pheochromocytoma can cause elevated blood pressures as well.
Hypotension is most commonly encountered during anesthesia
and in critically ill patients suffering from trauma, poisoning,
shock or severe heart failure. Both hypertension and hypotension
can be caused by drugs as well.
Given the varied causes of low and high blood pressure it is
clear that there are a multitude of indications to measure
blood pressure. Routine annual evaluation in healthy animals
and frequent monitoring in at-risk patients would be medically
sound practice.
Short term and long term compensatory mechanisms can be
activated to keep blood pressure within a physiological range.
However with certain diseases, these mechanisms don’t work
adequately any more and thus hypertension or hypotension
develop.
Hypertension
Abnormalities in Blood Pressure
Most commonly companion animals suffer from secondary
hypertension, that is there is an underlying disease causing
blood pressure to rise (see table 2). In humans the term
Blood pressure is - physiologically - one of the most tightly
controlled parameters in humans and animals, since maintaining
# FECAVA and EJCAP would like to point out that this paper represents the opinions of the authors and readers should not consider it as the rule or guideline of the
FECAVA. They should make their own judgements
(1) Small Animal Clinical Sciences, Western College of Veterinary Medicine,52 Campus Drive,Saskatoon, SK S7N 5B4 Canada
E-mail: endovet@juno.com
(2) Clinical Centre for Small Animals, Hoerstein, Moembriser Str. 100 - Germany E-mail: beate.egner@t-online.de
* Parts 2 and 3 of this paper will be published in subsequent issues of EJCAP
Part 2: Risk factor Hypertension I - Hypertensive damage to the heart and kidney - Diagnosis and treatment considerations
Part 3: Risk factor Hypertension II - Hypertensive damage to the eyes and the CNS - Diagnosis and treatment considerations
135
Blood Pressure in Small Animals - Part 1: Hypertension and hypotension and an update on technology - A.P. Carr
Routine Screening
Screening in
Emergency
Medicine
-
- shock
- postoperative
- trauma
monitoring
- pericardial
- hypertensive
effusion
crisis
- poisoning
- protracted
- Addisonian crisis
shock
- end stage heart
failure
general health check-ups
geriatric screening programs
non specific symptoms
vaccination
appointments
diseases frequently leading
to hyper- or hypotension, like
renal disease, hyperthyroidism,
diabetes mellitus,
hyperadrenocorticism, Addisons
disease, heart disease
Intensive Care
Monitoring
Screening
with rhythm
abnormalities
Treatment
Planning and
Assessment
Anaesthesia
Monitoring
- arrhythimia
- bradycardia
- tachycardia
cardiac patients
- pre-anaesthetic
- in all patients
examination
- intra-operative
treated
(hypertension or
monitoring
can occur)
- post-op
renal patients
surveillance
especially with
- proteinurea
- hypertension
hyper throid
patients when
using drugs
which lower or
elevate bp.
Table 1 Indications for blood pressure evaluation
primary or essential hypertension is commonly used when an
underlying reason is not found for elevated blood pressure. This
term is not appropriate in veterinary medicine. In those cases,
where an underlying causative disease cannot be identified,
the term idiopathic hypertension should be used. [1] Another
common cause for high blood pressure readings is white-coathypertension, which is not a true hypertensive state, rather a
short term response to a stressful situation. [10].
be critically reviewed afterwards by the veterinarian.
If repeated measurements or the presence of target organ
damage confirm pathologic hypertension, the next steps depend
on the severity and presence of TOD:
Minimal Risk of TOD: <150/95 but above the species specific
normal value; no treatment is recommended. In the presence
of other symptoms which might indicate an underlying disease,
efforts should be made to diagnose this disease and treat it if
possible.
Blood Pressure should be re-evaluated at least once a year.
According to the Guidelines of the ACVIM Hypertension
consensus panel [2] and the Veterinary Blood Pressure Society
(www.vbps-online.org) hypertension is defined according to its
risk for target organ damage (TOD)(Table 3).
Mild Risk of TOD: <160/100
The main focus should be put on diagnosing any underlying
disease and treatment of those diseases. The patient’s blood
pressure should be frequently re-evaluated.
If TOD is present additional medications may be needed.
Treatment of hypertension, potentially treating the underlying
disease may be adequate to treat this degree of hypertension.
Target value: <150/95. ACE-I are often used as they are beneficial
in heart and renal disease but also lower blood pressure up to
20 mmHg.
Isolated diastolic hypertension can cause TOD as can isolated
systolic hypertension. Because of this it is always strongly
recommended to measure both systolic and diastolic pressure
and to evaluate the patient for hypertension based on both
values.
Deciding when to initiate therapy for hypertension can be a
challenge since white coat hypertension can lead to inappropriate
therapy. Of course if target organ damage is present, especially
ocular or CNS signs, treatment should be initiated. In those cases
where TOD is not apparent and pressures are not dangerously
elevated, repeated measurements over the following days
are recommended to verify hypertension, preferably at least
on 3 occasions. If the results are still unclear or the patient
is uncooperative in the clinic setting, consideration should
be given to having the pet owner measure blood pressure at
home. Ideally blood pressure monitoring systems should offer
memory and download functions (HDO) so that the results can
Moderate Risk of TOD: <180/120
TOD and the benefits of hypertensive therapy have been
established for BP in this range [4,5,6,7,8,9]. Particular efforts
should be put into diagnosing not only potential underlying
diseases but also TOD. Again, treatment should be directed
towards the causative diseases and secondarily - if necessary,
additional drugs (e.g. Amlodipine for hypertension).
Risk Category
Systolic BP
Diastolic BP
Risk of future TOD
I
<150
<95
Minimal
II
150 - 159
95-99
Mild
III
160-179
100-119
Moderate
IV
>180
>120
Severe
Table 3 Categorisation of Hypertension[2,3]
136
EJCAP - Vol. 18 - Issue 2 October 2008
Disease
Haemodynamic Mechanism
Cardiovascular Effects
Periphery
Initial BP
changes
Later BP
changes
Heart disease
Catecholamine release,
RAAS activation
Heart rate Çζ SV Ç
(DCM in early stages only)
Æ CO Ç; myocardial tone
decreases as heart failure
progresses Æ CO È
Vasoconstriction,
volume retention
Æ increased preload
and afterload
Ç
È to ÈÈ
Kidney disease
RAAS activation,
growth factors
Æ LV hypertrophy
Æ heart rate Ç, SV Ç Æ
COÇ
Vasoconstriction (kidney:
Æ increased filtration pressure
Æ ... Æ glomerulosclerosis),
volume retention => increased
preload/afterload
Ç
ÇÇ (Ç)
Hyperthyroidism
Increased beta-adrenergic
activity, RAAS activation,
eventually secondary
nephropathy
Heart rate ÇÇ, SV Ç,
ventricular hypertrophy
Æ COÇ
Vasoconstriction, volume
retention Æ increased
preload/afterload
Ç
ÇÇ
Hyperadrenocorticism
Catecholamine synthesis Ç,
α and β receptor stimulation,
RAAS activation,
vasopressor effects ??
Heart rate Ç,
SV Ç Æ CO Ç,
LV hypertrophy
Vasoconstriction, volume retention
Æ increased preload/afterload
Ç
ÇÇ
Diabetes mellitus
Diabetic nephropathy,
lipid metabolism disturbance
Æ vasculopathy
Heart rate Ç, CO Ç,
LV hypertrophy
Vessel changes, vasoconstriction,
later volume retention
Ç
ÇÇ
Acromegaly
Increased aldosterone
secretion, increased sodium
and water retention
Unknown (somatotropininduced hypertrophy?)
Volume retention
Æ increased preload
(Ç)
(Ç)
Vasoconstriction, volume
retention Æ increased
preload/afterload
(Ç)
(Ç)
Hyperestrogenism
May temporarily
appear normal
in chronic disease
Pheochromocytoma
Catecholamine secretion
(massive, often episodic),
stimulation of renin release
Heart rate ÇÇ,
SV ÇÇ Æ CO ÇÇ
Vasoconstriction ÇÇ
ÇÇÇ
ÇÇÇ
Primary hyperaldosteronism
Increased secretion of
mineralocorticoids,
especially aldosterone
Unknown
Volume retention
(Ç)
Ç
Neurological changes
Lesions of diencephalon,
pain Æ sympathetic
nervous activity Ç Æ
catecholamine secretion Ç
Heart rate Ç,
SV Ç Æ CO Ç
Vasoconstriction
Ç
Ç
Anemia
Chemoreceptors sense
oxygen deficit
Heart rate Ç
SV Ç Æ CO Ç
Vasoconstriction
Ç
Ç
Table 2: Haemodynamic mechanisms of disease associated with hypertension
DCM = dilated cardiomyopathy, CO = cardiac output, LV = left ventricular, RAAS = renin-angiotensin aldosterone system, SV = stroke volume,
Ç = increases; È = decreases.
Severe Risk of TOD: >180/120
It is unlikely that white-coat hypertension would cause such
high values [2]. If no TOD is present, repeating blood pressure
readings several times over the next few hours can help to
eliminate white-coat hypertension as a differential. TOD is very
likely to develop with sustained blood pressures in this range.
Therefore - if the underlying disease can not be identified and
treated promptly or in a case where blood pressure is above
200/130 antihypertensive medication should be initiated
immediately and diagnosis of the disease should be the next
goal. Treatment can than be adjusted according to the individual
patient presentation. With TOD present, a more rapid reduction
of blood pressure is warranted. Amlodipine is a commonly used
Ca-Channel blocker for that purpose. It acts mainly on the
arterial walls and has almost no effects on the heart (16:1).
In this stage very often combinations of drugs are neccessary.
Especially proteinuria at present, ACE-I play an important role to
stabilise the patient both with regard to blood pressure and with
regard to kidney status.
Hypotension
Hypotension is quite common in daily veterinary practice.
Hypotension in awake animals can be found with advanced
stages of heart disease, with arrhythmias (bradycardia and
tachycardia), with cardiac tamponade, hypoxia, sepsis, shock
etc. .Hypotension is extremely common in anaesthetised patients
and is the main adverse side effect of anaesthesia. (like a cute
renal failure).
137
Blood Pressure in Small Animals - Part 1: Hypertension and hypotension and an update on technology - A.P. Carr
Severity
Awake animals
Inhalation anesthesia
Mild hypotension
<100/60
<90/50
Moderate hypotension
<90/50
<80/40
Severe hypotension
<70/50
<60/30
Table 4: Division of hypotension
Severity of hypotension is linked to the risk of malperfusion,
mainly of the kidney, the heart and the brain.
How to get reliable blood pressure readings
Although it is not a difficult task per se, there are some guidelines
which need to be followed to allow fast and reliable readings.
However the most important prerequisite is:
Severe and long-lasting depression of blood pressure can result
in inadequate perfusion of vital organs. The heart and the
brain are very susceptible and thus can suffer easily from severe
hypotension. The kidneys are also very susceptible to damage,
especially if renal autoregulation is impaired/lost. Acute renal
failure is a potential consequence of hypotension.
The willingness to measure blood pressure
The influence of environmental stress but also the influence
of an impatient examiner on blood pressure is described in
literature[10]. Thus certain guidelines should be followed to allow
a relaxed and fast reading as well as reliable accurate results:
What factors can lead to hypotension?
Generally decreases in heart rate, cardiac output, stroke volume
or total peripheral resistance can cause hypotension.
- Blood pressure measurements should be taken in a quiet
room.
- Visitors or employees should not walk in and out of the room
while a patient is being measured.
- The animal should have a few minutes to get used to the
environment prior to measurement.
- The animal should be handled in a calm and patient manner
- The pet’s owner should be present provided he or she is
able to calm the animal and does not contribute to the pet’s
anxiety.
- In each clinic, only a few individuals should be selected to
obtain blood pressure measurements to minimize operator
based variablilty.
- Measurements should be taken in a relaxed and comfortable
position for the pet.
- The appropriate equipment should be used and limitations
(Doppler, conventional oscillometry, Plethysmography) should
be well known to allow correct interpretation of the results.
- With HDO technology, measurements using the base of the
tail are easiest and fastest, though limbs can also be used.
- During the course of the 3-5 readings, ideally no conversation
should be carried out with the pet owner or other persons. This
allows the examiner to concentrate on the measurement.
Patients that are hypotensive prior to anaesthesia induction
are at much greater risk of developing severe hypotension in
comparison to normotensive or hypertensive patients. Chronically
hypertensive people are very prone to swings in BP and can get
quite hypotensive under GA. Also their equilibrium is set at a
higher BP so under anesthesia we need to have a higher cut-off
before we give BP support.
Because of this, blood pressure should be measured prior
to anaesthesia in patients with heart disease, symptoms
of hypotension (weakness, lethargy, cool extremities, poor
capillary refill time, syncope) or those animals which might not
be adequately hydrated.
In many cases fluid therapy can help to minimize hypotension
from various causes, especially if related to low circulating
volume.
Treatment of hypotension has to be directed towards
- Normalisation of venous return (e.g. re-positioning of the
animal).
- Addressing causative factors (arrhythmias, hypercapnia,
hypoxia).
- Fluids.
- Pressor and inotropic agents (sympathomimetics, nonadrenergic inotropes and vasopressors).
Short term variations in blood pressure
Physiological variation of blood pressure is always present
and depends on the basal sympathetic tone of the individual (up
to 10 - 20 mmHg in between the single readings)
Table 5 shows some of the key factors contributing to hypotension [11]
Heart rate È
CO È, SV È
Total peripheral resistance È
Alpha2-agonists
Opiates
Beta blockers
Increased vagal tone
AV block
Atrial standstill
Sick Sinus Syndrome
Hyperkalemia
Heart failure/insufficiency
Cardiac tamponade
Bradycardia/Tachycardia
Reduced venous return
(due to hypovolemia, vena cava
occlusion, positive pressure
ventilation, GDV, pericardial
tamponade,...)
Hypoxia
Hypercapnia
Hyperthermia
Surface warming of hypothermic
patients
Sepsis
Alpha2 antagonists
138
EJCAP - Vol. 18 - Issue 2 October 2008
Figure 1 A Conventional oscillometric BP
measurement unit
Figure 2 The HDO BP measurement unit
Stress related
Variations Sys
Stress related
Variations Dia
Figure 3 A Doppler BP
measurement unit
Stress related
Variations Sys
Stress related
Variations Dia
White coat effect/hypertension
This variation is a stress related elevation of blood pressure at
the beginning of the readings. Over time it generally disappears.
Therefore, additional readings are needed or allow the animal
additional time to relax. It may be a consideration to wait 5
minutes and then start the measurement series again.
or held by the owner.
Large dogs: If possible, take the measurements with the patient
positioned on the floor.
Positioning of the patient:
It is ideal if the measurement site is approximately on the same
level as the base of the heart.
That can be accomplished when measuring the patient in
- “down” position at the base of the tail or on the front limb
below the elbow.
- lateral recumbency, with the cuff being placed on the base of
the tail or on the forelimb on the ground.
- standing position, measuring on the base of the tail.
Technology
Blood pressure measurement is a simple procedure but requires
the use of technical equipment. The operator must therefore
- know the instrument.
- know how to operate the instrument and how to detect
sources of error.
- know how to correctly and carefully apply the cuff.
- minimize stress factors.
In general, since it is important to evaluate both the systolic and
diastolic blood pressure, preference should be given to technology
which determines both values. It is absolutely vital that the
operator be skilled with the equipment being used to maximise
the chances that reproducible results are obtained. A variety of
factors will influence which unit is best suited for an individual
clinic including ease of use, cost, number of units needed, etc.
Of course once a unit has been obained it is vital that it be used
frequently to become well versed in its use.
Stress related variation
This is a very common situation in the average practice. It is
hard to keep the clinic environment completely quiet, so these
variations are very likely to occur. In general, initially readings
with just minor physiologic variations are generated, then a
stress situation occurs (somebody coming into the room, a phone
rings, etc.). The next reading will be much higher, followed, if no
further stress occurs, by normal readings.
Thus it is vital to allow the animal to adjust to the environment:
Cats: take the cat out of its kennel. Let the cat decide which is
the preferred position (sitting or lying on the examination table,
being held by the pet owner).
Small dogs: The patient can be placed on the examination table
139
Blood Pressure in Small Animals - Part 1: Hypertension and hypotension and an update on technology - A.P. Carr
Table 6 Technical features of the different technologies
Doppler
Conventional
Oscillometry
High-definition
Oscillometry (HDO)
Gain
Acoustic detection of the
return of blood flow
(dependent on the
examiner’s individual
hearing capacity and
reaction speed at which the
examiner can visually
observe and mentally
register the numbers on the
sphygmomanometer
gauge)
Fixed preset values for
recognition of pulse
waveforms and
amplitudes
Allows manual adjustment
of amplitude recognition
settings (amplification) for
each individual patient
(range: 100 to 560-640)
Artifact
recognition
Not possible
Two approximation
strategies are used
(depending on
manufacturer)
Recognized artifacts are
eliminated and do not
interfere with
measurements
• Fuzzy logic
• Feedback loop
Valve action
Mechanical valve;
Linearity from ~160–80 mmHg
Mainly mechanical valves;
Linearity from ~160–80 mmHg
Electronic valve
Can detect and regulate
pressure within
microseconds; precise
measurement is therefore
possible, even outside the
160–80 mmHg range
Pulsedependent
linear deflation
rate/cutoff
value
Valve-determined cut off
value at ca. 160 mmHg;
Since the mechanical valve
is opened manually, linear
deflation of cuff is not
possible
Valve-determined cut off
value at ca. 160 mmHg;
Valve is opened
automatically (mechanical
or electronic valves, the
sensitivity of which can be
adjusted more or less
variably);
Real-time analysis and,
hence, real-time valve
programming is not
possible (8-bit processor);
Valve-determined cut off
value at ca. 160 mmHg;
Real-time analysis and
real-time valve
programming (securing
accuracy) is possible in
the 0–300 mmHg (-450 mmHg
- MD science) pressure
range (32-bit processor)
Processor
speed and
sampling rate
Real-time analysis not
possible;
Dependent on the
examiner’s hearing and
reaction capacity;
Detailed analysis not
possible
Real-time analysis not
possible;
Permits pulse ratedependent analysis (160–
250 max., depending on
the system), on average,
of one entire amplitude in
a maximum measurement
range of 0–250 mmHg
Permits real-time analysis;
Provides much higher
resolution and permits
analysis within microseconds; can therefore
detect even the smallest
signals and measure
extremely high heart rates
of 400 beats/min and higher
140
EJCAP - Vol. 18 - Issue 2 October 2008
Table 7: Implications of the different technologies for practical applications
Doppler
Conventional
oscillometry
High-definition
oscillometry (HDO)
Specified measurement
range
0–300 mmHg
0–300 mmHg
0–300 mmHg
Theoretical precision
~ 80–160 mmHg (valve)
and user-dependent
~ 80–160 mmHg (valve)
< 250 mmHg (processor)
0–450 mmHg
(valve and processor)
Actual precision
?
(User-dependent)
~ 80–160 mmHg
5–300 mmHg (5-450 mmHg MD
Science)
Use of patient-specific
measurement variables
Not possible
Manufacturer-dependent,
maximum inflation
pressure
Automatic or
manual adjustment of
maximum inflation and
deflation pressures, deflation
rate and gain
Cuff volume recognition
NO
NO
YES
Time per measurement
in cats
ca. 30 seconds to 2 minutes *
ca. 40 seconds to 2 min **
8–15 seconds ***
Measurement despite
arrhythmia
Not possible
Limited (fuzzy logic)/
Not possible
Possible
Sensitivity at
low amplitudes °
Limited;
There is no gain option since
signal amplification is linked
with noise amplification
Manufacturer-dependent
limitations;
Preset optimizer for cat
(Memoprint)
Gain options
depending on the unit 100 640 (50 - 1200 MD science)
Deflation rate °°
»Click« at 3 mmHg/min;
otherwise not definable
Generally 3 mmHg/sec;
Cardell: 3–7 mmHg/sec;
Memoprint: 3–6 mmHg/sec
Individual and pulsedependent adjustment from
3–18 mmHg/sec
High heart rate
Impedes measurement
considerably
Manufacturer-dependent
limitations occur at
160 bpm and higher
< 400 beats per minute
> 400 bpm possible with
MD Science
Provision of measurement
results
Acoustic signal, cuff pressure
read from sphygmomanometer
dial indicating either systolic
on mean arterial pressure can not be differentiated
Digital display of SAP,
DAP, MAP (depending on
manufacturer), and pulse
Real-time display of results
on screen of laptop or PC and/or
digital display on the unit for
users without PC connection;
graphics display can be
analyzed on PC at a later
time
Telemedicine capabilities 1
NO
NO
YES
Measurements during
anesthesia
May be limited (depending on
which anaesthetic is used)
May be limited (depending
on which anaesthetic is
used)
No limitations apply
Measurement at very
low pressures
(SAP < 60 mmHg)
Not possible
Not possible
Possible
Automated monitoring
function
NO
Feedback loop function on
some systems
(manufacturer-dependent)
Feedback loop function,
real-time measurement
recording and on-screen
presentation
*
**
Dependent on factors like patient cooperation, signal strength, hearing capacity of user, and manual valve opening rate, etc.
Mainly dependent on patient cooperativeness and therefore on (manufacturer-dependent) availability of fuzzy logic and feedback loop functions for
artifact elimination.
*** Dependent on heart rate: the higher the heart rate, the faster the measurement.
° Small amplitudes are mainly attributable to small-diameter blood vessels (small animals, caudal artery, etc.) but also to impaired arterial elasticity
(assess CNI as needed).
°° The higher the heart rate, the higher the deflation rate. Effects: a) To achieve as accurate a measurement as possible b) while simultaneously shorting
the measurement time.
1
Transmission of measurements to an expert for assessment
141
Blood Pressure in Small Animals - Part 1: Hypertension and hypotension and an update on technology - A.P. Carr
Fig. 6: HDO reading of a cat with CKD and hypertension. High
pre-systolic amplitudes indicate either severe vasoconstriction or
arterial loss of elasticity. (The systolic pressure is indicated by the
blue amplitude so everything that is before that amplitute is
‘pre-systolic’)
The presystolic wakes are on the left and are clearly elevated.
Fig. 4: HDO reading: normal blood pressure.
Literature
[1]
COWGILL (L.), KALLET (A.) - Recognition and management of
hypertension in the dog. In: Kirk RW, ed. Current Veterinary
Therapy VIII. Philadelphia, PA: WB Saunders, 1983: 1025-1028
[2] BROWN (S.), ATKINS (C.), BAGLEY (R.), CARR (A.), COWGILLL,
DAVIDSON (M.), EGNER (B.), ELLIOTT (J.), HENIK (R.), LABATO
(M.), LITTMAN (M.), POLZIN (D.), ROSS (L.), SNYDER (P.),
STEPIEN (R.) - Guidelines for the Identification, Evaluation, and
Management of Systemic Hypertension in Dogs and Cats. J Vet
Inern Med, 2007, 21: 542-558
[3] EGNER (B.), CARR (A.), BROWN (S.) - Essential Facts of Blood Pressure
in Dogs and Cats. ISBN 978-3-938274-15-6, VBS GmbH 2007
[4] SANSOM (J.), ROGERS (K.), WOOD (J.) - Blood pressure assessment
in healthy cats and cats with hypertensive retinopathy. Am J Vet
Res. 2004, 65(2): 245-52
[5] MATHUR (S.), SYME (H.), BROWN (C.) - et al. Effects of the calcium
channel antagonist amlodipine in cats with surgically induced
hypertensive renal insufficiency. Am J Vet Res, 2002, 63: 833-839
[6] KYLES (A.), GREGORY (C.), WOOLDRIDGE (J.) - et al. Management
of hypertension controls postoperative neurologic disorders after
renal transplantation in cats. Vet Surg, 1999, 28: 436-441
[7] GREGORY (C.), MATHEWS (K.), ARONSON (L.), et al. Central
nervous system disorders after renal transplantation in cats. Vet
Surg, 1997, 26: 386-392
[8] GRAUER (G.), GRECO (D.), GRETZY (D.) - et al. Effects of enalapril
treatment versus placebo as a treamtent for canine idiopathic
glomerulonephritis. J Vet Intern Med, 2000, 14: 526-533
[9] BROWN (S.), FINCO (D.), BROWN (C.) - et al. Evaluation of the
effects of inhibition of Angiotension converting enzyme with
enalapril in dogs with induced chronic renal insufficiency. Am J
Vet Res, 2003, 64: 321-327
[11] ERHARDT (W.), HENKE (J.), CARR (A.) - What is hypotension. From:
EGNER (B.), CARR (A.), BROWN (S.) - Essential Facts of Blood Pressure
in Dogs and Cats. ISBN 978-3-938274-15-6, VBS GmbH 2007
[12] SCHMELTING (B.), EGNER (B.), KORTE (S.), WEINBAUER (G.)
- High Definition Oscillometry, a new method for non-invasive
blood pressure measurement in concious and sedated common
marmosets. J AALA, 46(2): 144
5a
5b
Fig. 5a + b: HDO reading and corresponding ECG: sinus block.
Changes in cardiac output as well as the arrhythmia can be verified
in the HDO pattern.
Acknowledgements
Permission to reprint Tables 2, 4 and 5 has been kindly given
by Erhardt W, Henke J, Carr A, Egner B: Importance of Blood
Pressure Measurement. In: Essential Facts of Blood Pressure in
Dogs and Cats. P 46-48, VBS GmbH 2007
Editor's Note
The ‘Blood Pressure in Small Animals’ paper in this issue ,is the first of two commissioned by FECAVA to bring readers up to date with all aspects
of the subject. It is inevitable therefore that the section on Technology gives extensive information regarding the recent advances in oscillometric
blood pressure monitoring technology. It should however be borne in mind that many Veterinary surgeons, including some who specialise in cardiology prefer to continue to use the oscillometric and Doppler units to which they are accustomed , and which they find work very well. EJCAP
would welcome any comments or experience with the different systems available. If these are forthcoming we intend to publish letters or a summary of points made in our next issue. The authors of the paper have been involved with the development of HDO technology, but have declared no
financial interest in the S+B Med VET monitor.
142
CARDIOLOGY
REPRINT PAPER (F)
Case report: mitral valve disease in a
large breed dog
E. Bomassi (1)
SUMMARY
This case describes a particular form of mitral regurgitation in a 13 year old large breed dog. This form of valvular
insufficiency in large breed dogs is quite different from those described in small breed dogs. Clinical, radiographic
and echocardiograpic findings and possible treatments of this particular form are presented and discussed.
Key words: Mitral regurgitation; valvular insufficiency; large breed dog.
heart murmur was heard. Respiratory sounds were increased;
crackles were mostly heard during the end of inspiration.
This paper originally appeared in:
Prat Méd Chir Anim Comp* (2007) 42: p 123-130
The main differential diagnosis was congestive cardiac
insufficiency with pulmonary oedema, mitral failure, and
arrhythmia. Diagnostic tests were performed to evaluate all the
symptoms.
Introduction
Mitral endocardiosis is a chronic degenerative disease of
the mitral valvular apparatus. It is characterised by myxoid
degeneration with distortion of the free side of the leaflets. This
distortion is responsible for deficient functioning of the valve
and regurgitation. This leads to left heart insufficiency. This is
the most common canine heart disease. Aged male dogs of
small breeds are mainly affected [1,2]. However this disease has
also been described in large breed dogs [3,4].
This clinical case describes chronic mitral valve disease in a large
breed dog.
Right lateral (figure 1) and dorso-ventral (figure 2) thoracic
radiographs revealed bilateral cardiomegaly (Buchanan’s vertebral
scale = 13 ; normal = 9.7 +/- 0.5 [5] ; the transverse diameter
was more than 2/3 of the total diameter of the thorax). The
Figure 1: right lateral thoracic radiograph: left-sided cardiomegaly,
venous densification, and alveolar pulmonary oedema.
Clinical case
A 13 year old male Saluki weighing 25kg was presented for
lethargy and difficulty breathing of a few days duration. Vaccinations were up to date. Mitral insufficiency had been diagnosed
by another veterinarian a year earlier by echocardiography.
Enalapril (0.5 mg/kg divided BID) had been given since. Rectal
temperature was within normal limits. Capillary refill time
was increased to 4 seconds. There was effort intolerance and
symptoms were present even at rest. Respiration was dyspnoeic
and the rate was increased (35 breaths per minute). The femoral
pulse was thready and a pulse deficit was noted. The heart rate
was high (about 180 to 190 beats per minute). Rhythm was
irregular. A high intensity (4/6) holosystolic left sided apical
(1) Centre Hospitalier Vétérinaire des Cordeliers, 29 avenue du Maréchal Joffre, 77100 Meaux. E-mail: eric.bomassi@wanadoo.fr
* Presented by AFVAC (France)
145
Case report: mitral valve disease in a large breed dog - E. Bomassi
Figure 2: dorso-ventral thoracic radiograph: cardiomegaly and
alveolar pulmonary oedema.
Figure 5: echocardiography (M-mode), right parasternal short axis
image, transventricular view: left systolic and diastolic ventricular
dilatation.
radiographs confirmed the diagnosis of congestive disease with
pulmonary oedema.
An electrocardiogram (6 Leads, 25 mm/s, 10 mm/mV) (figure
3) revealed an increased and highly irregular heart rate (about
250-260 beats per minute). Electrocardiographic ventricular
morphologies were as follows:
- Sinus supraventricular morphology (normal complexes like
complex no 3 for example);
- Paroxystic right ventricular morphology (enlarged complexes
like complex no 2 example);
- Intermediate morphology (fusion complexes ie. mixed
morphology between normal and enlarged complex no 4 for
example).
Figure 3: 6-lead electrocardiogram, 25 mm/s, 10 mm/mV:
paroxysmal left ventricular extrasystoles.
size of the left atrium was particularly increased. The tracheovertebral angle was decreased. Pulmonary venous densities
were present on the lateral view (figure 1). The pulmonary
parenchyma showed interstitial and alveolar densities consistent
with alveolar pulmonary oedema (figures 1 and 2). These
All these changes lead to the conclusion of an intermittent
left ventricular tachycardia (with series of left ventricular
extrasystoles).
Figure 4: echocardiography (two-dimensional mode), right
parasternal short axis image, transaortic view: left atrial dilatation.
Figure 6: echocardiography (two-dimensional mode), right
parasternal long axis image, four-chamber view: view of the mitral
valve during diastole.
146
EJCAP - Vol. 18 - Issue 2 October 2008
Figure 7: echocardiography (two-dimensional mode), right
parasternal long axis image, four-chamber view: view of the mitral
valve during systole, minor prolapse.
Figure 8: echocardiography (pulsed Doppler mode), left parasternal
long axis image, four-chamber view: restrictive transmitral flow.
Echocardiography confirmed severe, mostly left-sided, chamber
dilatation. The LA/Ao ratio was increased (figure 4) (LA/Ao =
2.7; normal < 1.6 [6]), as well as the LVEDD/Ao ratio (figure 5)
(LVEDD/Ao = 3.1; normal < 1.8 [7]). Ventricular dilatation was
also observed in M-mode during systole and diastole (figure 5)
(LVEDD = 7.04 cm; normal < 4.4 cm [8]; LVESD = 4.04 cm;
normal < 2.9 cm [8]). The free side of the mitral valve leaflet was
mildly thickened during diastole (figure 6) and systole (figure
7), and a small prolapse was seen (figure 7). Chordae tendinae
were normal.
Transmitral flow was recorded in pulsed-wave Doppler
echocardiography (figure 8) and showed a restrictive type
(Appleton type 2, Em/Am= 2.04). A high velocity mitral
regurgitation flow was recorded (Vmax=4.16m/s). All other
flows (aortic, pulmonary and tricuspid) were within normal
limits.
An electrocardiogram (6 Leads, 25 mm/s, 10 mm/mV) (figure
10) showed marked improvement in the arrhythmia, with just
a few isolated extrasystoles still being present. Chemistry panel
(BUN, creatinine, ALT, ALKP, glucose, Na, K, Cl) was within
normal limits. The treatment was maintained and the dose of
frusemide was decreased from 4 mg/kg to 2 mg/kg.
Figure 9: echocardiography (pulsed Doppler mode), left parasternal
long axis image, four-chamber view: mitral regurgitation flow.
A haemotology and chemistry panel (BUN, creatinine, ALT,
ALKP, glucose) were within normal limits.
The definitive diagnosis was mitral insufficiency responsible for
grade 3a heart failure (ISACHC classification [9]), with alveolar
pulmonary oedema and intermittent ventricular tachycardia.
Enalapril was maintained at the same dosage. Since the owners
were not willing to leave the dog in the hospital, frusemide
4mg/kg divided BID [10] was prescribed for the pulmonary
oedema, mexiletine 5mg/kg divided BID was prescribed for the
arrhythmia [11], and pimobendan 0.5mg/kg divided BID was
prescribed for its inotropic effect as recommended with at least
grade 2 cardiac insufficiency [10,12].
Figure 10: electrocardiogram 6 Leads, 25 mm/s, 10 mm/mV:
isolated left ventricular extrasystoles.
The dog was presented for a recheck 10 days later. Clinical signs
were markedly improved. Intolerance was observed only during
moderate to marked effort. Heart rate was decreased and the
rhythm was more regular. Respiratory signs were within normal
limits.
147
Case report: mitral valve disease in a large breed dog - E. Bomassi
A recheck was made over the phone 3 months later and no
clinical signs were reported by the owners.
A recheck appointment to include radiographs, electrocardiogram and echocardiography was scheduled for 6 months later.
small breed dogs. The clinical presentation is different, and it is
possible that the course and pathophysiology of the two entities
are different. More studies are necessary to identify and confirm
these findings.
Discussion
References
Chronic mitral valve disease is the most common heart
disease in the dog. It mainly affects small breed dogs [1,2],
in which significant morphological changes to of the mitral
valve apparatus occur (the free side of the leaflets appears
bumpy, thickened and fibrotic; the chordae tendinae and the
myocardium are fragile, fibrotic and prone to rupture). This
disease is also seen in large breed dogs in which the changes
to the mitral apparatus are different [3,4]: morphological
anomalies of the mitral apparatus are less marked but there is
significant valvular insufficiency.
This case describes this particular type of chronic mitral valve
disease in a large breed dog. Several characteristic anomalies
are seen here [3,4,13,14]: the valve is only mildly thickened
and the prolapse is minimal but nonetheless associated with
severe regurgitation and anatomical changes (atrial and
ventricular dilatation). Other findings are less typical in a
large breed dog [13,14], and include a high intensity heart
murmur (4/6). The type of ventricular arrhythmia observed in
this case is the second most frequent encountered, with atrial
fibrillation being more common [14].
The aetiology of this particular form of mitral disease in large
breed dogs has not been clearly identified [13,14]. It could
be a congenital form of mitral dysplasia, or a myocardial
insufficiency. There has been no study to date to confirm
these hypotheses [13].
The treatment of this form of mitral disease is classic and
mainly focuses on treating the cardiac insufficiency, including
congestive signs and associated signs (arrhythmias, etc.). The
use of pimobendan is subject to discussion. It is currently
recommended in the treatment of grade 2 cardiac insufficiency
[10,12] (ISACHC classification [9]) but due to its inotropic
action, it is mainly useful when myocardial insufficiency
is present. It is possible that myocardial insufficiency might
develop earlier in large breed dogs with mitral disease than
in small breed dogs, allowing the use of this drug earlier in
the disease process [13,14]. Benefits drawn from its inotropic
action would therefore be greater [13,14]. One of the current
difficulties is to precisely evaluate myocardial function with
echocardiography when mitral regurgitation is present, because
the main measuring tools (fractional shortening, systolic intervals,
volume index) lack sensitivity [13,14] in this case.
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
BUCHANAN (J.W.) - Causes and prevalence of cardiovascular
disease. In Kirk RW and Bonagura JD ed. Current Veterinary
Therapy XI. Philadelphia, WB Saunders. 1992, 647-655
HAGGSTROM (J.), PEDERSEN (H.D.), KVART (C.) - New insights
into degenerative mitral valve disease in dogs. Vet. Clin. North.
Am. Small Anim. Pract. 2004, 34(5): 1209-1226
DE MADRON (E.) - Primary acquired mitral insufficiency in adult
large breed dog. Proceeding of the 10th ACVIM Forum. 1992,
608-609
DE MADRON (E.) - Unsual aspect of mitral valve disease in the
dog. Proceeding of the 16th ACVIM Forum. 1998, 116-118
BUCHANAN (J.W.), BUCHELER (J.) - Vertebral scale system to
measure canine heart size in radiographs. J. Amer. Vet. Med.
Assn. 1995, 206: 194-199
RISHNIW (M.), ERB (H.N.) - Evaluation of four 2-dimensional
echocardiographic methods of assessing left atrial size in dogs. J.
Vet. Intern. Med. 2000, 14: 429-435
LE BOBINNEC (G.) - Indices de ratio échocardiographiques en
mode TM. In : Proceeding of the 1st International Canine Valvular
Disease Symposium. Paris 2004, 30-34
DE MADRON (E.) - L’échocardiographie en mode M chez le chien
normal. Thèse Doct. Vet., Alfort, 1983
The International Small Animal Cardiac Heart Council (ISACHC).
Recommendations for the diagnosis and the treatment of heart
failure in small animals. 1994, 5.
BONAGURA (J.D.) - Cardiovascular Drugs. Proc. 14th ECVIM-CA
Congress. September 2004, Barcelona, Spain
MEURS (K.M.), SPIER (A.W.), WRIGHT (N.A.), ATKINS (C.E.),
DEFRANCESCO (T.C.), GORDON (S.G.), HAMLIN (R.L.), KEENE
(B.W.), MILLER (M.W.), MOISE (N.S.) - Comparison of the effects of
four antiarrhythmic treatments for familial ventricular arrhythmias
in Boxers. J. of Am. Vet. Med. Assoc. 2002, 221(4,): 522-527
LOMBARD (C.) - Veterinary Study for the Confirmation Of
Pimobendan in Canine Endocardiosis – results of the vetSCOPE
study. In : Proceeding of the 1st International Canine Valvular
Disease Symposium. Paris 2004, 67-70
HAGGSTROM (J.) - Mitral regurgitation in large dogs. J. Vet.
Cardiol. 2004, 6(2): 6-7
BORGARELLI (M.), ZINI (E.), D’AGNOLO (G.), TARDUCCI (A.),
SANTILLI (R.A.), CHIAVEGATO (D.), TURSI (M.), PRUNOTTO (M.),
HAGGSTROM (J.) - Comparison of primary mitral valve disease in
the German Shepherd dog and in small breeds. J. Vet. Cardiol.
2004, 6(2): 27-3
How to contact the FECAVA Office
and Secretary
Glossary:
LA: left atrium
Ao: aorta
LVEDD: left ventricular end diastolic diameter
LVESD: left ventricular end systolic diameter
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148
ORTHOPAEDICS
REPRINT PAPER (SAVAB)
Interobserver agreement in the
diagnosis of canine hip dysplasia
using the standard ventrodorsal
hip-extended radiographic method
G. Verhoeven(1), F. Coopman (1), L. Duchateau(2), J. H. Saunders (1), B. Van Rijssen (1), H. Van Bree (1)
SUMMARY
Objectives: To determine the agreement between observers and to investigate the effect of observer experience in
diagnosing canine hip dysplasia and providing final scoring of hips using the standard ventrodorsal hip-extended
radiographic method. The agreement of the final scoring, with a presumed correct assessment based on the Norberg
angle, is also investigated.
Methods: Thirty observers were requested to read 50 ventrodorsal hip-extended radiographs of 25 dogs according
to Federation Cynologique International criteria. Groups of experienced (nine members) and inexperienced (21
members) observers were used.
Results: For providing the distinction between dysplastic versus non-dysplastic dogs, the average interobserver
agreement was 72 per cent and was significantly higher (P<0-0001) than the score that could be expected by chance
without any agreement between observers. For providing the final score (A, B, C, D or E), an average interobserver
agreement of 43.6 per cent was found. In the experienced group, an agreement score of 76 per cent was found for the
distinction between AB versus non-AB and an agreement score of 81 per cent was found for the distinction between
C versus non-C. The agreement score was significantly higher (P<0.001) for the experienced group than for the
inexperienced group in all cases. Agreement between the presumed correct assessment based on the Norberg angle
and the observer‘s evaluation was low (P=0.35), irrespective of whether the observers were experienced (71.8 per cent
correct assessments) or inexperienced (69 per cent correct assessments).
Clinical Significance: Although interobserver agreement is low, observer experience increases agreement.
[Coopman and others 2004].
In North America, the diagnosis of CHD is made by radiographic
evaluation of the hips according to the protocol established
by the American Veterinary Medical Association using the
subjective standard ventrodorsal hip-extended view and
applying a 7-point grading system [Keller 2003]. In continental
Europe, the recommendations of the Federation Cynologique
International (FCI) using a five-grade scale from A to E (Table 1)
are followed to a large extent [Flückiger 1993]. In this scoring
system, dog’s hips are classified as A, B, C, D, or E. Dogs with A
(no signs of hip dysplasia) and B (near-normal hip joints) hips are
This paper originally appeared in the Journal of Small
Animal Practice* (2007) 48, 387–393
Introduction
Canine hip dysplasia (CHD) is a debilitating developmental
disease first described by Schnelle (1935). The breed prevalence
in the USA as estimated by the Orthopedic Foundation for
Animals (OFA) varies between 10 and 48 per cent [Keller 2003].
These rates are comparable to the results in Belgium and Europe
(1)Department of Medical Imaging and(2) Department of Physiology, Biochemistry and Biometry,
Ghent University, Salisburylaan 133, B-9130 Merelbeke, Belgium. E-mail: geertverhoeven.adr@telenet.be
*Presented by SAVAB (Belgium)
149
Interobserver agreement in the diagnosis of canine hip dysplasia.. - G. Verhoeven et al
A
No signs of hip dysplasia
Femoral head and acetabulum are congruent, and the joint space is narrow
The cranial acetabular edge is congruent with the femoral head
The NA measures at least 1000
The FHC is clearly medial to the dorsal acetabular edge
There are no signs of osteoarthritis
B
Near-normal hip joints
Femoral head and acetabulum are slightly incongruent, but the NA measures at least 100
The cranial acetabular edge is curvilinear and smooth, and the cranial effective acetabular rim is horizontal
The FHC is just medial to or on the dorsal acetabular edge
There are no signs of osteoarthritis
C
Mild hip dysplasia
Femoral head and acetabulum are incongruent
The NA measures at least 950
There is mild receding of the cranial acetabular rim
The FHC is on the dorsal acetabular edge or slightly lateral to it
Mild osteoarthritis is present
D
Moderate hip dysplasia
Femoral head and acetabulum are obviously incongruent
The NA measures at least 900
The FHC lies clearly lateral to the dorsal acetabular edge
There may be receding of the cranial effective acetabular rim
Signs of osteoarthritis are usually present
E
Severe hip dysplasia
The femoral head is markedly subluxated or luxated
The NA measures less than 900
The FHC lies obviously lateral to the dorsal acetabular edge
The craniolateral acetabular rim is obviously receding
Obvious signs of osteoarthritis are usually present
FHC Femoral head centre, NA Norberg angle
Table 1. Scoring system according to the Federation Cynologique International regulations
considered non-dysplastic and are therefore recommended for
use in breeding programmes. Dogs with C hips are considered
mildly affected and can be used in the breeding programme
in certain instances, whereas D and E dogs are considered
clearly dysplastic and are therefore not considered as breeding
candidates. However, in some countries and for some breeds, it
is not explicitly forbidden to breed with dogs that have D and
E hips. In the UK, the British Veterinary Association/ Kennel
Club uses a scheme with nine different radiographic parameters
where each parameter is given a point value between 0 and
6 except the caudal acetabular edge which is scored 0 to 5,
depending on the degree of severity [Gibbs 1997]. These
radiographic evaluations have been used to reduce the incidence
of CHD [Brass 1989].
Despite the extensive use of various protocols using the
subjective hip-extended method over the past 30 years, the
slow progress in decreasing the incidence of CHD remains a fact
[Powers and others 2004]. This may be attributed to several
factors such as the insensitivity in detecting laxity of the hip
joint, high interobserver variation, degenerative joint disease
that is often not visible at the age the radiographs are made and
breeders continuing to use dysplastic dogs [Brass 1989, Morgan
and others 2000, Keller 2003]. The effect of breeding affected
dogs that have not been assessed by any method is unclear and
difficult to investigate.
To date, there are few studies that have assessed the variation
among radiologists in assigning hip scores. One study found that
the level of agreement between observers, using a subjective
method, was very low [Smith and others 1996]. Paster and
others (2005) stated that between and within-radiologist
grading for CHD varies significantly when using standard
ventrodorsal hip-extended radiography. Saunders and others
(1999) found a significant difference between radiologists
evaluating ventrodorsal or dorsoventral hip-extended views.
The main objective of this study was to investigate the
interobserver agreement in determining dysplastic versus nondysplastic and final scoring using the FCI grading system. We
further investigated the agreement of the dysplastic/nondysplastic result with the FCI-proposed standard based on the
Norberg angle (NA). The effect of experience on agreement
between observers was also investigated.
Materials and methods
Data collection
Original radiographs of 25 dogs were obtained from the database
of the National Committee for Inherited Skeletal Disorders
(NCISD) of Belgium. For each dog, one pair of radiographs
was available. Radiographs of the same dog were different in
position and/or exposure.
All radiographs were numbered from one to 50, taking care
that radiographs of the same dog were not filed consecutively.
Additionally, care was taken to avoid radiographs with exuberant
signs of degenerative joint disease of the hip joint.
In total, 30 observers were recruited from the universities of
Bern (one), Ghent (11), Giessen (five), Utrecht (one), Zurich
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EJCAP - Vol. 18 - Issue 2 October 2008
Fig 1. Transparent HD ruler; Eickemeyer
Fig 2. Transparent HD ruler; Eickemeyer
(one) and private practitioners as members of the Flanders
Orthopaedic Working Group (FOWG) [11]. Two groups were
created. The experienced group (nine members) consisted
of board-certified radiologists (ECVDI), surgeons (ECVS) and
full professors in radiology or surgery. Furthermore, to be
categorised as experienced, each member had to be active in
the NCISD for at least 10 years. One member of the experienced
group was neither board certified nor a full professor but has
been active in the NCISD for 23 years. The inexperienced group
(21 members) contained residents in diagnostic imaging and
surgery and private practitioners active in the FOWG.
Each observer was asked to evaluate the original radiographs
individually, unaware of the fact that for every dog, two
radiographs were presented. Film readings were performed
under similar environments for each observer as much as possible
in a darkened room. Viewing boxes with shutters were used to
exclude extraneous light. Not all boxes had the same light bulbs
because film reading was performed in different universities.
The observers were asked to clearly indicate whether the right
and left hip joints were dysplastic or non-dysplastic and to give a
final score (FS) on the right and left hip joint according to the FCI
criteria (A, B, C, D or E), irrespective of whether they accepted or
rejected the radiograph for its technical quality. The NA was not
provided on the radiographs, and observers used free choice in
decision to measure the NA or not. The observers who decided
to measure the NA used a transparent template of their own
choice. Examples of two of these templates are shown in Figs
1 and 2. Observers were not allowed to indicate the femoral
head centre (FHC), being the centre of best fitting circle on the
template overlying the femoral head, or to write other markings
on the films. The observers were not asked to provide the NA
to the authors.
It must be emphasised that the authors chose not to standardise
the reading procedure. The observers were asked to read the
films in the same manner as they would perform in their official
screening procedure. In this way, investigation of interobserver
agreement reflects the situation as is currently present in the
different screening committees.
After the films had been read by the different observers, the NA
was measured on each film by the second author (F. C.). Using
the HD ruler as presented in Fig 1, the FHC was marked on the
film. A line was drawn through both FHCs and between the
FHC and the craniolateral acetabular edge. The angle between
these lines was measured using a standard goniometer with 10
accuracy. Following this procedure, a coefficient of variation
of 4 per cent could be obtained [Coopman and others 2006].
Based on this NA alone, the hip joint was scored dysplastic/
nondysplastic. According to the FCI criteria (Table 1), a hip
joint is considered dysplastic if the NA is less than 100. This
classification between dysplastic/non-dysplastic, based on the
NA measured by the second author, was presumed to be the
correct assessment for statistical analysis purposes.
Statistical analysis
An agreement score was derived for each radiograph by
determining the percentage of pairs of observers who made
Table 2. Relative agreement between experienced observers in FCI scoring, dysplasia/non-dysplasia determination, dogs that are considered
suitable for breeding (per cent AB) and dysplastic dogs (per cent CDE) and observers who measured NA for every hip joint
Observer
Per cent
grade A
Per cent
grade B
Per cent
grade C
Per cent
grade D
Per cent
grade E
Per cent nondysplastic
Per cent
AB
1
2
40
22
13
39
29
9
0
62
62
24
24
0
52
52
3
31
34
30
5
0
65
65
4
2
46
43
9
0
15
5
14
46
34
6
0
6
21
56
18
5
0
7
3
30
50
15
8
14
48
27
9
16
35
Mean
17
40
Per cent
CDE
NA
38
38
Y
48
48
Y
35
35
N
48
85
52
Y
60
60
40
40
N
77
77
23
23
Y
2
29
33
71
67
Y
11
0
44
62
56
38
N
26
13
0
56
51
44
39
N
31
11
0
51
57
49
42
FCI Federation Cynologique International, NA Norberg angle, Y Yes, N No
151
Per cent
dysplastic
Interobserver agreement in the diagnosis of canine hip dysplasia.. - G. Verhoeven et al
Observer
Per cent
grade A
Per cent
grade B
Per cent
grade C
Per cent
grade D
Per cent
grade E
Per cent nondysplastic
Per cent
AB
Per cent
dysplastic
Per cent
CDE
NA
10
25
37
37
1
0
62
62
38
38
N
11
27
34
28
11
0
61
61
39
39
N
12
25
49
25
1
0
74
74
26
26
Y
13
11
40
43
6
0
59
51
41
49
N
14
47
25
12
16
0
75
72
25
28
Y
15
52
33
14
1
0
85
85
15
15
Y
16
29
20
30
21
0
53
49
47
51
N
17
14
37
11
30
8
54
51
46
49
N
18
8
16
42
33
1
24
24
76
76
N
19
2
22
40
30
6
24
24
76
76
N
20
22
34
33
11
0
56
56
44
44
Y
21
8
31
43
16
2
39
39
61
61
N
22
32
37
28
3
0
69
69
32
32
Y
23
22
33
39
2
4
55
55
45
45
N
24
17
50
20
13
0
67
67
33
33
Y
25
18
53
29
0
0
71
71
29
29
N
26
16
47
28
6
3
68
63
32
37
N
27
21
41
24
11
2
63
62
37
37
N
28
28
31
31
10
0
63
59
37
41
Y
29
23
31
37
9
0
56
54
44
46
Y
30
36
40
17
7
0
71
76
29
24
Y
Mean
23
35
29
11
1
59
58
41
42
Table 3. Relative agreement between inexperienced observers in FCI scoring, dysplasia/non-dysplasia determination, dogs that are
considered suitable for breeding (per cent AB) and dysplastic dogs (per cent CDE) and observers who measured NA for every hip joint
FCI Federation Cynologique International, NA Norberg angle, N No, Y Yes
the same diagnosis: no dysplasia or dysplasia, AB (no breeding
restriction) or not and C (mild dysplasia) or not. Without any
interobserver agreement, this agreement score will be on
average 50 per cent (as many agreeing as disagreeing pairs).
Therefore, data were first tested by a linear mixed model with
normally distributed error term and dog as random effect to see
whether the agreement score was significantly higher than 50
per cent. Next, a mixed model with dog as random effect and
group as fixed effect was used to test whether the agreement
score differed between the experienced and inexperienced
groups of observers. Additionally, it was tested whether the
agreement score differed between the experienced observers
who measured the NA and the experienced observers who did
not measure the NA.
An agreement score was also derived based on the FCI score
for each radiograph by determining the percentage of pairs of
observers who assigned the same FCI score, and it was also
tested whether the FCI agreement score differed between the
experienced and inexperienced groups of observers by a mixed
model with dog as random effect and group as fixed effect.
Finally, the assessment of dysplasia/ non-dysplasia based on the
NA was performed, and it was tested whether the percentage of
presumed correct assessments differed between the experienced
and inexperienced groups of observers based on a generalised
mixed model with binomially distributed error term, observer as
random effect and group as fixed effect.
Results
Dysplastic/non-dysplastic
The average agreement between observers to make a distinction
between dysplasia/ non-dysplasia was 72 per cent and was
significantly higher (P<0.0001) than 50 per cent, the expected
score when there would be no agreement.
The agreement score was significantly higher (P<0.0001) for the
experienced group (71.3 per cent) than for the inexperienced
group (63.1 per cent).
AB (no breeding restriction) or not
The agreement between experienced observers to make a
distinction between AB or not AB was 76 per cent and was
significantly higher (P<0.0001) than 50 per cent, the expected
score when there would be no agreement.
The agreement score was significantly higher (P<0.0001) for
the experienced group (76 per cent) than for the inexperienced
group (67 per cent).
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EJCAP - Vol. 18 - Issue 2 October 2008
C (mild dysplasia) or not
The agreement between experienced observers to make a
distinction between mild dysplasia or not mild dysplasia was 81
per cent and was significantly higher (P<0.0001) than 50 per
cent, the expected score when there would be no agreement.
The agreement score was significantly higher (P<0.0001) for
the experienced group (81 per cent) than for the inexperienced
group (66 per cent).
permits breeding with mildly affected animals may be justified.
This prevents the breeding population from becoming too small,
which makes the genetic variability too low and can increase
the prevalence of other genetic disorders. In situations where
mildly affected animals are allowed to breed, it is not only
important to make a distinction between normal to near-normal
hips, mildly affected animals and moderate to severe affected
animals but also to know which animals have optima forma hips
(A hips) because these animals are the preferable partners for
mildly affected animals (C hips). A correct assessment between
observers and across borders is important to demonstrate
the credibility of the screening procedure and because it is of
psychological importance for dog owners to have a dog with
optimal hips. Owners prefer to have an A score in the free cases or
a C score if the dog is affected. For all these reasons, logical and
psychological, it is important to correctly classify hip joints at all
stages, within and between screening committees. Furthermore,
careful attention to refined phenotypic classification reduces
a primary source of heterogeneity and is directly beneficial to
genome-wide association studies [Cardon 2006].
Our study shows that observers classify dogs as non-dysplastic/
dysplastic, AB or not, C or not or in refined classes (A, B, C,
D and E) with insufficient agreement. Furthermore, some
observers do not classify A (no signs of hip dysplasia; Table
1) and B (near-normal hip joints; Table 1) hip joints as free of
dysplasia (Tables 2 and 3), as is prescribed by the FCI criteria and
as is commonly presumed. Incorrect classification means that
some dysplastic dogs receive a CHD-free score and are used
in breeding programmes. There is a particular problem in the
accurate classification of B-scoring (near-normal or transitional
cases according to some observers) hip joints. These results and
observations might explain the scepticism that exists in breeding
organisations towards the routine screening methods for CHD.
Disagreement between observers inevitably leads to a
considerable number of false-positive (loss of genetic variation)
and false-negative dogs (genetically affected). Allowing
false-negative dogs to breed maintains hip dysplasia in the
population, whereas false-positive dogs, which could decrease
the susceptibility for hip dysplasia, are rejected from the pool.
This may explain the slow progress of decreasing hip dysplasia
over the past few decades [Powers and others 2004].
Our results show an agreement of 72 per cent between pairs
of observers as to whether the animal should be classified as
having a normal or abnormal phenotype, which is significantly
higher than the expected score of 50 per cent when there
would be no agreement but much lower than the 100 per
cent one should have in an ideal screening situation. These
findings are in contradiction with the excellent results of OFA
that found an agreement in 93.4 per cent [Corley and Hogan
1985] to 94.9 per cent [Keller 2003] of the cases as to whether
the animal should be classified as having normal, borderline or
abnormal phenotype. This would indicate that the OFA uses an
almost perfect screening procedure. In contrast to the excellent
results presented by the OFA, Smith and others (1996) used a
weighted kappa analysis to quantify the agreement of hip scores
in ventrodorsal radiographic projections from 125 large and
giant-breed dogs older than two years. Three board-certified
veterinary radiologists evaluated hips using the OFA system.
For the 2-point scoring scheme (normal versus dysplastic) used
FCI scoring (A to E)
Agreement between observers was found in only 43.6 per cent
of the cases. For the experienced observers, this agreement was
significantly (P<0.0001) higher (52.49 per cent) compared with
inexperienced observers. Tables 2 and 3 illustrate the relative
agreement results between experienced and inexperienced
observers for FCI scoring and dysplasia/non-dysplasia
determination, respectively.
Discrepancy of non-dysplasia/ dysplasia versus AB/CDE
scoring
Not all observers followed the FCI criteria consistently: some
discrepancies were observed in the interpretation of nondysplasia/
AB scores and dysplasia/CDE scores. This discrepancy was seen
in four out of nine experienced observers and in eight out of
21 inexperienced observers. Three experienced and three
inexperienced observers had a discrepancy of greater or equal
to 5 per cent (Tables 2 and 3). Most discrepancies were found in
determining B- and C-scored hips.
Norberg angle
Using the NA as the correct assessment for determining dysplasia,
no significant differences (P=0.35) were observed between the
experienced group with percentage of correct assessment equal
to 71.8 per cent and the group of inexperienced observers with
percentage of correct assessment equal to 69 per cent.
NA and agreement in the experienced group
As the experienced group showed better overall interobserver
agreement compared with the inexperienced group, the
influence of NA measurement on agreement was studied only
in the former group. The most important factor in current
breeding practice is the ability to distinguish between AB or not
and C or not, so we focussed on interobserver agreement of
these scores.
In the experienced group, four observers decided not to measure
the NA for every hip joint, while five observers did measure
the NA for every hip joint (Table 2). There was no significant
difference in agreement for AB or not (P=0.08) or for C or not
(P=0.57) between experienced observers who measured the
NA and those who did not.
Discussion
To decrease the incidence of inherited disorders, all affected
animals should be excluded from breeding. Therefore, the
distinction between dysplastic and nondysplastic dogs is far
more important than the classification of dogs into five (FCI) or
seven (OFA) categories. However, in situations where a disease
has a high prevalence, a breeding strategy which temporarily
153
Interobserver agreement in the diagnosis of canine hip dysplasia.. - G. Verhoeven et al
in this study, kappa values ranged from 0.31 to 0.68, which is
more or less in agreement with our result.
Where the more refined 7-score system of the OFA was used, all
three radiologists agreed on the same hip phenotype in 73.5 per
cent of the cases [Keller 2003]. These percentages of agreement
are high considering the subjective nature of the evaluation
[Smith and others 1996, Smith 1997, Corley and others 1997,
Paster and others 2005]. In the study by Smith and others (1996),
the level of agreement between the three radiologists using the
7-score system was poor, with kappa values ranging from 0.04
(almost no agreement) to 0.20. Within-radiologist variability
was slightly better, with kappa values ranging from 0.38 to
0.45 in that study. This poor level of agreement seems to be in
accordance with our results, where an average agreement of
43.6 per cent for the five-score system was found. Unpublished
data from the Belgian Committee reveal that the agreement
between two different observers for the FS not only can be as
low as 0.27 but also be as high as 0.7, when using the kappa
analysis. Observers who have been reading hip radiographs
together over an extended period of time seem to develop a
more consistent agreement score (agreement harmonisation).
The exact reasons for the discrepancy between our results and
the results of the OFA remain hypothetical. A first hypothesis is
the difference in observer experience. Our results indicate that
there is a significant influence of experience on the agreement
between observers. Secondly, the OFA evaluates dogs that are
at least two years of age, increasing the chance of detecting
degenerative changes which make it much easier to classify dogs
as dysplastic or non-dysplastic. The OFA also gives the observer
the additional opportunity to give a borderline score (between
B and C) in cases where no clear distinction between normal
and abnormal is possible. The FCI allows final reading of hips
in animals one year of age and allows the observer to evaluate
degenerative joint disease (DJD) subjectively if a dog is older
than 2 years, giving the opportunity to score a mildly affected
dog as B and not C. Thirdly, the OFA is a centralised organisation
whereas the FCI allows local and national committees and even
individuals to read hips. Finally, the agreement scores were
estimated differently. Our agreement score is the result of a
statistical analysis, whereas Keller (2003) counted the amount
of radiographs that had three similar scores. In our study, we
compared 30 observers and defined the number of agreeing
pairs of observers. When there is no agreement between
observers and scores are just given at random, this agreement
score will be on average 50 per cent.
It should be stated that the observers in our study were forced
to read radiographs of suboptimal quality. Permitting the
observers to reject radiographs of poor quality might or might
not improve the interobserver agreement. We intentionally
prevented observers from rejecting the radiographs for their
radiographic quality in order to study the impact of radiographic
quality on interobserver agreement. This research is currently
underway at this institution. Quality control of radiographs for
CHD screening is not or insufficiently mentioned in the other
reports concerning interobserver agreement [Corley and Hogan
1985, Smith and others 1996, Smith 1997, Corley and others
1997, Keller 2003, Paster and others 2005].
An additional finding of our study indicates that there is no
agreement between the presumed correct assessment, based
solely on the NA, and the evaluation of the experienced
observers. Observers do not seem to interpret the NA values
as prescribed in the FCI criteria, which is in agreement with a
study by van der Velden (1983), who claimed that NA, used as
a sole objective parameter, fails to meet the requirements to
replace the subjective final scoring. The fact that no improved
agreement is found between observers who measured the NA
during scoring confirms the questionable value of the NA in
diagnosing CHD.
The question of validity of the NA has also been raised by Culp
and others (2006), who stated that using a NA threshold of
1050 (OFA) resulted in a high degree of false-positive and falsenegative diagnoses. This is in accordance with other reports that
studied the NA. Tomlinson and Johnson (2000) investigated
the NA threshold of 1050 in golden retrievers, Rottweilers and
German shepherd dogs and concluded that this was not a
reliable predictor of normal hip status. Smith and others (1993)
found DJD in dogs with a NA of more than 1050. It should be
noted that, according to FCI regulations, a NA of 1000 or more
corresponds to grades B and A hips, respectively, indicating that
the FCI uses even less stringent requirements than the OFA for
determining hip quality status.
Our results show disagreement in 28 per cent of pairs of observers
for determining dysplasia/non-dysplasia and disagreement of
the observer’s evaluations with the presumed correct assessment
based on the NA. According to the experienced group, the
range of dogs that were dysplastic was 23 to 85 per cent, while
the inexperienced group found a range of 15 to 76 per cent
of dysplastic dogs. Determination of AB or not and C or not
is comparable to the determination of dysplasia/nondysplasia.
No consensus is found on the relationship between the refined
scoring and classifying dogs as normal or abnormal. An even
higher disagreement was found when assessing the agreement
for the different FCI scores. Observers seem to have their own
reading style. Some used a template to measure the NA, while
others chose not to measure the NA. Different templates were
used. The templates as shown in Figs 1 and 2 only help to
determine the NA of 105, 100 and 90. Even when measuring
with an accuracy of 10, measuring errors of 4 per cent can occur
[Coopman and others 2006]; therefore, NA measurement is not
a highly reproducible technique. The higher variability seen in
the inexperienced group cannot be because of measurement
or no measurement of the NA as there were equal numbers of
observers in both groups who chose to measure NA as those
who did not. The observers were not allowed to draw on the
radiographs, which may have had some impact on the accuracy
of their NA measurement. However, it must be emphasised
that the observers were not asked to determine the exact NA
measurement but to determine dysplasia/non-dysplasia.
Besides the difference in determining the NA, other reasons for
the low agreement in our study could be the different viewing
conditions, the time needed to read all films and observers
subjectively assessing the hip quality status without following
the agreed regulations.
A limitation of this study is the lack of standardisation of the
reading process. This could have an impact on the recognition
of individual causative factors of disagreement. Further studies
are needed to identify these factors or to confirm the possible
causes of disagreement that are mentioned in this study.
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EJCAP - Vol. 18 - Issue 2 October 2008
Third International Conference: Advances in Canine and Feline
Genomics and Inherited Disorders. 2006, August 2 to 5, Davis,
CA, USA. p 43
CORLEY (E. A.), HOGAN (P. M.) - Trends in hip dysplasia control:
analysis of radiographs submitted to the Orthopedic Foundation
for Animals, 1974 to 1984. Journal of the American Veterinary
Medical Association, 1985, 187:805-809
CORLEY (E. A.), KELLER (G. G.), LATTIMER (J. C.), ELLERSIECK (M. R.) Reliability of early radiographic evaluations for canine hip dysplasia
obtained from the standard ventrodorsal radiographic projection.
Journal of the American Veterinary Medical Association, 1997,
211:1142-1146
CULP (W. T. N.), KAPITAN (A. S.), GREGOR (T. P.), POWERS (M. Y.),
MCKELVIE (P. J.), SMITH (G. K.) - Evaluation of the Norberg Angle
threshold: a comparison of Norberg Angle and Distraction Index as
measures of coxofemoral degenerative joint disease susceptibility
in seven breeds of dogs. Veterinary Surgery, 2006, 35:453-459
FLÜCKIGER (M.) -The standardised analysis of radiographs for hip
dysplasia in dogs. Objectifying a subjective process. Kleintierpraxis,
1993, 38:693-702
GIBBS (C.) - The BVA/KC scoring scheme for control of hip dysplasia:
interpretation of criteria. Veterinary Record, 1997, 13: 275-284
KELLER (G.) - The Use of Health Databases and Selective Breeding: A
Guide for Dog and Cat Breeders and Owners. 4th edn. Orthopedic
Foundation of Animals Inc., Columbia, MO, USA, 2003.
MORGAN (J. P.), WIND (A.), DAVIDSON (A. T.) - Hip dysplasia. In:
Hereditary Bone and Joint Diseases in the Dogs. Schlütersche,
Hannover, 2000, Germany. pp 131-171
PASTER (E. R.), LAFOND (E.), BIERY (D. N.), IRIYE (A.), GREGOR (T. P.),
SHOFER (F. S.), SMITH (G. K.) - Estimates of prevalence of hip
dysplasia in Golden Retrievers and Rottweilers and the influence
of bias on published prevalence figures. Journal of the American
Veterinary Medical Association, 2005, 226:387-392
POWERS (M. Y.), BIERY (D. N.), LAWLER (D. F.) EVANS (R. H.), SHOFER
(F. S.) MAYHEW (P.), GREGOR (T.P.), KEALY (R.D.), SMITH (G.
K.) - Use of the caudolateral curvilinear osteophytes as an early
marker for future development of osteoarthritis associated with
hip dysplasia in dogs. Journal of the American Veterinary Medical
Association, 2004, 225:233-237
SAUNDERS (J. H.), GODEFROID (T.), SNAPS (F. R.), FRANCOIS (A.),
FARNIR (F.), BALLIGAND (M.) - Comparison of ventrodorsal and
dorsoventral radiographic projections for hip dysplasia diagnosis.
Veterinary Record, 1999, 145:109-110
SCHNELLE (G. B.) - Some new diseases in dog. American Kennel
Gazette, 1935, 52:25-26
SMITH (G. K.) - Advances in diagnosing canine hip dysplasia.
Journal of the American Veterinary Medical Association, 1997,
210:1451-1457
SMITH (G. K.) GREGOR (T. P.), RHODES (W. H.) - Coxofemoral joint
laxity from distraction radiography and its contemporaneous and
progressive correlation with laxity, subjective score, and evidence
of degenerative joint disease from conventional hip-extended
radiography in dogs. American Journal of Veterinary Research,
1993, 54:1021-1042
SMITH (G. K.) BIERY (D. N.), RHODES (W. H.) - Between- and withinradiologist accuracy of subjective hip scoring of the ventrodorsal
hip-extended radiograph (Abstract). Proceedings of the
International Symposium on Hip Dysplasia and Osteoarthritis in
Dogs, 1996. Cornell University, New York, USA. p 20
TOMLINSON (J. L.), JOHNSON (J. C.) - Quantification of measurement
of femoral head coverage and Norberg Angle within and among
four breeds of dogs. American Journal of Veterinary Research,
2000, 61:1492-1500
VAN DER VELDEN (N. A.) - Hip dysplasia in dogs. Veterinary Quarterly,
1983, 5:3-10
Nevertheless, we chose to investigate interobserver agreement
with the reading processes currently present in the different
screening committees, with the limitations that we did not
allow quality assessment. Furthermore, the radiographic
quality in investigating the agreement between observers in
other reports is never clearly stated. We still have no idea of
how quality assessment is performed in different screening
committees. In the current study, quality assessment was
intentionally not performed in order to avoid preselection of
the presented radiographs. This will allow the evaluation of the
influence of a quality assessment on interobserver agreement.
Another limitation is the large number of observers used in this
study, which could be responsible for the high range of scores
that may influence the interobserver agreement. However, the
number of observers should not have an impact on agreement
in a sound CHD screening procedure. Because no exact copies
of radiographs were used for the same dog, intra-observer
agreement could not be investigated.
In this study, observers classify dogs as dysplastic/non-dysplastic
or into different categories with insufficient agreement.
Conclusion
Agreement between observers of different European countries
who score hips following the FCI criteria is too low. There is
no consensus on whether near-normal hip joints should be
considered as dysplastic or not. Experience improves agreement
between observers. There is insufficient agreement between
the presumed correct assessment of dysplasia/non-dysplasia
and the evaluation of the experienced observers, indicating
that NA is not reproducibly used as a sole parameter in CHD
evaluation by the experienced observers. Standardisation of
film reading is highly recommended. The currently used hipextended radiographic method for CHD screening may have
to be re-evaluated. A screening system that consistently allows
the distinction between dysplasia/nondysplasia and between
different levels of hip quality status is needed to improve
interobserver agreement.
Acknowledgements
The authors thank the following persons for evaluating the
radiographs: M. Flückiger, H. Hazewinkel, M. Kramer, J. Lang
and B. Tellhelm.
References
BRASS (W.) - Hip dysplasia in dogs. Journal of Small Animal Practice
1989, 30:166-170
CARDON (L.) -Delivering new disease genes. Science, 2006, 314:
1403-1405
COOPMAN (F.), PAEPE (D.), VAN BREE (H.), SAUNDERS (J. H.) - The
prevalence and evolution of canine hip dysplasia in Belgium
(Abstract). Annual Scientific Conference Proceedings, The
European Association of Veterinary Diagnostic Imaging and
The European College of Veterinary Diagnostic Imaging. 2004 ,
November 18, Ghent, Belgium. p 68
COOPMAN (F.), COMHAIRE (F.), SCHOONJANS (F.), DE BRABANDER
(K.) - Hips dysplasia research at Ghent University; towards a new
approach to assess hip quality? (Abstract). Proceedings of the
155
ORTHOPAEDICS
REPRINT PAPER (CH)
Mandibular fracture in a Lhasa Apso
with renal secondary
hyperparathyroidism
P. Roux (1)
SUMMARY
A three-year-old Lhasa Apso was presented with a manibular fracture following a fight with another dog. The physical
examination revealed generalised excessive mobility of the entire dentition. Radiographs revealed generalised
mandibular demineralisation. Routine laboratory analyses revealed severe anaemia and azotaemia, compatible with
chronic renal disease. The findings were considered consistent with renal secondary hyperparathyroidism resulting
in bone demineralisation and minimal-trauma fracture.
Keywords: dog, jaw, hyperparathyroidism, renal disease, osteopenia
A three-year-old, female Lhasa Apso was presented on an
emergency basis for facial trauma following a fight with another
dog, which lead to a dropped jaw, ptyalism and pain on
mandibular manipulation.
the tooth roots and alveolar bone. These revealed a marked
generalised decrease in bone density with loss of trabecular
structure and absence of the lamina dura (Figs. 1 and 2). The
teeth, which appeared to be freely floating in the alveolar bone,
were of normal radiodensity. No evidence of receding of the
alveolar bone was observed. A fracture line was apparent on the
ventral border of the body of the left mandible (Fig. 3). This was
barely visible because of the diminished thickness of the bone
cortex and reduced bony contrast due to bony demineralisation
(Fig. 4).
Physical examination findings
Laboratory examinations
This paper originally appeared in:
Schweiz. Arch. Tierheilk.* (6/2007) 149(6): 277-279
Introduction
The dog was quiet and alert on physical examination. No
external lesions were found on the head. The jaw was partially
dropped and displaced to the left. Manipulation of the
mandible appeared painful and the dog was anaesthetised
for further examination. Oral examination revealed moderate
plaque formation, mild periodontitis with pocket formation not
exceeding 3mm, and marked loosening of the teeth of both the
mandible and maxilla.
Routine blood analyses revealed severe anaemia and severe
azotaemia (Table 1)
Haematocrit (%)
12
Red blood cells (x10 /l)
9
Radiographs
Intra-oral radiographs were performed in order to evaluate
Results
Reference interval
14
37 – 55
2.02
5.5 – 8.5
Leukocytes (x10 /l)
6.2
6 – 17
Haemoglobin (mmol/l)
3.1
12 – 18
Urea (mmol/l)
51.1
0 – 8.5
Creatinine (µmol/l)
476
0 – 130
(1) Veterinary Clinic Peseux, Route de Neuchâtel 6, CH-2034 Peseux E-Mail: proux@net2000.ch
Also at Division of Small Animal Surgery and Stomatology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Switzerland.
* Presented by SVK/ASMPA (Switzerland)
157
Mandibular fracture in a Lhasa Apso with renal secondary hyperparathyroidism - P. Roux
Figure 1: Intra-oral radiograph of the right maxillary arcade.
The lamina dura has completely vanished around the roots of
the premolar and molar teeth. The maxilla has lost its trabecular
structure and bone density is severely diminished although the
density of the teeth is unaffected.
Figure 2: Intra-oral radiograph of the right manibula at the
level of the fourth premolar and first two molar teeth: periapical
radiolucency and loss of vertical bone structure along the tooth
roots are evident. A faint old fracture line can be seen along the
ventral border of the mesial cortical bone near the fourth premolar.
Figure 4: Intra-oral
radiograph of the mandible
at the level of the canine and
incisive teeth: osteopenia is
particularly marked around
the incisive teeth. The lamina
dura is still visible around the
apical third of the roots of the
canine teeth.
Figure 3: Intra-oral
radiograph of the left
mandible at the level of the
fourth premolar and first
two molar teeth: periapical
lesions, similar to those
observed in the preceding
radiograph, are evident.
A fracture line is visible
along the mesial root of the
first molar tooth.
Diagnosis
D leads to hypocalcaemia, which results in a compensatory
increase in parathyroid production of PTH. Decreased glomerular
filtration and impaired renal excretion of phosphorus in CRI
exacerbate the hypocalcaemia. [Fukagawa M. et al]
Evidence of bone demineralisation is generally seen first in the
mandible, then the maxilla and other bones of the head, followed
by the remaining bones of the axial and appendicular skeleton.
Both maxiallary bones are generally severely demineralised before
signs of osteopenia are apparent in the rest of the skeleton.
[Ziólkowska H. et al] This can lead to a pliable jaw, [Wiggs R.B.,
Lobprise H.B.] referred to as rubber jaw. Boney demineralisation
of the jaw is evident on radiographs and characterised by
marked thinning of the cortices. Osteopenia of the jaw may be
so severe that a very marked increase in radiographic contrast
between bone and tooth is apparent, since teeth are the only
hard tissues not affected by demineralisation. One of the most
manifest changes is the complete disintegration of the lamina
dura. Lastly, the trabecular structure of the bone tissue vanishes,
leaving a homogenous radiographic image. [White S.C., Pharoah
Findings were considered consistent with renal secondary
hyperparathyroidism.
Discussion
Hyperparathyroidism is an endocrine disorder, characterised by
an excess in circulating parathyroid hormone (PTH). This results
in increased resorption of calcium from bone due to stimulation
of osteoclastic activity. Primary hyperparathyroidism is due to
a primary dysfunction of the parathyroid glands; secondary
hyperparathyroidism can be nutritional, due to an excessively
low calcium-to-phosphorus ratio in the diet or renal, due to
chronic renal insufficiency (CRI). [Garcia-Rodriguez M.B. et al] To
confirm the diagnosis, laboratory evaluation in this case should
have been completed with serum calcium and phosphorus
levels, PTH levels, and a urinalysis. [Polzin D.J. et al]
Renal secondary hyperparathyroidism is caused by a deficient
metabolism of vitamin D in CRI. This secondary hypovitaminosis
M.J.].
158
EJCAP - Vol. 18 - Issue 2 October 2008
References
The teeth are normally maintained in place by Sharpey’s fibres,
which constitute the fibrous part of the periodontal ligament.
These fibres form the external layer of the dental roots, anchored
in the cementum on one side and the alveolar bone, on the
other. Histological studies demonstrate that these fibres remain
anchored in the cementum but the insertion into alveolar bone is
practically lost in hyperparathyroidism. [Harvey C.E., Emily P.E.].
This explains the loosening of teeth observed in this disorder.
Chronic renal disease is common in aging animals but is
infrequent to rare in young animals. A bilateral renal fibrosis,
referred to as progressive juvenile nephropathy, has been
described in young dogs of various breeds. [Camichael D.T. et
al]. In addition, renal dysplasia is recognised in some breeds,
including the Golden Retriever and Shih Tzu. [Ohara K. et al.)
No biopsy or post-mortem examination was performed in the
dog in the present case report and a suspicion of a progressive
juvenile nephropathy remains speculative.
The owners of the dog in this report did not suspect disease
in their pet prior to presentation, and only retrospectively were
aware of a progressive increase in water intake and urination.
Surprisingly, the dog was fed exclusively on a dry food, which
it managed to eat despite the weakness of the jaw. Based on
the laboratory findings, osteopenia and jaw fracture, a poor
prognosis was given, and the owner elected for euthanasia.
WHITE (S.C.), PHAROAH (M.J.) - Oral radiology, principles and
interpretation. 4th Edition 2000. Mosby
WIGGS (R.B.), LOBPRISE (H.B.) - Veterinary dentistry. Principles and
practice. 1997. Lippincott-Raven
HARVEY (C.E.), EMILY (P.E.) Small animal dentistry. 1993. Mosby
CARMICHAEL (D.T.) et al. - Renal dysplasia with secondary
hyperparathyroidism and loose teeth in a young dog .J Vet Dent,
1995, 12(4): 143-146
OHARA (K.) Et al. - Renal dysplasia in a shih tzu dog in Japan. J Vet Md
Sci. 63(10): 1127-1130, 2001
FUKAGAWA (M.) et al. - Renal osteodystrophy and secondary
hyperparathyroidism. Nephrol Dial Transplant (2002) 17 (Suppl
10): 2-5
ZIÓŁKOWSKA (H.) et al. - Imaging of bone in the diagnostics of renal
osteodystrophy in children with chronic renal failure. Med Sci
Monit, 2001; 7(5): 1034-1042
GARCÍA-RODRÍGUEZ (M.B.) et al. - Renal handling of calcium and
phosphorus in experimental renal hyperparathyroidism in dogs.
Vet. Res. 34 (2003) 379-387
POLZIN (D.J.) et al. - Chronic kidney disease. Ch. 260. In textbook of
veterinary internal medicine. 6th Ed. Ettinger SJ, Feldman EC. Pp
1756-1785. Ed Saunders-Elsevier. 2005
159
ENDOCRINOLOGY
REPRINT PAPER (E)
Central diabetes insipidus and
secondary hypothyroidism
associated with a pituitary
macroadenoma in a dog
T. Tejada (1), V. Lario (1), J. López-Grado (1), D. Borras (2), A. Font (3)
SUMMARY
An eight-year-old female beagle was presented with unilateral mydriasis in the left eye. Twelve months later, mydriasis
developed in the right eye, together with polyuria, polydipsia, lethargy, absence of oestrus and non-pruritic bilateral
truncal alopecia. Bilateral mydriasis, central diabetes insipidus and secondary hypothyroidism were suspected to be
the result of pituitary neoplasia. At necropsy, a pituitary macroadenoma was found, confirming the secondary nature
of the hypothyroidism.
Key words: Diabetes insipidus, secondary hypothyroidism, pituitary macroadenoma, dog.
signs in patients with diabetes insipidus [Feldman et al., 2001;
Rijnberk, 2002] but dogs with central diabetes insipidus resulting
from a pituitary tumour may present with neurological signs such
as stupor, disorientation, ataxia, seizures and tremors [Feldman
et al., 2001]. Chronic cases may present with blindness and fixed
dilated pupils resulting from compression and disruption of the
optic nerves by the expanding mass [Eigenmann, 1992; Oliver et
al., 2003; Davison et al., 1991].
The majority of cases of acquired secondary hypothyroidism
in dogs result from impaired secretion of thyrotropinstimulating hormone (TSH) by the pituitary thyrotropic cells
caused by pituitary neoplasia [Feldman et al., 2001; Catharine
et al., 2002]. Neoplasia-induced hypophyseal destruction
may cause endocrinopathies such as hypoadrenocorticism
(hypocortisolism from secondary adrenal insufficiency) and
reproductive dysfunction (failure to cycle, irregular oestrus,
and hypogonadism) [Feldman et al., 2001]. Clinical signs may
vary depending on neoplastic hormonal activity and degree of
compression of adjacent structures [Feldman et al., 2001].
The objective of this article is to report a clinical case of a dog
presenting mydriasis, polyuria, polydipsia, lethargy, bilateral
truncal alopecia and anoestrus which, after a complete
diagnostic work-up, was diagnosed as having central diabetes
This paper originally appeared in:
Clin.Vet.Peq.Anim* (2006), 26(2): p125-129
Introduction
Central diabetes insipidus is a polyuric syndrome resulting from
lack of vasopressin, which is necessary to concentrate urine
for water conservation. Central diabetes insipidus is caused
either by destruction of the centres that synthesize vasopressin
(supraoptic and paraventricular nuclei of the hypothalamus) or by
loss of the ducts that transport vasopressin to the storage space
and release reservoirs in the posterior pituitary. Both may be
the result of any condition that damages the neurohypophyseal
system. The most common causes in dogs and cats are head
trauma, neoplasia and malformations of the hypothalamus or
hypophysis. Primary intracranial tumours associated with central
diabetes insipidus in dogs and cats include craniopharyngioma,
pituitary chromophobe adenoma, and pituitary chromophobe
adenocarcinoma [Feldman et al., 2001; Rijnberk, 2002].
There is no breed-, sex-, or age-related predisposition for central
diabetes insipidus. Polyuria and polydipsia are the typical clinical
(1) Clinica Vets, c/Pau Casals 1, E-08860 Castelldefels. E-mail: tesate@yahoo.com
(2) Citopat Veterinaria, c/ Font del Remei 28-30, E-08023 Barcelona
(3) Hospital Ars Veterinaria, c/ Cardedeau 3, E-08023 Barclona
* Presented by AVEPA (E)
161
Central diabetes insipidus and secondary hypothyroidism associated with a pituitary macroadenoma in a dog - T. Tejada
insipidus and secondary hypothyroidism, presumably due to a
pituitary macroadenoma, which was eventually confirmed at
necropsy.
Case history
An eight-year-old female beagle was presented with unilateral
mydriasis in the left eye and, according to the owner, visual
loss. No further information was obtained from the history
and physical examination revealed a good general condition.
Ophthaemological examination demonstrated a negative
direct and consensual pupillary light reflex in the left eye and a
positive direct and consensual pupillary light reflex in the right
eye. Menace reaction was normal in both eyes. No lesions were
observed in the cornea, uvea, lens or retina.
Since no lesions were detected on the ophthaemological
examination, a neurological diagnostic work-up was performed.
Cerebrospinal fluid was collected, but no changes were
found. Haematological profile revealed leucopoenia and nonregenerative anaemia. A latex agglutination test for detection
of serum antitoxoplasma antibodies (Toxolatex™, Fumuoze
Laboratories) was performed, with a high positive result.
Electromyography revealed fibrillation potentials on the medial
canthus of the left eye. A lesion of the parasympathetic nucleus
of the oculomotor nerve or at the level of the optic tract
was diagnosed. Treatment with trimethoprim-sulphametoxazol
was initiated, at a dose of 25 mg/kg/12 h for one month,
supplemented with folic acid. At the end of the treatment
period, a control test for toxoplasmosis was performed, with
a negative result. Haematological values had also returned to
normal. However, mydriasis in the left eye persisted.
Twelve months later, mydriasis developed in the right eye. During
this period, the owner had noticed failure to cycle, apathy,
lethargy, polyuria and polydipsia. On physical examination, the
dog had bilaterally symmetrical non-pruritic alopecia. Direct and
consensual pupillary light reflexes were negative in both eyes,
but there was a normal response to the menace reaction, with
bilateral mydriasis and fixed pupils.
Clinicopathological studies revealed a normal haematological
profile and increased cholesterol, triglyceride and alkaline
phosphatase concentrations. Serum protein electrophoresis was
within normal limits. Urine specific gravity was 1.004. A test for
antitoxoplasma antibodies was negative.
The differential diagnosis for increased cholesterol and
triglycerides includes hypothyroidism and liver disease. The
differential diagnosis for polyuria and polydipsia (diabetes
mellitus, hypercalcaemia and renal disease were ruled out
through normal biochemistry values, and there were no signs
suggestive of pyometra) included hyperadrenocorticism, liver
disease and diabetes insipidus. Further tests performed included:
determination of TSH, total tetraiodothyronine (T4) and free T4.
The values obtained were: TSH 0.05 ng/ml (reference values:
0.01-0.6), total T4 0.16 µg/dl (reference values: 0.8-2.1) and free
T4 0.65 µg/dl (reference values: 0.9-1.6). These values, together
with signs such as lethargy and bilateral truncal alopecia, are
compatible with hypothyroidism. Fasting and 2-hour postprandial
serum bile acids values were obtained and were within normal
limits. A low-dose dexamethasone test was performed, giving
a 8-hour cortisol concentration of 0.83 µg/dl (reference value:
Figure 1. Ventral aspect of the brain. The pituitary area is
infiltrated by a diffuse mass with a granular surface.
< 1.5 µg/dl). Abdominal ultrasound revealed normal adrenal
glands, homogeneous liver parenchyma and normal spleen and
kidneys. The results of the low-dose dexamethasone test and
the normal adrenal ultrasonography made hyperadrenocorticism
highly unlikely.
Since hyperadrenocorticism and liver disease were ruled out,
diabetes insipidus was diagnosed as the cause for polydipsia and
polyuria. A water deprivation test would have been indicated
to differentiate central and nephrogenic diabetes insipidus,
but the owner refused it. A urine protein/creatinine ratio was
obtained, with a value of 0.33 mg/dl (normal value < 1 mg/
dl). A presumptive diagnosis of central diabetes insipidus was
made and a therapeutic trial with desmopressin (DDAVP) was
initiated.
Treatment with a synthetic levothyroxine at a dose of 22 µg/kg/12
hours was also prescribed to control hypothyroidism. Treatment
for central diabetes insipidus consisted of DDAVP, as mentioned
earlier. There is an intranasal preparation for humans (Minurin®)
and we used it at a dose of 1 drop every 8 hours instilled in
the ocular conjunctiva. Fifteen days after treatment was started
the animal was re-examined, and showed a good response. The
dog had regained her normal activity and personality. Water
intake was 30 % less and urine specific gravity was 1.015. A
total T4 evaluation was performed one month after treatment,
obtaining concentrations in the high normal range. Synthetic
levothyroxine dose was adjusted to a maintenance dose of 22
µg/kg once daily.
Four months after treatment was initiated, the dog had a seizure
that was controlled with rectal administration of diazepam.
Serum glucose, calcium and urea concentrations were within
normal limits. The next day the dog was presented in status
epilepticus. It was treated with diazepam (constant infusion
pump) and phenobarbital, but died a few hours later.
At necropsy, macroscopic brain lesions consisted of soft
tissue rarefaction in the pituitary depression and a diffuse,
granular mass in the ventral diencephalon. In a coronal brain
section, a discoloured mass with a diameter of 1.3 cm of
soft consistency compressed the adjacent neural parenchyma
(Fig.1-2). Microscopic brain lesions consisted of infiltrative
local proliferation of epithelial cells organized in solid plaques,
162
EJCAP - Vol. 18 - Issue 2 October 2008
Figure 2. Coronal section of the brain at pituitary level. The
tumour, with a maximum diameter of 1.5 cm, is a lobulated mass
with a homogeneous brownish coloration. It contains multiple
small cavities with clear mucilaginous material.
Figure 3. The tumour cells are arranged in cords and there is a
muciform material (bluish grey in the figure) building-up between
them. Cells have a distinctly eosinophilic cytoplasm, a round
nucleus, often with irregular margins, heterogeneously distributed
chromatin and a generally obvious nucleolus.
nests and strings separated by fine connective tissue septa.
(Fig.3.) These cells had a moderately abundant, acidophilic and
homogeneous cytoplasm and a rounded, angular or vesicular
nucleus with clear, reticular chromatin and inconspicuous
nucleolus, with a low grade of anisokaryosis. No mitotic figures
were observed. The histopathological diagnosis was pituitary
macroadenoma. Immunohistochemistry studies were negative
for TSH, ACTH, PRL and GH. No lymphocytic infiltration, atrophy
or microscopic lesions could be found in the thyroid gland that
would suggest primary hypothyroidism.
treating the infection and with the dog now being negative to
antitoxoplasma antibodies, it was thought that mydriasis would
eventually resolve, which did not happen. When mydriasis
developed in the right eye 12 months later, a central nervous
system lesion was suspected. Toxoplasmosis relapse was ruled
out through serology.
Pituitary tumours may cause visual field deficits by compression
of the optic chiasm. These tumours grow in both a rostral and
caudal direction, so visual signs develop late in the course of
the disease, during growth of the neoplastic mass [Oliver et
al., 2003]. Visual signs are not commonly found with signs of
cerebral tumours but may be suggestive of neoplasia affecting
the optic chiasma. Such manifestations are uncommon in
pituitary adenomas and macroadenomas [Ogilvie et al., 1996].
Even though these tumours are located in close proximity to
the optic chiasma, blindness is not a common sign [Ogilvie et
al., 1996]. The beagle in our case developed ocular lesions,
unilateral mydriasis and loss of vision prior to other clinical signs
caused by the pituitary tumour, which appeared twelve months
later. The course of events in this dog is similar to other cases
previously published, such as a boxer that presented progressive
blindness of one-year duration and was diagnosed as having a
pituitary neoplasia using magnetic resonance imaging [Mascort
et al., 1996]. Other authors have also found acute blindness
associated to pituitary tumours, diagnosed using computerized
axial tomography [Davison et al., 1991].
In our case, by the time bilateral mydriasis was evident, the
dog was also lethargic, apathetic and had polyuria/polydipsia,
presented failure to cycle and had bilateral non-pruritic truncal
alopecia. Secondary hypothyroidism was suspected, based on
low TSH, total T4 and free T4 concentrations.
Primary hypothyroidism, caused by decreased production of
triiodothyronine (T3) and T4 by the thyroid gland, is characterized
by increased TSH concentrations due to a negative feedback
in the hypothalamus-hypophysis-thyroid gland axis [Rodón,
1999]. In human beings, an increased serum TSH concentration
characterizes primary hypothyroidism before any decline in
Discussion
Pituitary adenomas cause a significant dysfunction of this gland.
Dogs may present for neurological signs or hypopituitarism.
The latter is characterized by insufficiency of one, several or all
of the hypophyseal hormones. Clinical signs may also include
blindness, dilated and fixed pupils due to compression of the
optic nerves, hypogonadism and polyuria/polydipsia due to
insufficient pituitary secretion of vasopressin [Eigenmann, 1992].
In our case, the dog presented initially a unilateral mydriasis in
the left eye and loss of visual acuity as the only clinical signs.
Pupillary abnormalities are common and may be the result of
ophthalmologic or neurological disease [Oliver et al., 2003].
Differential diagnosis included iris atrophy and lesions in the
cornea, lens or retina. Increased intraocular pressure may also
cause pupillary dilation [Oliver et al., 2003]. We did not suspect
a neurological lesion until the ophthalmologic evaluation ruled
out ocular disease.
The neurological work-up led to the diagnosis of optic
neuropathy, probably caused by toxoplasmosis and was treated
as such. It eventually became evident that toxoplasmosis was an
incidental finding and was not causing mydriasis. Toxoplasmosis
is an infection caused by a protozoan named Toxoplasma gondii.
This parasite can enter the eye either through the blood stream
or the optic nerve, causing granulomatous lesions [Gelatt,
1999], cranial nerve deficits and optic neuritis, although such
findings are more common in cats [Breitschwerdt, 2002]. After
163
Central diabetes insipidus and secondary hypothyroidism associated with a pituitary macroadenoma in a dog - T. Tejada
basal concentrations of thyroid hormones is detected [Feldman
et al., 2001]. In general, 70 % - 80 % of dogs with primary
hypothyroidism have high serum TSH concentrations [Rodón,
1999]. In dogs with secondary hypothyroidism, caused by
decreased thyroid hormone production due to a hypothalamic or
pituitary disease, low TSH concentrations should be expected.
Hypothyroidism alone did not explain the existence of polyuria
and polydipsia. Since the dog had high serum alkaline
phosphatase concentrations and a urine specific gravity
of 1.004, hypothyroidism was thought to be secondary to
Cushing’s syndrome. Secondary hypothyroidism is caused
by deficient TSH secretion by the pituitary thyrotrophic cells.
From the clinical standpoint, the most important factor to
consider is the suppressor effect of glucocorticoids, either by
exogenous administration or due to spontaneous acquired
hyperadrenocorticism [Feldman et al., 2001]. The normal adrenal
gland size, visualized by ultrasonography and the normal results
in the low-dose dexamethasone test eliminated this possibility.
After ruling out renal and liver disease, hypercalcemia, pyometra,
hyperadrenocorticism and diabetes mellitus as causes for
polyuria/polydipsia, a diagnosis of diabetes insipidus was made.
The hypophysis is a gland that secretes several hormones
that control other endocrine glands. The hypophysis itself has
another “master” gland: the hypothalamus. The hypophysis
is composed of two different parts, both anatomically and
functionally. One is the adenohypophysis, which secretes growth
hormone, TSH, prolactin, adrenocorticotropin hormone, folliclestimulating hormone, melanocyte-stimulating hormone and
luteinizing hormone, all regulated by hypothalamic hormones.
The other part is the neurohypophysis, which does not secrete
hormones but stores and releases two hormones produced in
the hypothalamus: oxytocin and antidiuretic hormone (ADH) or
vasopressin [Tortora et al., 1996].
The function of vasopressin is to reduce urine excretion. Under the
influence of ADH, the kidneys extract water from urine and return
it to the blood stream, thus reducing urine volume. Secretion
of ADH depends on the hydration status of the body. When
dehydrated, the blood’s water content is lower than normal. The
high solute concentration increases osmotic pressure, which triggers
hypothalamic osmoreceptors that stimulate vasopressin secretion
and release in the neurohypophysis [Tortora et al., 1996].
The term diabetes insipidus refers to the production of increased
quantities of dilute urine [Rijnberk, 2002]. There is a central
diabetes insipidus, caused by insufficient production and release
of vasopressin by the neurohypophysis, and a nephrogenic
diabetes insipidus, characterized by impaired responsiveness of
the nephron to vasopressin. The modified water deprivation test
is designed to determine whether endogenous vasopressin is
released in response to dehydration or the kidneys react to such
stimulus. Once the test is completed it is possible to differentiate
between central and nephrogenic diabetes insipidus [Feldman
et al., 2001]. This test is stressful for the animal, there is risk for
dehydration and the dog needs to be monitored and hospitalized
[Rijnberk, 2002].
As an alternative to the water deprivation test, we chose a simpler
although less advanced method to diagnose central diabetes
insipidus: response to treatment with DDAVP (desmopressin).
This is a vasopressin synthetic analogue with antidiuretic
activity. Using it for diagnosis should be considered only when
the differential diagnosis includes just central and nephrogenic
diabetes insipidus [Feldman et al., 2001]. One to four drops of
DDAVP are instilled onto the conjunctiva. A reduction in water
intake or an increase in urine specific gravity should be observed
5-7 days after treatment is initiated, strongly suggesting a
diagnosis of central diabetes insipidus; administration of
DDAVP does not help dogs with nephrogenic diabetes insipidus
[Feldman et al., 2001]. In this case, we observed a good response
to treatment. Further controls sometimes showed abnormal
values for urine specific gravity, but the owner reported that
he was not always able to instil the drops properly. Polyuria and
polydipsia seemed to be controlled. Hypothyroidism was treated
with a synthetic levothyroxine. The dog regained her normal
activity and the bilateral truncal alopecia improved.
The presence of a pituitary tumour was suspected because
of the bilateral mydriasis (probably due to compression of
the optic chiasma), central diabetes insipidus (caused by
vasopressin deficiency due to a lesion in the neurohypophysis)
and secondary hypothyroidism (caused by deficient TSH
secretion by the hypophysis). A similar syndrome has been
previously described in a case report of a boxer diagnosed as
having hyperadrenocorticism and central diabetes insipidus as
a consequence of a pituitary tumour, confirmed by necropsy,
which also revealed secondary hypothyroidism [Barr, 1985].
Other authors describe the case of a Dobermann with central
diabetes insipidus, anisocoria and hypothyroidism, diagnosed
at necropsy as having a pituitary tumour [Neer et al., 1983].
Unfortunately, the secondary nature of the hypothyroidism
could not be confirmed because the tissue was lost.
As a general rule, dogs and cat with central diabetes insipidus
remain asymptomatic with appropriate treatment. Without
treatment dogs and cats can have an acceptable quality of life
as long as water is supplied constantly, keeping in mind there is
risk of dehydration [Feldman et al., 2001]. Dogs with aggressive
pituitary or hypothalamic diseases such as growing neoplasia
have a poor prognosis. Neurological signs are frequent [Feldman
et al., 2001]. In our case, four months after diagnosis and
treatment of central diabetes insipidus, the dog started to have
seizures that eventually led to status epilepticus and death.
It is very difficult to confirm the presence of a cerebral tumour in
the clinical setting. Skull radiographs rarely reveal lesions [Ogilvie
et al., 1996]. We radiographed the skull of the dog when she
started having neurological signs but no information of diagnostic
value was obtained. Magnetic resonance imaging would have
been the procedure of choice [Ogilvie et al., 1996], but the
owner refused it. Definitive diagnosis is usually confirmed at
necropsy [Ogilvie et al., 1996]. One article describes the findings
in 20 dogs with central diabetes insipidus caused by pituitary
tumours diagnosed with computerized axial tomography and
confirmed at necropsy, seven of which had neurological signs.
The authors recommend using magnetic resonance imaging or
computerized axial tomography once central diabetes insipidus
is diagnosed, before neurological signs develop, for prognostic
purposes [Harb et al., 1996].
In our case, necropsy revealed the presence of a pituitary
macroadenoma that confirmed the clinical diagnosis. The
histopathological lesions in the thyroid gland confirmed that
hypothyroidism was secondary to a pituitary disease, since no
primary changes were found in the gland.
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EJCAP - Vol. 18 - Issue 2 October 2008
References
GELATT (K.) - Veterinary ophthalmology. 3ª edición. Ed. Lippincott
Williams & Wilkins, 1999: 283.
HARB (M.F.), NELSON (R.W.), FELDMAN (E.C.), SCOTT-MONCRIEFF
(J.C.), GRIFFEY (S.M.) - Central diabetes insipidus in dogs: 20 cases
(1986-1995). J Am Vet Med Assoc, 1996, 209(11): 1884-1888.
MASCORT (J.), MAYOL (M.), CLOSA (J.M.), FONT (A.) - Cirugía de los
tumores intracraneales. Clínica Veterinaria de Pequeños Animales,
1996, 16(1): 21-24.
NEER (T.M.), REAVIS (D.U.) - Craniopharyngioma and associated central
diabetes insipidus and hypothyroidism in a dog. J Am Vet Med
Assoc, 1983, 182(5): 519-520.
OGILVIE (G.), MOORE (A.) - Managing the veterinary cancer patient:
a practice manual. 2ª printing. Ed. Veterinary Learning Systems,
1996: 293-297.
OLIVER (J.), LORENZ (M.), KORNEGAY (J.) - Manual de neurología
veterinaria. 3ª edición. Ed. Multimédica, 2003: 302, 295.
RIJNBERK - Diabetes insípida, in Ettinger (S.), Feldman (E.) Textbook
of Veterinary Internal Medicine. Volume 2. 5ª edición. Ed. Inter–
Médica, 2002: 1529-1534.
RODÓN (J.) - Diagnóstico del hipotiroidismo canino. Canis et Felis.
1999, 38: 47-63.
TORTORA (G.) - Principios de anatomía y fisiología. 7ª edición. Ed.
Mosby/Doyma Libros, 1996: 524-533.
BARR (S.C.) - Pituitary tumor causing multiple endocrinopathies in a
dog. Aust Vet J., 1985, 62(4): 127-129.
BREITSCHWERDT (E.B.) - Rickettsiosis, in: Ettinger (S.), Feldman (E.):
Textbook of Veterinary Internal Medicine. Volume 1. 5ª edition.
Ed. Inter-Médica, 2002:456.
CATHARINE (J.), SCOTT-MONCRIEFF (R.), GUPTILL-YORAN (L.) Hipotiroidismo, in: Ettinger (S.), Feldman (E.): Textbook of
Veterinary Internal Medicine. Volume 2. 5ª editión. Ed InterMédica, 2002:1578-1579.
DAVISON (M.G.), NASISSE (M.P.), BREITSCHWERDT (E.B.), THRALL
(D.E.), PAGE (R.L.), JAMIESON (V.E.), ENGLISH (R.V.) - Acute
blindness associated with intracranial tumors in dog and cats:
eight cases (1984-1989). J Am Vet Med Assoc, 1991,199(6):
755-758.
EIGENMANN (J.E.) - Enfermedades hipofisarias-hipotalámicas, in:
Ettinger (S.): Textbook of Veterinary Internal Medicine. Volume 2.
3ª edición. Ed. Inter- Médica, 1992: 1670-1673.
FELDMAN (E.), NELSON (R.W.) - Endocrinología y reproducción en
perros y gatos. 2ª edición. Ed. Mc Graw – Hill interamericana,
2001; 14-19; 33-38; 82-100.
165
DIAGNOSTIC IMAGING
REPRINT PAPER (A)
Magnetic resonance imaging features of orbital inflammation with
intracranial extension in four dogs
S. Kneissl (1), M. Konar (2), A. Fuchs-Baumgartinger (3), B. Nell (1)
SUMMARY
This retrospective study describes the clinical and magnetic resonance (MR) imaging features of chronic orbital
inflammation with intracranial extension in four dogs (two Dachshunds, one Labrador, one Swiss Mountain).
Intracranial extension was observed through the optic canal (n=1), the orbital fissure (n=4), and the alar canal (n=1).
On T1-weighted images structures within the affected skull foramina could not be clearly differentiated, but were
all collectively isointense to hypointense compared with the contralateral, unaffected side, or compared with gray
matter. On T2-, short tau inversion recovery (STIR)-, or fluid-attenuated inversion recovery (FLAIR)-weighted images
structures within the affected skull foramina appeared hyperintense compared with gray matter, and extended with
increased signal into the rostral cranial fossa (n=1) and middle cranial fossa (n=4). Contrast enhancement at the level
of the affected skull foramina as well as at the skull base in continuity with the orbital fissure was observed in all
patients. Brain oedema or definite meningeal enhancement could not be observed, but a close anatomic relationship
of the abnormal tissue to the cavernous sinus was seen in two patients. Diagnosis was confirmed in three dogs (one
cytology, one biopsy, one necropsy) and was presumptive in one based on clinical improvement after treatment.
This study is limited by its small sample size, but provides evidence for a potential risk of intracranial extension of
chronic orbital inflammation. This condition can be identified best by abnormal signal increase at the orbital fissure
on transverse T2-weighted images, on dorsal STIR images, or on postcontrast transverse or dorsal images.
Key words: brain, dog, inflammation, magnetic resonance imaging, orbit.
This paper originally appeared in: Veterinary Radiology & Ultrasound* (2007), 48(5): p 403-408.
The original publisher was Wiley-Blackwell Publishing Ltd who have kindly given permission to us to reprint the paper in EJCAP.
Introduction
Advantages in diagnostic imaging, such as B-mode sonography,
computed tomography and magnetic resonance (MR) imaging
make it possible to examine intraocular structures of opaque
eyes and to gain precise information on the soft tissues of the
orbit [3,4]. In general, CT or MR imaging is recommended
for patients with ocular disease in which radiography and
ultrasonography fail to produce a diagnosis or for which surgery
Orbital inflammation is a common problem in the dog,
accounting for the majority of all orbital diseases [1]. Frequent
clinical signs are exophthalmus, enophthalmus, strabismus, or
reflex disorders. Orbital inflammation impacts neurologists and
neuro-ophthalmologists because all of the entities can cause
neural dysfunction or dysmotility [2].
(1) Clinical Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
(2) Department of Clinical Veterinary Medicine, University of Bern, Bern, Switzerland
(3) Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria
Address for correspondence: Dr. Sibylle Kneissl, Veterinärplatz 1, A-1210 Vienna. E-mail: sibylle.kneissl@vu-wien.ac.at
* Presented by VÖK (Austria)
167
Magnetic resonance imaging features of orbital inflammation with intracranial extension in four dogs - S. Kneissl
is proposed. Compared with CT, MR imaging can be used to
assess the presence and extent of orbital infection as focal or
diffuse regions of abnormal signal intensity, due to an increase
in water (edema) in the involved regions. Areas of inflammation
should enchance with intravenous contrast medium and are
easily seen on T1-weighted, postcontrast images. Abscesses
are quite conspicuous in CT and MR images because of fluid
pockets and contrast enhancement of the abscess wall. Foreign
bodies, if seen on CT or MR images, may appear discrete
with lack of contrast enhancement. Although chronic orbital
inflammation generally appears as diffuse swelling without loss
of architecture, concurrent mass effect can be misdiagnosed as
a tumour, particularly if minor osteolysis or intracranial extension
is present [5-10].
Clinical signs present for fewer than 14 days were classified
as acute and clinical signs present for more than 14 days
were classified as chronic. MR features, including mass effect
(present, absent), extension (rostral or middle cranial fossa;
sinus cavernosus, buccal region, pterygopalatine fossa,
infratemporal fossa, or cranial cervial region) and MR imaging
signal of the skull foraminae (optic canal, orbital fissure, and
alar canal) were noted. The MR imaging signal was graded as
abnormal if there was a distinct asymmetric signal at the skull
foramen in unilateral lesions or a definite mass effect in two
sequences of the same patient in bilateral lesions. Further, MR
imaging signs of brain oedema, meningeal enhancement, or
cavernous sinus involvement were specifically noted. Because
superficial structures, such as cortical veins, could potentially
mimic focal meningeal enhancement, we defined the presence
of enhancement in at least two planes as a criterion for definite
meningeal enhancement.
Not much information is available on the intracranial extension
of orbital inflammation in animals. In humans, this is a rare
condition; the intracranial extension of an orbital inflammatory
process develops through the orbital fissure into the middle
cranial fossa and the cavernous sinus [11,12]. This paper reports
the clinical and MR imaging features of four dogs with orbital
inflammation and secondary intracranial extension.
Based on the MR images, further diagnostic tests were
conducted, including cerebrospinal fluid (CSF) analysis, biopsy,
aspiration cytology, bacterial culture, or orbital exploration.
Owing to financial constraints one dog was treated medically for
presumed inflammatory disease without further investigation.
Material and methods
Results
This retrospective study included all patients that underwent
MR imaging of the eyes and orbit during a 35-month period
between April 2001 and March 2004. Out of 37 such MR
imaging studies, five animals had orbital inflammation without
intracranial extension, and four dogs (two Dachshunds, one
Labrador, one Swiss Mountain dog) had orbital inflammation
with intracranial extension. There were three intact males and
one intact female. Mean age was 6.4 years (range, 1.8-13.5
years).
A variety of clinical signs were noted in the four dogs.These
included exophthalmus (n=3), endophthalmus (n=1), facial
pain (n=4), chemosis (n=2), diffuse facial swelling (n=2), and
reduced mobility of the jaw (n=2). Three patients had unilateral,
one dog had bilateral signs. According to the history, all dogs
had chronic clinical signs that began suddenly. The tentative
clinical diagnosis in each dog was orbital inflammation. To rule
out neoplastic disease and explore the total extent of the orbital
lesion, all dogs were subjected to MR imaging.
In each dog, MR imaging was performed using a low field
strength unit (Outlook 0.23 Tesla, Gold Performance®, Philips
Medizinische Systeme, Vienna, Austria). All dogs were under
general anesthesia and scanned in sternal recumbency with the
head in a flexible coil (diameter: 12.5-24 cm). Imaging included
transverse T1-weighted spin echo images (TR 350-650/TE 12-30),
dorsal T1-weighted 3D gradient echo images with multiplanar
reformatting features (TR 30-34/ TE 9; flip angle 341), transverse
T1-weighted 3D gradient echo images (TR 50/TE 12; flip angle
551), and transverse T2-weighted fast spin echo (TR 5500/TE 90)
images. T1-weighted images were repeated after intravenous
administration of gadodiamide (Omniscan, Nycomed, Oslo,
Norway) or gadobenate dimeglumine (MultiHance®, Bracco
Österreich GmbH, Vienna, Austria) at a dose of 0.15mmol/kg
body weight. If considered necessary, additional sequences,
such as dorsal plane fluidattenuated inversion recovery (FLAIR)
(TR 5063/TE 2100/TI 90), short tau inversion recovery (STIR) (TR
1168/TE 70/TI 16), or T2-like completely balanced steadystate
gradient echo [13] (CBASS) images were acquired. Slice thickness
was 0.9-4mm in T1-weighted images, 3.7mm in T2-weighted
images, 0.9 in T2-like weighted images, 3mm in FLAIR images,
and 3.0-3.5mm in STIR images. The T1-weighted 3D gradient
echo and CBASS sequences could be reformatted in any desired
plane provided slice thickness was <1.1mm.
On MR images, a retrobulbar mass, characterized by a fluidfilled cavity and an intensely enhancing wall, was noted in three
dogs. The mass effect was isointense to hypointense compared
with the adjacent soft tissue on T1-weighted images and had
a hyperintense centre on T2-weighted images. Intravenous
contrast medium led to rim enhancement in each dog. One dog
with diffuse orbital inflammation did not have a retrobulbar
mass effect.
The orbital inflammation extended to the buccal region (n=3),
pterygopalatine fossa (n=4), infratemporal region (n=2), and
cranial cervical region (n=3). Intracranial extension occurred
through the optic canal (n=1), orbital fissure (n=4), or the
alar canal (n=1). On T1-weighted images structures within the
affected skull foramina could not be clearly differentiated, but
were collectively isointense to hypointense compared with the
contralateral, unaffected side, or compared with gray matter
(Fig. 1). On T2-, STIR-, or FLAIR-weighted images structures
within the affected skull foramina appeared hyperintense
compared with gray matter, and extended with increased T2,
STIR, and FLAIR signal into the rostral cranial fossa (n=1) and
middle cranial fossa (n=4) (Fig. 2).
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Fig. 1. Dorsal T1-weighted pre- (A) and postcontrast (B) gradient echo (GRE) 3D images (30/9/341), and the corresponding multiplanar
reconstructions (MPR) along the axis of the orbital conus of the contralateral (C) and the affected (D) eye of patient 4. The retrobulbar
abscess (A), the lining of the orbit (arrowhead), the contrast-enhanced abnormal tissue within the orbital fissure and the cranial cavity
(arrow) can be seen. The normally enhancing, conspicuous structure close to the skull foramen corresponds to the plexus pterygoideus
(PP). FO, orbital fissure; H, hypophysis.
Contrast enhancement at the level of the skull foramen as well
as at the skull base in continuity with the orbital fissure was
observed in all dogs. Further contrast enhancement lead to
hyperintensity and thickening of the periorbita in all patients
(Fig. 1). Definite involvement of the cavernous sinus, brain
oedema, or definite meningeal enhancement was not observed
in any patient, although the abnormal tissue had a close antomic
relationship to the cavernous sinus in two dogs. Based on the
imaging characteristics, the cause of the orbital inflammation
was identified in one dog as being due to bilateral molar dental
root inflammation. The cause of the orbital inflammation was
not apparent in the other three dogs. Abscess was proven by
necropsy in one dog, by biopsy in one dog, and cytology in one
dog.
Bacterial culture was performed and was positive in two
dogs. CSF analysis was performed in one dog and there was
pleocytosis (512/ml, reference: <15/ml), increased protein
(72mg/dl, reference: <48mg/dl), and increased glucose (106mg/
dl, 82% of the serum glucose level). The findings in patients that
underwent biopsy or cytologic analysis of an aspirate at the time
of imaging had chronic nonsuppurative inflammation.
169
Magnetic resonance imaging features of orbital inflammation with intracranial extension in four dogs - S. Kneissl
Fig. 2. Dorsal fluid-attenuated inversion recovery (FLAIR)-weighted (5063/90/2010) (A), transverse T2-weighted (5500/90) (B) as well
as transverse T1- (350/ 30) pre- (C) and postcontrast MR images (D). Note the retrobulbar mass effect (A) with extension into the cranial
cervical region (CCR) and orbital fissure (arrow). Structures within the orbital fissure cannot be differentiated, but appear hyperintense
compared with the contralateral, unaffected side, on T2- and FLAIR-weighted images and hypointense to isointense on T1-weighted
images. There is contrast enhancement of the structures within the orbital fissure. The patient was diagnosed with septic meningitis and
purulent inflammation of CN III at necropsy 30 days after imaging.
In one patient treatment with antibiotics and nonsteroidal
antiinflammatory drugs led to complete resolution. Two
patients recovered following surgical intervention (molar tooth
extraction in one patient and drainage of an abscess via the
pterygopalatine fossa in other patient), followed by treatment
with antibiotics and nonsteroidal antiinflammatory drugs. One
patient did not respond to therapy and the owner requested
euthanasia. At necropsy examination, performed 30 days after
imaging, there was diffuse inflammation of the soft tissue and
an ascending purulent inflammation of oculomotor nerve (CN
III) with concurrent septic meningitis of the affected right side.
Discussion
We could not identify any report of intracranial infection
secondary to orbital inflammation in animals, although
intracranial infection has been observed secondary to trauma,
otitis media/interna, and hematogenous spread of bacteria,
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EJCAP - Vol. 18 - Issue 2 October 2008
viruses, fungi, and protozoa in the dog and the cat [14-25].
concurrent finding in other studies of orbital cellulitis and was
seen in three of the four dogs in this study. However, chronic
orbital inflammation can potentially be misinterpreted as
neoplastic infiltration, especially if concurrent mass effect, minor
osteolysis or intracranial extension is present [3-10].
In children intracranial spread of orbital inflammation is rare
but bears the risk of morbidity if inadequately treated [26-28].
Intracranial complications include meningitis, cavernous sinus
thrombosis, and abscess of the brain parenchyma or subdural or
epidural spaces. The following MR imaging patterns of orbital
cellulitis extending into the cranial cavity have been identified in
humans: (1) abnormal soft tissue at the orbital fissure extending
into the middle cranial fossa; (2) expansion of the ipsilateral
cavernous sinus; and (3) abnormal thickening or enhancement
of the meninges in continuity with the orbital lesion [11,12]. In
this study, we identified structures within and continuous with
the skull foramina with increased T2, STIR, and FLAIR signal
as well as contrast enhancement in the rostral cranial fossa
(n=1) and middle cranial fossa (n=4). In two patients, a close
anatomic relationship to the cavernous sinus was observed,
so that a possible expansion into the ipsilateral sinus could
be hypothesized. Definite meningeal enhancement was not
observed in any dog in this study. In one study [29], meningeal
enhancement was seen in only 28% of dogs with inflammatory
CSF, which suggests it is an insensitive sign of intracranial
infection.
In contrast to a study with high-field MR imaging [39], we could
not clearly differentiate all structures within the orbital fissure,
but in unilateral disease the abnormalities could be depicted in
comparison with the contralateral, unaffected side. Therefore,
the most useful planes for imaging were the transverse and
dorsal planes because they allowed left-to-right comparison.
On T1-weighted images structures within the affected skull
foramina were all isointense to hypointense compared with the
contralateral, unaffected side, or compared with gray matter.
Affected structures appeared hyperintense compared with gray
matter on T2, STIR, or FLAIR images. The most useful sequences
were T2-weighted or STIR images. Despite their lower signalto-noise ratio, the better soft tissue contrast allowed the
identification of an abnormal signal increase. After contrast
medium administration, multiplanar reconstruction along the
orbital conus was helpful to assess the intracranial extent of
the disease. In man, T1-weighted postcontrast, coronal, and
axial MR images with chemical fat suppression using spoiler
gradients are best to assess the extension of disease into the
cavernous sinus and meninges [11,12,40]. We have not acquired
postcontrast T1-weighted images with fat suppression in our
patients. This could be the reason for the inability to delineate
the abnormalities within the cavernous sinus or meninges.
Contrast enhancement at the skull base continuous with the
orbital lesion following the intravenous administration of contrast
medium was observed in all patients. Because the enhancing
structure followed the course of the cranial nerves, it is most
likely represented infected nerve sheath, or inflammatory tissue.
This was documented in one dog where purulent inflammation
of CN III was found, as well as by findings in humans [11,12].
In humans, the prognosis for intracranial extension of orbital
inflammation is good provided it is diagnosed and treated by
surgical exploration and appropriate antibiotic therapy [31-34].
This is in accordance with the findings of the study with
intracranial inflammation secondary to otitis media/interna [17].
In this study three of four patients were treated successfully.
Another finding was the hyperintensity and thickening of the
periorbita that was revealed after contrast medium injection.
The periorbita is a cone-shaped fibrous membrane enclosing the
eyeball and its muscles, vessels, and nerves. It is attached with
its base to the bony rim of the orbit, fusing with the periosteum
[30]. Presumably, the contrast enhancement and thickening
reflects an inflammatory process secondary to orbital cellulitis. To
our knowledge, this MR imaging finding has not been described
in animals. In humans, subperiosteal abscess is described as a
complication of orbital cellulitis. However, epidemiology may
differ in humans [31-34].
In conclusion, this study provides evidence for a potential risk
of intracranial extension of chronic orbital inflammation. This
condition can be identified best by abnormal signal increase
within the orbital fissure on transverse T2-weighted images,
on dorsal STIR images, or on transverse or dorsal postcontrast
images.
The most common cause of orbital cellulitis is spread of infection
from the paranasal sinuses, particularly the ethmoid sinus in
children, so that ethmoid sinusitis and sub-periosteal abscess
are frequently associated with orbital cellulitis [31,33]. In animals
frequently described causes of orbital cellulitis are odontogenic
or traumatic [35,36]. While extension of destructive tumours
from the nasal cavity into the orbit, and vice versa, is well
documented in dogs and cats, [3-10,37] chronic infection such
as aspergillosis does not lead to orbital spread in dogs [38].
Thickening and contrast medium uptake of the periorbita may
support the diagnosis of orbital cellulitis, although this may not
be specific.
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in 11 cats and 4 dogs. J Vet Intern Med, 2006, 20: 648-656.
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(T.) - Magnetic resonance imaging and pathologic findings
associated with necrotizing encephalitis in two Yorkshire Terriers.
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- Meningeal enhancement on magnetic resonance imaging in 15
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clinical findings and MR imaging. J Vet Med A Physiol Pathol Clin
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Clin, 2001, 41: 71-86.
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cerebrospinal fluid. Vet Radiol Ultrasound, 2005, 46: 17-22.
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Neuroradiol, 2005, 26: 553-559.
172
DIAGNOSTIC IMAGING
ORIGINAL WORK
Sonographically detected change of
splenic diameter after medetomidine administration in dogs
M. Pruss (1), A. Tidholm (1))
SUMMARY
Ultrasound can be used to detect changes in splenic size which are due to pathological conditions or caused by
administrated drugs. The diameter of the spleen in ten healthy dogs was measured before and 15 minutes after
administration of 30μg/kg medetomidine intramuscularly. There was a statistically significant (p=0.0001) increase in
splenic diameter after injection. However the change in splenic diameter can not be considered to be of clinical relevance.
No subjective changes in tissue echogenicity were detected before and after medetomidine administration.
Key words: dog, spleen, size, diameter, ultrasound, sedation, medetomidine
Introduction
volume measured during laparotomy [7]. To date, no data are
available about the effect of medetomidine sedation alone on
splenic size detected ultrasonographically. The purpose of this
study was to quantify the splenic size of healthy dogs before and
after medetomidine sedation.
The size, location and presence of parenchymal abnormalities
are commonly evaluated when the spleen is examined via
ultrasonography [1]. Different pathological conditions, such as
an acute systemic bacterial or fungal infection, extramedullary
haematopoiesis and amyloidosis or lymphocytic, malignant
histiocytic or mastocytic infiltrations, may cause splenic
enlargement [1,2,3]. Various anaesthetic agents are known to
increase the splenic size in dogs due to congestion [4,5]. When
sedation or anaesthesia is used to facilitate the ultrasonographic
examination, it is important to be able to distinguish between
drug related or disease related splenic enlargement.
It has been shown that acepromazine, thiopental, but not
propofol, enlarge the splenic diameter measured sonographically
in healthy beagle dogs [4]. Medetomidine is a commonly used
sedative to restrain dogs for examination, because of the
possible antagonism with atipamizole [6]. Medetomidine is
also commonly used to sedate dogs for diagnostic ultrasound.
Previously, the combination of a medetomidine and butorphanol
premedication followed by a ketamine and diazepam induction
and halothane maintenance has shown an increase in splenic
Materials and Methods
The spleen of ten client owned dogs that underwent an
arthroscopy or a tibia plateau levelling osteotomy were
measured before and 15 minutes after administration of
30µg/kg (intramuscularly) medetomidine. Apart from their
orthopaedic disorders, the dogs were healthy. Each patient
underwent a physical examination. All dogs had a normal red
and white blood cell count. In none of the dogs, clinical or
ultrasonographic evidence of splenic disease was found. The
spleen was considered normal if the contour was smooth and
regular, and the parenchyma uniform, finely textured and more
echogenic than the liver and the cortex of the left kidney [1].
All ten dogs were included in the study; large mongrels [3],
flat coated retrievers [2], Rottweilers [2], German shepherd [1],
(1) Djursjukhuset Albano ,Rinkebyvägen 23 ,S-182 36 Danderyd Sweden
E-mail: matthias.pruss@djursjukhus-sthlm.se
173
Sonographically detected change of splenic diameter after medetomidine administration in dogs - M. Pruss, A. Tidholm
Fig. 2. Measurement of the spleen diameter in the region of the
major splenic veins after administration of 30μg/kg medetomidine.
The measurement was made of the maximum diameter in the
minimum dimension.
Fig. 1. Measurement of the spleen diameter in the region of the
major splenic veins before medetomidine administration. The
measurement was made of the maximum diameter in the minimum
dimension.
Results
Labrador retriever [1] and golden retriever [1]. There were six
female dogs, two of them castrated and four male dogs, one of
them castrated.
Before and after medetomidine administration, an ultrasound
examination was performed following a scheme previously
described [4]. A 3 to 12 MHz linear probe** and standardised
settings were used. The spleen was scanned in every dog to
rule out splenic disease. The images were collected at three
sites along the splenic hilus at the region of major splenic
veins (Fig. 1, Fig. 2). The lowest measured value was used for
statistic evaluation. The measurements were made of maximum
diameter in the minimum dimension before and 15 minutes
after medetomidine administration.
The splenic tissue echogenicity was evaluated by comparison
with the liver and the cortex of the left kidney, directly after the
measurement of the splenic size.
Statistical analysis was performed with a standard computer
software programme #. Data are presented as mean ± standard
deviation. Comparisons were made by use of Student’s t test
for paired data. Values of p<0.05 (two tailed) were considered
significant.
In every dog the splenic diameter increased after medetomidine
administration.
The results of the descriptive statistics are shown in Table 1.
A statistically significant increase in the mean splenic diameter
measured at the hilus in the maximum diameter in the minimum
dimension was found 15 minutes after administration of 30µg/
kg medetomidine ( p=0.0001) (Table 2). The mean difference in
splenic diameter before and after medetomidine administration
was 0.369 cm. The 95% confidence interval of this difference
ranged from 0.236 cm to 0.501 cm. No subjective changes
in tissue echogenicity were detected after medetomidine
administration.
Discussion
This study shows that there is a statistically significant increase in
splenic diameter in dogs medicated with 30µg/kg medetomidine
intramuscularly. This is, to the authors’ knowledge, the first study
reporting on splenic size after the use of medetomidine alone.
When splenomegaly is present, it is important to know if it is
drug related or disease related. A variety of different diseases
** Philips HD11XE, Philips Medical System Netherland B.V., 5684 PC Best,
Holland
# JMP 3.2, SAS Institute Inc., Cary, NC, USA
Table 1. Descriptive Statistics for Age, Body Weight, Red and White Blood Cell Count and Thrombocytes (N=10 dogs).
Variable
Age (years)
Mean
6.4
Standard
Deviation
± 4.4
Minimum
0.8
Maximum
12
Body weight (kg)
36.6
± 5.0
29.5
46
Haematocrit (%)
45.2
± 3.7
38.0
51
RBC (10*12/L)
6.5
± 0.6
5.3
7.4
WBC (10*9/L)
10.2
± 2.6
6.6
13.6
372.3
± 61.7
Thrombocytes 10*9/L)
262
RBC, red blood cells; WBC, white blood cells.
174
455
EJCAP - Vol. 18 - Issue 2 October 2008
Before Medetomidine
After Medetomidine
p-value
Mean Diameter (cm)
1.804
2.173
0.0001
Standard Deviation
±0.349
±0.418
The results of the two tailed paired t-test statistical analysis are presented (p-value).
Table 2. Maximum Diameter in the Minimum Dimension of Spleens before and 15 Minutes after 30μg/kg Medetomidine Administration
(N=10 dogs)
may cause an isoechogenic splenomegaly, for example bacterial
or fungal infections, extramedullary haematopoiesis and various
infiltrative diseases [1]. Acepromazine and thiopental are also
known to increase the splenic size, whereas propofol does not
seem to change the splenic diameter [4,5]. The combination of
medetomidine, butorphanol, ketamine, diazepam and halothane
is reported to increase the splenic volume [7]. The suspected
cause for splenic enlargement may be smooth muscle relaxation
[4]. As it is known that medetomidine reacts with the alpha
2b-receptors in vascular smooth muscles [6], it was suspected
that sedation using medetomidine alone would cause splenic
enlargement.
Measurements of the quantitative acoustic properties of the
spleen in dogs showed an increased attenuation and a trend to
increased backscatter after acepromazine administration [4]. No
subjective changes in splenic echogenicity using a comparison
between liver, left kidney and spleen [1] could be detected in
dogs examinated in this study. A possible change in the acoustic
properties, beneath the threshold of subjective detection, was
beyond the goals of this study.
The clinical significance of this study is that if medetomidine is
used as a chemical restraint of dogs for diagnostic ultrasound,
findings of increased splenic size must be critically judged.
Nevertheless the change of splenic diameter after medetomidine
administration is in the same magnitude as the standard deviation
for mean spleen diameter in unsedated dogs. So the effect of
medetomidine sedation, although statistically significant, has no
clinical relevance during routine splenic examination.
[6] MURRELL (J.C.), HELLEBREKERS (L.J.) - Medetomidine and dexmedetomidine: a review of cardiovascular effects and antinociceptive
properties in the dog. Vet Anaesth Analg, 2005, 32: 117-127.
[7] WILSON (D.V.), EVANS (A.T.), CARPENTER (R.E.), et al. - The effect
of four anesthetic protocols on splenic size in dogs. Vet Anaesth
Analg, 2004, 31: 102-108.
References
[1] NYLAND (T.G.), MATTOON (J.S.), HERRGESELL (E.R.), et al. - Spleen.
In: NYLAND )T.G.), MATTOON (J.S.) (eds): Small animal diagnostic
ultrasound. Philadephia: WB Saunders, 2002, 128-144.
[2] KONDE (L.J.), WRIGLEY (R.H.), LEBEL (J.L.), et al. - Sonographic and
radiographic changes associated with splenic torsion in the dog.
Vet Radiol Ultrasound, 1989, 30: 41-45.
[3] COUTO (C.G.), HAMMER (A.S.) - Diseases of the lymph nodes
and the spleen. In: Ettinger SJ, Feldmann EC (eds): Textbook of
veterinary internal medicine. Philadephia: WB Saunders, 1995,
1930-1946.
[4[ O’BRIEN (R.T.), WALLER (K.R.), OSGOOD (T.L.) - Sonographic
features of drug –induced splenic congestion. Vet Radiol
Ultrasound, 2004, 45: 225-227.
[5] HAUSNER (E.), ESSEX (H.), MANN (F.C.) - Roentgenologic
observation of the spleen of the dog under ether, sodium amytal,
pentobarbital sodium and pentothal sodium anesthesia. Am J
Physiol, 1938, 121: 387-391.
175
Notes for contributors to the European Journal
of Companion Animal Practice
CONTRIBUTIONS in the form of original research papers, review articles and clinical case histories on all aspects of Companion
Animal (excluding Equine) veterinary medicine and surgery are invited. All submissions are refereed by the EJCAP Editorial
Board and will be subjected to a full peer review. The work should be essentially European ie largely undertaken within
Europe. Submissions are accepted on the understanding that they have not been published elsewhere and that they are
subject to editorial revision. All material published is the copyright of EJCAP.
FORMAT
Manuscripts should be typed, double-line spaced, on one side of the paper only and with wide margins, in the English
language. A covering letter and three copies of the manuscript should be submitted together with three sets of any
illustrations. All abbreviations should be spelt out in full the first time they are used in the text. Medicines should be referred
to by the generic name only. (A footnote stating clearly the proprietary name, countries where available and manufacturers
can be included).
PAPERS
Papers should include a title of not more than 20 words, the names, qualifications and addresses of each author, and a
summary of not more than 200 words. They should be set out in the following sections: summary, introduction, materials
and methods, results, discussion, acknowledgements and references. Clinical papers or case reports should follow a similar
overall arrangements, modified appropriately. The text should be as concise as possible; the whole length should not exceed
4000 words except by special arrangements (that is, about four to six pages of EJCAP (depending on illustrations).
TABLES AND ILLUSTRATIONS
Tables should be presented separately from the text. The legend should clearly explain what data the table is presenting
without the need to refer back to the text. Tables should not duplicate information presented in figures.
Line figures and photographs will normally be reproduced at column width (76 mm). The author’s name, title of the paper
and number of the figure should be pencilled lightly on the back of each illustration. Black and white transparencies and
prints are acceptable. Colour is preferred. Where transparencies are submitted, they should be accompanied by a set of
prints. Prints should be clear and sharp. Original x-rays should be submitted if available to allow logotronisation. If this
is not possible, good quality prints will suffice. High resolution electronic copies will be ideal if the paper is seleced for
publication
REFERENCES
In the text references should be cited by a number eg. [1} [2].(Vancouver style) A list of references at the end of the paper
marked with the appropriate number should show the names and initials of the author, the title of the paper, the volume
number (plus issues number if appropriate) followed by page numbers. Example:
[16] SMITH (G.K.), TORG (J.S.) - Fibular head transposition for repair of cruciate-deficient stifle in the dog. J Am Vet Med Assoc, 1985,
187:375. (Vancouver style)
MEASUREMENTS
Measurements should be expressed in the metric system or in SI units. Temperatures should be given in oC. Centrifugation
speeds should be given in g. Decimal points should be shown at the foot of the line e.g. 5. 5 not 5,5 or with the point above
the baseline.
ETHICS
Papers may be rejected on ethical grounds if the severity of the experimental procedure does not appear to be justified by
the value of the work presented.
SUBMISSION ADDRESS
FAO Prof Ellen Bjerkås
Norwegian School of Veterinary Science,
PO Box 8146 - Dep,
N - 0033, OSLO, Norway.
E-mail: ellen.bjerkas@veths.no
176
DIAGNOSTIC IMAGING
REPRINT PAPER (D)
Magnetic resonance imaging
findings in dogs with suspected
ischaemic myelopathy due to
fibrocartilaginous embolism
V. M. Stein(1), F. Wagner(1,2), C. Bull(1), A. Gerdwilker(1), F. Seehusen(3), W. Baumgärtner(3), A. Tipold(1)
SUMMARY
Objective: Dogs suspected of suffering from fibrocartilaginous embolization (FCE) were evaluated in a retrospective
study regarding their findings in magnetic resonance imaging (MRI).
Material and methods: 26 dogs (February 2004 – February 2006) met the inclusion criteria for evaluation of which 22
were suspected of suffering from FCE. Six of these dogs were euthanased and FCE was confirmed histopathologically.
The remaining 4 of the 26 dogs suffered from explosive disc herniation.
Results: Eighteen of the 26 dogs showed an intramedullary hyperintensity in T2-weighted spinecho (SE) images
whereas in the remaining eight dogs the spinal cord was normointense. Different factors possibly influencing the
presence or absence of hyperintensity were evaluated.
Conclusions: The absence of an intramedullary hyperintensity in T2-weighted images does not exclude the existence of
FCE. The time lapse since clinical signs began and the MR imaging as well as the size and localisation of the embolised
blood vessels may have an important impact on the appearance of FCE during MRI. An explosive intervertebral disc
herniation can produce the same MRI findings as FCE.
Clinical relevance: The study presented provides important insights into the diagnostic approach to dogs with
fibrocartilaginous embolism using MRI.
Key words: Fibrocartilaginous embolism, spinal cord infarction, MRI, hyperintensity in T2, normointensity
from FCE [12, 10, 19, 35]. The classical clinical signs are often
asymmetric, non-progressive and non-painful after the first 24
hours [12, 23, 11].
The clinical diagnosis was formerly achieved as one of exclusion
of compressive lesions by myelography and/or computed
tomography [26]. The coalescence of history, signalment,
findings of neurological examination and the lack of signs of
compressive lesions in radiography support the presumptive
diagnosis of an ischemic myelopathy due to an FCE. Definitive
diagnosis can only be made by histopathology of the affected
spinal cord segment.
This paper originally appeared in:
Tierärztl Prax *2007; 35 (K): 163-174
Introduction
Fibrocartilaginous embolization (FCE) of the spinal cord inducing
an ischaemic myelopathy is a common cause of acute paresis or
plegia of the thoracic and/or pelvic limbs in the dog [9]. Large
breeds are predominantly affected but recently the literature also
reports smaller and even chondrodystrophic breeds suffering
(1)Department of Small Animal Medicine and Surgery, University of Veterinary Medicine, Bischofsholer Damm 15, D-30173 Hannover.
(2) Department of Clinical Sciences of Companion Animals,Faculty of Veterinary Medicine, Utrecht University, The Netherlands.
(3) Institute of Pathology, University of Veterinary Medicine, Bünteweg 17, D-30559 Hannover.
Corresponding author: E-mail: veronika.stein@tiho-hannover.de
*Presented by GSAVA(Germany)
177
Magnetic resonance imaging findings in dogs with suspected ischaemic myelopathy ... - V.M. Stein, et al
In human medicine from 1989 onwards magnetic resonance
imaging (MRI) has been the diagnostic method of choice in
suspected ischemic myelopathy [7]. Although various authors
recommend the use of MRI for diagnosis of FCE in dogs [26, 9,
4] very little information exists concerning the MRI findings in
the veterinary patient.
With the advent of MRI in veterinary medicine a valuable tool
is now available for the ante mortem diagnosis of FCE in the
dog. Therefore, it was the aim of this study to evaluate MRI
findings of dogs with the presumptive diagnosis of ischemic
myelopathy due to FCE. In six dogs the diagnosis was confirmed
by histopathology.
pelvic limbs, frequently with a notable asymmetry of the lesion in
which MRI was performed. Dogs were excluded if MRI displayed
compressive spinal cord lesions such as intervertebral disc diseases,
neoplasia or vertebral subluxations and luxations or if they had
received more than one administration of glucocorticosteroids
prior to submission to our clinic as an influence on the MRI
findings could not be excluded. Acute spinal cord bleeding
was identified on the basis of its appearance on MRI with
hyperintensities on T1-weighted images [33]. Intramedullary
neoplasias were differentiated from ischemic myelopathy due to
their growth pattern with displacement of spinal cord tissue or
mass effect and contrast enhancement [22].
Forty-nine dogs suffering from peracute to acute paresis which
were examined with MRI were identified over the observation
period of two years. Twenty-three dogs were excluded as they
showed compressive lesions on MRI. In the remaining 26 dogs
an ischaemic myelopathy due to FCE was suspected in 22 dogs.
Six of these 22 dogs were euthanased on request of the owner
and FCE was confirmed by histopathology. The remaining four
of the 26 dogs with non-compressive myelopathy suffered from
explosive intervertebral disc herniations as confirmed by either
intraoperative or histopathological findings. The findings of dogs
Material and Methods
Patients
The medical records of patients that were presented at the
Department of Small Animal Medicine and Surgery of the
University of Veterinary Medicine Hannover between February
2004 and February 2006 were retrospectively evaluated. Dogs
were included in the study if they suffered from peracute to
acute non-progressive paresis or plegia of the thoracic and/or
Table 1: Summary of the data of dogs with suspected fibrocartilaginous embolization (FCE; n = 22); Y = years, M = months, m = male,
f = female, c = castrated, s=spayed, LMN = lower motor neuron system, UMN = upper motor neuron system, affected spinal cord
segments are indicated in parentheses, the darker lines indicate dogs with necropsy. An accentuation of neurological signs was evaluated
on the basis of the reflexes in plegic dogs.
Case- Breed
No.
Age
Body weight Gender Motor function deficit and neuroanatomical localisation
(in kg)
1
Bernese mountain dog
5Y
46
m
paraplegia with left-sided accentuation, LMN (L4-S3)
2
Briard
6 Y, 11 M
37,5
f
paraplegia, LMN (L4-S3)
3
Mastino neapolitano
(Neopolitan Mastiff)
6 Y, 6 M
58
fs
paraparesis with right-sided accentuation, UMN (T3-L3)
4
German rough-haired
pointer
7 Y, 8 M
42
m
paraplegia with left-sided accentuation, LMN (L4-S3)
5
Mixed breed
8 Y, 10 M
23
f
severe paraparesis, UMN (T3-L3)
6
Mixed breed
8Y
20
m
paraplegia, UMN (T3-L3)
7
Yorkshire terrier
3 Y, 10 M
3,5
m
severe tetraparesis with right-sided accentuation, LMN (C6-T2)
8
Bernese mountain dog
9 Y, 8 M
42
m
severe tetraparesis, LMN (C6-T2)
9
Mixed breed
6Y
32
m
paraparesis with left-sided accentuation, UMN (T3-L3)
10
Bernese mountain dog
1 Y, 6 M
30
f
monoparesis left hind limb, LMN (L4-S3)
11
Labrador retriever
7 Y, 10 M
34
mc
paraparesis with right-sided accentuation (plegia), UMN (T3-L3)
12
Labrador retriever
3 Y, 11 M
45
m
paraparesis with right-sided accentuation (plegia), UMN (T3-L3)
13
Hovawart
8Y
36,5
f
paraparesis with right-sided accentuation, LMN (L4-S3)
14
Golden retriever
6 Y, 7 M
40
m
paraparesis with left-sided accentuation, LMN (L4-S3)
15
Whippet
6 Y, 11 M
14,5
m
tetraparesis with left-sided accentuation, UMN (C1-C5)
16
Giant schnauzer
5 Y, 7 M
36
f
tetraplegia with right-sided accentuation, LMN (C6-T2)
17
Labrador-mix
8 Y, 3 M
26
m
paraplegia with right-sided accentuation, UMN (T3-L3)
18
Golden retriever
4 Y, 10 M
29
f
paraplegia, UMN (T3-L3)
19
Canadian shepherd dog
5 Y, 11 M
36
f
paraplegia, LMN (L4-S3)
20
Border collie
6 Y, 8 M
20,5
m
paraparesis with right-sided accentuation, LMN (L4-S3)
21
Jindo
12 Y, 1 M
20
f
paraparesis with left-sided accentuation, UMN (T3-L3)
22
Landseer
5 Y, 10 M
60
m
severe paraparesis, LMN (L4-S3)
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EJCAP - Vol. 18 - Issue 2 October 2008
✶
maintained on inhalant isoflurane (Isofluran-Baxter®, Baxter
Deutschland GmbH, Unterschleißheim) and oxygen (anaesthesia
machine with assisted ventilation, (Titus, Dräger Medizintechnik
GmbH, Lübeck). T2-weighted turbo spinecho (TSE) were
obtained in sagittal (repetition time, TR of 4700 ms, echo time,
TE of 112 ms, flip angle 180°) and transverse (TR 3458 ms, TE 96
ms, flip angle 180°) planes to demonstrate the intramedullary
hyperintensity which is described in the literature. In single cases
with T2-weighted intramedullary hyperintensity additional T1weighted SE (TR 330 ms, TE 12 ms, flip angle 90°), and contrastenhanced T1-weighted SE images (Gadolinium-Dimeglumine,
GdDTPA, Magnevist®, Schering Deutschland GmbH, Berlin; 0.2
mmol/kg body weight i.v.) were performed to more precisely
characterise the lesions. The slice thickness was 3 mm for sagittal
and 4 mm for transverse planes.
Findings of MR imaging were correlated with vascular topography
with respect to lesion localisation within the spinal cord, single
premedication with glucocorticosteroids, time interval between
onset of neurological signs and execution of MRI, localisation
of the lesion, severity of neurological signs, and clinical course
and outcome.
✶
Figure 1: Magnetic resonance imaging (MRI) findings of the
cervical spinal cord in T2-weighted turbo spinecho (TSE) images
in sagittal plane of dog no. 16. From C6 to C7 an intramedullary
hyperintensity is clearly visible (arrow). The nuclei pulposi of
C6/7 (star) and Th1/2 (star) appear hypointense, and the discus
intervertebralis C6/7 seems reduced in volume compared to
neighbouring disci.
with explosive intervertebral disc herniations were compared to
those of dogs with FCE.
Results
Neurological examination
Twenty-six dogs with peracute to acute non-progressive paresis
or plegia of the thoracic and/or pelvic limbs were included in
our study in which MRI was performed and compressive lesions
were excluded. In 22 of these 26 dogs FCE was suspected
whereas in the remaining four dogs explosive intervertebral disc
herniations were diagnosed. The MRI findings of dogs with these
diseases are presented and compared with each other. Possible
correlations between MRI appearance and pretreatment with
glucocorticosteroids, time interval between onset of neurological
signs and execution of MRI, localization of the lesion, severity of
neurological signs, and outcome were assessed.
The median age of the dogs at the time of presentation was 6
years and 6 months (range 1 year and 6 months to 12 years and 1
month). Thirteen dogs were male (two were castrated) and nine
dogs were female (one was spayed). Twenty dogs belonged to
the large breeds (weight ≥ 20 kg) whereas only two dogs had a
body weight of less than 20 kg. The most frequent breeds were
A neurological examination was performed in all patients to
identify the localisation of the lesion. All dogs showed acute or
peracute neurological signs attributable to the cervical, thoracic
or lumbar spinal cord (Table 1). During hospitalisation the dogs
were neurologically evaluated daily to document the clinical
course of the disease.
Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI; Magnetom Impact Plus,
1.0 Tesla, Siemens, Erlangen) was performed under general
anaesthesia. Dogs were premedicated with intravenous diazepam
(diazepam ratiopharm®, Fa. Ratiopharm GmbH, Ulm, 1 mg/kg
body weight i.v., maximum 30 mg) and propofol (Narcofol®,
cp-pharma, Burgdorf, to effect). All dogs were intubated and
Figure 2: MRI findings of the thoracolumbar spinal cord in T2-weighted TSE images in sagittal (a) and transverse (b) planes of dog no. 17.
(a) The sagittal plane clearly depicts an intramedullary hyperintensity above the intervertebral disc space Th13/L1 (arrow). Nuclei pulposi
of Th12/13, L1/2, and L2/3 are hypointense (arrowheads), the discus intervertebralis of Th13/L1 appears reduced in volume compared to
neighbouring disci (arrowheads with star). (b) The transverse plane displays that the grey matter is predominantly affected.
▲ ▲✶ ▲ ▲
a
b
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Magnetic resonance imaging findings in dogs with suspected ischaemic myelopathy ... - V.M. Stein, et al
Case
No.
Duration
to MRI
sagittal
Findings of MRI in T2-weighted Turbo Spinecho (TSE) sequence
transversal
12
<8h
Intramedullary hyperintensity at L2/3, discus intervertebralis
L2/3 hypointense
Intramedullary hyperintensity predominantly in grey
matter at L2/3 with right-sided accentuation
18
<8h
Intramedullary hyperintensity at Th9 to Th11
Diffuse intramedullary hyperintensity from Th9 to
Th11 without accentuation on one side
2
< 24 h
Intramedullary hyperintensity at L4/5 with right-sided
accentuation
Intramedullary hyperintensity of grey and white
matter on the right side
3
< 24 h
Normointense spinal cord, multiple hypointense
degenerated disci intervertebrales in thoracic spine
-
4
< 24 h
Normointense spinal cord, disci intervertebrales L6/7 and
L7/S1 mildly hypointense
-
5
< 24 h
Intramedullary hyperintensity at L2, discus intervertebralis
L2/3 mildly hypointense
Hyperintensity of grey matter at L2/3 without
accentuation on one side
6
< 24 h
Intramedullary hyperintensity at Th12/13, discus
intervertebralis Th12/13 mildly reduced in volume compared
to adjacent disci, hypointense disci cranial to Th10
Hyperintensity of grey matter at Th12/13 without
accentuation on one side
14
< 24 h
Intramedullary hyperintensity at L3/4, discus intervertebralis
L1/2 hypointense
Diffuse intramedullary hyperintensity of grey and
white matter with left-sided accentuation
19
< 24 h
Intramedullary hyperintensity from L1 to L4, disci
intervertebrales L6/7 and L7/S1 hypointense, L3/4
moderately hypointense
Intramedullary hyperintensity predominantly in grey
matter without accentuation on one side
20
< 24 h
Normointense spinal cord, multiple hypointense disci
intervertebrales cranial to Th10 and caudal to Th13
-
22
< 24 h
Intramedullary hyperintensity from L4 to L6
Hyperintensity predominantly of grey matter without
accentuation on one side
9
24 – 48 h
Normointense spinal cord, discus intervertebralis at Th12/13
hypointense
-
10
24 – 48 h
Normointense spinal cord
Normointense spinal cord
11
24 – 48 h
Intramedullary hyperintensity at Th13/L1, discus
intervertebralis Th13/L1 mildly reduced in volume, disci L3/4
and L4/5 hypointense
Diffuse intramedullary hyperintensity at Th13/L1 with
right-sided ventral accentuation
16
24 – 48 h
Intramedullary hyperintensity at C6 to C7, disci
intervertebrales C6/7 and Th1/2 hypointense, discus C6/7
appears reduced in volume
Intramedullary hyperintensity with right-sided
accentuation
17
24 – 48 h
Intramedullary hyperintensity at Th13/L1, disci
intervertebrales Th12/13, L1/2, and L2/3 hypointense
Intramedullary hyperintensity predominantly of grey
matter at Th13/L1 without accentuation on one side
1
> 48 h
Intramedullary hyperintensity from L2 to L5 with left-sided
accentuation, no sign for degeneration of nucleus pulposus
Intramedullary hyperintensity with left-sided dorsal
accentuation
7
> 48 h
Intramedullary hyperintensity at C5/6
Intramedullary hyperintensity of grey and white
matter at C5/6 with right-sided accentuation
8
> 48 h
Normointense spinal cord, disci intervertebrales of cervical
spinal cord generalized hypointense
Normointense spinal cord
13
> 48 h
Normointense spinal cord, disci intervertebrales L1/2, L2/3,
L3/4, and L7/S1 moderately hypointense
Normointense spinal cord
15
> 48 h
Normointense spinal cord, disci intervertebrales C5/6 and
C6/7 hypointense
Normointense spinal cord
21
> 48 h
Intramedullary hyperintensity at Th11-Th12 with left-sided
accentuation, multiple hypointense disci intervertebrales
cranial to Th11
Diffuse intramedullary hyperintensity of grey and
white matter on the left side
Table 2: Finding of MR imaging in the T2-weighted TSE sequence in sagittal and transverse planes with respect to the time interval
between initiation of neurological signs and execution of MRI. – = no transverse plane was conducted in this patient. The darker lines
indicate dogs with normointense spinal cord in T2-weighted images. h = hours
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EJCAP - Vol. 18 - Issue 2 October 2008
C
▲
b
a
c
Figure 3: MRI findings of the thoracolumbar spinal cord in T2-weighted TSE images in a sagittal plane of a dog suffering from
explosive intervertebral disc herniation (a), and histopathological presentation of the lesion in the Alcian blue stain (b and c). Above the
intervertebral disc space Th13/L1 the intramedullary hyperintensity is clearly visible (arrow), the nucleus pulposus of Th13/L1 appears
moderately hypointense and reduced in volume compared to neighbouring disci (arrowhead). (b) Severe malacia in the ventromedial
funiculi of the spinal cord white matter with detection of dark blue-stained explosively extruded disc material (25x, original magnification).
(c) Detail of b (100x, original magnification). C = central canal
Bernese mountain dogs (n = 3), Labrador retrievers (n = 2), and
Golden retrievers (n = 2). Further breeds included were Briard,
Mastino neapolitano (Neopolitan Mastiff), German rough-haired
pointer, Yorkshire terrier, Hovawart, Whippet, Giant schnauzer,
Canadian shepherd, Border collie, Jindo, and Landseer, as well
as four mixed-breed dogs.
The most frequent neuroanatomical localisations of the
lesions were the upper motor neuron system (UMN, T3-L3, n
= 9), and the lower motor neuron system (LMN, L4-S3, n =
9) of the pelvic limbs. Therefore, the most frequent clinical
presentation was a paraparesis or –plegia. The cervical spinal
cord was only affected in four dogs, with tetraparesis in three
dogs and tetraplegia in one dog (no. 16). The cervical lesions
were localized to the UMN (C1-5) in one dog and to the LMN
(C6-T2) in three dogs. In the majority of cases (about 70%) an
asymmetry of the neurological signs was noted (Table 1).
In 14 dogs MRI displayed a focal intramedullary hyperintense
lesion in T2-weighted TSE images (Figures 1, 2 and 3, Table
2). These findings can be interpreted as intramedullary
swellings due to focal oedema. In eight dogs no lesion could
be identified in T2-weighted images, in these dogs the spinal
cord was normointense over the whole area of neuroanatomical
localization (Table 2). In transverse T2-weighted TSE images
a hyperintensity could also be detected in 14 dogs. A good
correlation was found between MRI findings and clinical
signs as seven of the eight dogs with asymmetric neurological
deficits showed an asymmetric hyperintensity in T2-weighted
transverse images (Table 1 and 2). In five of six dogs suffering
from symmetric neurological signs the T2 hyperintense lesions
were also relatively symmetric, affecting both sides of the spinal
cord (Table 1 and 2). In seven dogs with an intramedullary T2
hyperintense lesion an additional T1-weighted sequence was
conducted. The T1-weighted images of the spinal cord appeared
normointense in five dogs (nos. 6, 7, 14, 17, 22), therefore, no
lesion was detectable within the area of the neuroanatomical
localisation of the lesion, and the hyperintensity in corresponding
T2-weighted images. In two dogs (nos. 11 and 21) the T2-
hyperintense lesion appeared hypointense on T1-weighted
images. No correlation could be assessed for the differential
appearance of the lesions on T1-weighted images and the time
interval between onset of neurological signs and execution of
MRI. After intravenous injection of GdDTPA no, or only a mild,
enhancement was detected within the hyperintense lesion in
the spinal cord.
Various influencing factors might be responsible for the
variable appearance of the FCE lesions on MR imaging. We
tried therefore to identify possible correlations between the
presence or absence of an intramedullary hyperintensity in T2weighted images and pretreatment with glucocorticosteroids,
time interval between onset of neurological signs and execution
of MRI, localization of the lesion, severity of neurological signs,
and clinical course and outcome.
Fourteen patients showed a T2-weighted intramedullary
hyperintensity of which seven dogs displayed a complete loss
of motor function (= plegia), and the other seven showed a
partial loss of motor function (= paresis). Of the eight dogs with
T2-weighted normointense spinal cord only one dog displayed a
plegia whereas seven dogs showed a paresis (Table 1, 2). Dogs
with a neuroanatomical localisation of their lesion in the upper
motor neuron system (UMN; C1−5 or T3−L3) might be more
prone to develop an oedema compared with dogs with lesions
in the lower motor neuron system (LMN; C6−T2 or L4−S3)
which is due to differences in vascular topography along the
spinal cord. Seven of ten dogs with a lesion in the UMN showed
an intramedullary oedema and only three dogs displayed a
normointense spinal cord. Twelve dogs suffered from a lesion in
the LMN of which seven showed a T2-hyperintense lesion and
five dogs a normointense spinal cord (Table 1, 2, 3).
Fifteen dogs were premedicated with a single dose of
glucocorticosteroids prior to referral. Nine of these dogs
showed a characteristic intramedullary hyperintensity on T2weighted images whereas in six dogs no hyperintensity could
be detected. Therefore, no correlation was found between pretreatment with glucocorticosteroids and presence or absence of
181
Magnetic resonance imaging findings in dogs with suspected ischaemic myelopathy ... - V.M. Stein, et al
T2
Influencing factors
number
hyperintense
normointense
Vascular topography
Lesion UMN (C1-C5; T3-L3)
10
7
3
Lesion LMN (C6-T2; L4-S3)
12
7
5
Single dose of glucocorticosteroids
15
9
6
Severity of motor deficits
22
14 → 7 Plegia
→ 7 Paresis
Clinical course
13
8 Improvement after 12.5 days
5 Improvement after 4.2 days
Time interval between onset of neurological
signs and MRI
< 24 h
24 – 48 h
> 48 h
11
5
6
8
3
3
3
2
3
8
→ 1 Plegia
→ 7 Paresis
Table 3: Potential influencing factors on the appearance of fibrocartilaginous embolization (FCE) in T2-weighted images. h = hours, UMN
= upper motor neuron system, LMN = lower motor neuron system
hyperintense lesions on T2-weighted TSE images (Table 3).
The time interval between onset of neurological signs
and execution of MRI did not seem to influence whether
the localisation in the spinal cord defined by the neurological
examination showed a hyper- or normointensity on T2-weighted
images. Half of the dogs (11 of 22) were referred on the day when
the neurological signs began, the MR imaging was therefore
performed within 24 hours after the signs started. In five other
dogs MRI was performed 24−48 hours after onset of first signs,
whereas in the remaining six dogs it was conducted more than 48
hours after onset of clinical signs. Eight of eleven dogs examined
within 24 hours showed an intramedullary hyperintensity on T2,
the spinal cord was normointense in the other three dogs. In the
patients examined 24−48 hours after the onset of signs in three
dogs a hyperintensity could be detected whereas in two there was
none. Six dogs were examined more than 48 hours after initiation
of neurological signs of which three showed a hyperintensity and
in the other three the spinal cord was normointense (Table 3).
Therefore, no correlation was established regarding MRI findings
and the hours which had elapsed after onset of neurological
signs and MRI study performed.
The clinical course of the disease was evaluated in 13 patients.
In nine patients re-examination was not possible. These were
one dog which died during general anaesthesia, six dogs
which were euthanased on the request of the owner, and two
further dogs which we were not able to follow-up. Eight of 13
patients with follow-up examination displayed an intramedullary
hyperintensity in T2. In these dogs a neurological improvement
was evident after a mean of 12.5 days (this was defined as
incipient motor function in previously plegic dogs or unassisted
movements in previously paretic dogs unable to walk without
support). The clinical course was also assessed for five dogs with
normointense spinal cord in T2-weighted images. The mean
time for neurological improvement of these dogs was 4.2 days,
and thus neurological improvement was more rapidly achieved
in this group of dogs (Table 3).
The nuclei pulposi showed a decreased signal intensity in
T2-weighted TSE images in 17 dogs which can be interpreted
as evidence for their degeneration. Some nuclei pulposi also
demonstrated a reduced volume compared to adjacent nuclei
(Table 2). The nucleus directly underneath the hyperintense lesion
in the spinal cord was affected in seven dogs whereas in six dogs
Figure 4: (a) MRI findings of the lumbar spinal cord in T2-weighted TSE images in a sagittal plane of dog no. 4. The spinal cord of this
dog is normointense. (b) Histopathologic detection of fibrocartilaginous material in a vessel of the white matter at L4 (200x, original
magnification, H&E stain). (c) In the white matter adjacent to the lesion single swollen axonal cylinders (spheroids, arrow), as well as
myelophages in so called “digestion chambers” (arrowhead; 400x, original magnification, H&E stain) can be demonstrated.
▲
b
a
182
c
EJCAP - Vol. 18 - Issue 2 October 2008
Figure 5: MRI findings of the lumbar spinal cord in
T2-weighted TSE images in a transverse plane of dog
no. 14 (a), and microscopic view on the transverse
slide through the fixated spinal cord at L5/6 in H&E
stain of the same dog (b; 5x, original magnification).
(a) In the MR image the intramedullary
hyperintensity is clearly visible affecting the rightsided grey and white matter. (b) Severe unilateral
multifocal malacia of the dorsal ventral and lateral
funiculi white matter due to an ischaemic necrosis
caused by a fibrocartilaginous embolus. C = central
canal.
C
a
b
it could not be evaluated as the spinal cord was normointense.
However, the degenerated nuclei pulposi were within the
area of the clinically defined neuroanatomical localisation of
the lesion in these dogs. In four dogs the degenerated nuclei
were more than two intervertebral disc spaces apart from the
T2 intramedullary hyperintensity. No signs of degeneration of
nuclei pulposi were found in five dogs (Table 2).
All four dogs with either intraoperatively (n = 2) or
histopathologically (n = 2) confirmed explosive intervertebral
disc herniation causing the neurological signs showed an
intramedullary hyperintensity in T2-weighted TSE images
which was comparable to most of the dogs with suspected
fibrocartilaginous embolization of the spinal cord. The
hyperintensity was above the discus intervertebralis of Th12/13
in two dogs, and of Th13/L1 in the other two dogs (Figure 3). In
two of the four patients the nuclei pulposi of the above named
intervertebral disc spaces appeared hypointense and reduced
in their volume compared with adjacent nuclei. Additional T1weighted SE images were obtained in two dogs, one presenting
a hypointense medullary lesion, and the other a lesion which
was isointense to the surrounding spinal cord tissue.
A histopathological examination was performed in six of the
22 dogs with suspected FCE, and in two of the four dogs with
explosive intervertebral disc herniations. In three of the FCE dogs
an acute ischaemic myelomalacia was found and fibrocartilaginous
material was detected in arterial blood vessels (dog nos. 2, 4,
14; Figure 5, 6). Two of these patients (nos. 2, 14) showed a
T2 intramedullary hyperintensity whereas in one patient (no. 4)
the spinal cord was normointense (Figure 4). In the remaining
cases (dog nos. 19, 21, and 22) the histopathological results were
compatible with an acute ischemic myelomalacia at L1−4 (dog
no. 19), L4−6 (no. 22), or at the thoracolumbar junction (no. 21)
but without detection of fibrocartilaginous emboli.
In all four dogs with explosive intervertebral disc herniations
oedema and a blue discoloration of the spinal cord was clearly
visible intraoperatively at the area of hyperintensity in T2weighted MR images. In all cases a durotomy was performed
and the spinal cord was evaluated as being mildly to severely
malacic. Both dogs with severe malacia were euthanased on
request of the owner and necropsy was performed. In both
cases histopathology displayed severe myelomalacia and
chondroid disc material in the spinal cord (Figure 3), a severe
Figure 6: Cross sectional area of the spinal cord of dog no. 14 with a medullary infarction due to fibrocartilaginous embolism at 100x
original magnification in the Alcian blue (a) and periodic acid schiff (PAS) stain (b). Fibrocartilaginous embolus in a white matter vessel
with malacia of the adjacent tissue. Fibrocartilaginous material stains blue with Alcian blue and lucent magenta with PAS staining.
b
a
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Magnetic resonance imaging findings in dogs with suspected ischaemic myelopathy ... - V.M. Stein, et al
bleeding with cartilaginous material within the coagula were
found additionally in one of the dogs. Therefore, the suspected
diagnosis of explosive intervertebral disc herniation was
histopathologically confirmed.
This arborisation is segmental to either both sides or alternating
to one or the other side [13, 27]. An embolization in the area
of unilateral branching consequently causes an ischaemia in
one half of the spinal cord (Figure 5a and b). This anatomy
therefore explains why single quadrants of the spinal cord can
be affected whereas others in the same area are completely
spared [11, 26]. One study stated a clinical asymmetry in 5565% of the cases [17] which is reflected by the findings of our
study with asymmetrical signs in approximately 70% of the
dogs. The asymmetry found in neurological deficits correlated
with the findings of MR imaging in transverse planes exhibiting
accentuation of the hyperintensity on one side of the spinal
cord. The medical history frequently relates to initial asymmetric
signs which progressed to symmetrical deficits which can be
explained by the propagating cytotoxic oedema in the spinal
cord tissue [9].
The diagnosis of FCE was formerly achieved by the exclusion
of compressive diseases following unremarkable myelography
or demonstration of mildly attenuated contrast columns along
the lesion [9]. In human medicine MR imaging has been used
as the modality of choice in the diagnosis of FCE since 1989 [7].
With the advent of MRI in veterinary medicine a new potential
diagnostic tool for the intra vitam diagnosis of FCE is available. It
was the aim of this study to assess whether FCE can be visualized
with this non-invasive technique and the diagnosis can be
confirmed. Although many authors in the veterinary literature
recommend the use of MRI in suspected FCE cases [9, 26, 31]
statements about the findings are sparse. Literature on MRI
findings in cats and dogs with FCE were only published recently.
Findings described were oedema and spinal cord swelling in the
area of the lesion [31], which could be seen as intramedullary
hyperintensity on T2-weighted images [2, 19, 24, 25, 35].
Enhancement with contrast agent after intravenous injection
is dependent on the age of the infarction. In the early phase
after initiation of neurological signs only a very mild to absent
enhancement was detected [2, 19]. The uniform presentation
of FCE with an intramedullary hyperintensity in T2-weighted
images does not comply with the results of this study.
In the study presented here a compressive extradural lesion was
excluded in all 26 dogs. In 18 dogs a T2-weighted hyperintense
lesion was detected in the spinal cord (14 of which an FCE was
suspected, and four dogs with explosive intervertebral disc
herniation) whereas 8 dogs with characteristic history and
clinical appearance suggesting FCE displayed a normointense
spinal cord which is contrary to descriptions in the literature.
However, one case with absent hyperintensity (dog no. 4) was
histopathologically examined, and fibrocartilaginous material
was detected in arterial vessels and thus FCE confirmed by
histology. Potential factors influencing presence or absence of a
T2-weighted intramedullary hyperintensity were evaluated and
are discussed below.
One possible influence could arise from the neuroanatomical
localisation of the lesion taking into consideration the
differences in the topography of the supplying blood vessels of
the spinal cord as well as the size of the embolized vessel. The
spinal cord is protected against ischaemic insults by its extensive
leptomeningeal vessel anastomoses. However, the intrinsic
parenchymal vessels constitute a terminal vascular bed [11]. The
differential vascular topography may have an additional impact
Discussion
Fibrocartilaginous embolizations (FCE) of the spinal cord inducing
an ischaemic myelopathy are common causes of acute paresis or
plegia of the thoracic and/or pelvic limbs in the dog [9, 12, 14,
10, 2]. FCE is also described in the cat [29, 1, 24, 25], horse [30],
pig [34] and cattle [9].
Other causes of ischaemic myelopathy could be a vascular occlusion
due to atherosclerosis, thrombi, bacterial, parasitic or neoplastic
emboli [26, 9]. The pathophysiology of FCE is unknown. Several
theories have been proposed and are controversially discussed
(summarized in 9). The occlusion of an artery or a vein by an
FCE results in local ischaemia. In consequence neurons cannot
maintain their aerobic metabolism and lose membrane polarity.
Calcium and sodium enter the cells and potassium ions diffuse
to the extracellular space. Water secondarily follows the osmotic
gradient into the intracellular space leading to an intracellular
or cytotoxic oedema [5]. The anaerobic metabolism leads to
the accumulation of lactate and its derivates which lower the
pH of the cell. Concurrently cytokines and excitatory amino
acids (glutamate and aspartate) are released and free radicals
(superoxide, hydrogen peroxide, and nitrogen monoxide) are
generated which attack cell membranes resulting in parenchymal
malacia [15].
FCE is often seen in large breed dogs. A higher pressure in
the nucleus pulposus and larger blood vessels are possible
explanations for this breed predilection [12]. Miniature schnauzer
and young Irish wolfhounds seem to be predisposed to this
disease [21, 20]. In the study presented here approximately
90% of the patients comprised large breed dogs (body weight
≥ 20 kg).
The occurrence of FCE can be as early as eight weeks of age
and, according to the literature, is most commonly encountered
in dogs aged between three and six years [26, 10, 9, 21].
However, the median age of dogs in our study was 6 years and
6 months.
The neurological signs are dependent on the anatomical
localisation of the infarction and the severity of the ischaemia.
Medullary infarctions can occur focally along the whole
spinal cord. The intumescences are frequently affected due
to differences in the topography of the blood vessels [9, 13]
leading to lesions of the LMN system (reduced or absent spinal
reflexes). In this study the numbers of patients with lesions in the
UMN (T3-L3) and LMN (L4-S3) for the pelvic limbs were equally
distributed. Summers et al. [32] report that in about 60% of the
cases a paresis or plegia of the hind limbs – therefore a lesion
localised caudally to T3 – can be observed. In the dogs described
in this study an even higher percentage of approximately 80%
showed deficits in the pelvic limbs. Frequently, an asymmetry
of the neurological signs is notable [9], with almost absent
deficits on the unaffected side [26]. This can be explained by the
anatomy of the blood vessel branching. The A. spinalis ventralis
gives rise to the Aa. sulcocommissurales which supplies one
side of the spinal cord grey matter and areas of white matter.
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EJCAP - Vol. 18 - Issue 2 October 2008
on spinal cord vulnerability. The smallest number of radicular
arteries and diameter of the vessels are found in the thoracic
area [8]. Moreover, the number of Aa. sulcocommissurales per
centimetre of spinal cord is significantly lower in the thoracic
compared with the cervical and lumbar area [9]. Therefore, it
can be assumed that the incidence of a vascular embolisation
in an area of lower vessel density might be rare compared to
areas of higher vessel density. On the other hand a vascular
embolisation in an area of low vessel density might lead
to more detrimental effects on the spinal cord [9]. This is in
accordance with the finding that the majority of dogs with a
neuroanatomical localisation of the lesion at T3–L3 displayed a
T2-weighted intramedullary hyperintensity.
The presence or absence of an intramedullary hyperintensity
in T2 did not seem to correlate with a single dose of
glucocorticosteroids as both, dogs with and without
glucocorticosteroid administration showed hyperintense or
normointense lesions. Abramson et al. [2] describe that a
single application of glucocorticosteroids prior to referral is not
sufficient to completely mask an inflammatory disease of the
spinal cord on MR imaging. It can therefore be assumed that
one dose of glucocorticosteroids does not have a considerable
influence on the detection of an intramedullary oedema.
The time interval between onset of neurological signs and
execution of MRI might have an impact on the detectability of
the lesion. Abramson et al. [2] observed that time elapsed since
onset of clinical signs influenced the appearance of the lesion
on T1-weighted images and after contrast application whereas
T2-weighted images constantly detected a hyperintensity.
According to our results there was no significant influence of
time on MRI appearance for cases evaluated within 48 hours
after onset of neurological signs. However, the dogs of the study
presented here were generally examined earlier in the course of
their disease compared to the study of Abramson and colleagues
[2]. Findings in human medicine also point to a dependence of
MRI appearance on the age of the lesion [16]. Weidauer et al.
[36] described an absence of an intramedullary hyperintensity
in patients examined early after the onset of their neurological
deficits. MRI follow-up examinations in these patients disclosed
a hyperintensity after five to eight days. An influence of the time
interval between onset of neurological signs and MRI is difficult
to assess in veterinary medicine as follow-up examinations
necessitating general anaesthesia are rarely indicated.
Concerning the severity of signs dogs with T2 hyperintense
lesions were affected to a different degree whereas dogs
with normointense spinal cord had a tendency for less severe
neurological deficits. This has to be considered in context to the
clinical course of the patients. Dogs with normointense spinal
cord showed a faster neurological improvement compared to
dogs with an intramedullary hyperintensity. The absence of an
intramedullary hyperintensity therefore might indicate a less
severe or less extensive damage of the spinal cord.
The status of the nuclei pulposi adjacent to the ischaemic
myelopathy had not been extensively evaluated until now.
In some studies they appeared unaltered whereas in others
radiographic or histopathological findings suggested their
degeneration [11, 32]. The description of Grünenfelder and
colleagues [19] is of special note as they could not assess signs of
disc degeneration in a dog with suspected FCE in an initial MRI
examination but in a follow-up examination 14 days later it was
clearly visible in a disc neighbouring the hyperintensity. Nuclei
pulposi normally show high signal intensity on T2-weighted
TSE images [3]. A partial loss of the signal intensity suggests
degeneration in the sense of dehydration or herniation of the
nucleus. In the study presented here seven dogs showed signs
of disc degeneration adjacent to the T2-weighted intramedullary
hyperintensity. Only in four dogs degenerated discs were more
than two intervertebral disc spaces distant to the intramedullary
lesion. This finding implicates a relation between degenerated
nuclei pulposi and the localisation of FCE.
The definitive diagnosis of FCE is achieved by histopathological
examination. An ischaemic myelopathy in the area of the lesion
constitutes a characteristic finding. Confirmation of FCE is
performed by detection of fibrocartilaginous material partially or
completely occluding arteries or veins of the spinal cord, which is
histologically and histochemically identical to nucleus pulposus
material [6, 12]. Emboli stain positive for mucopolysaccharides,
blue in Alcian blue stain and bright magenta in PAS (periodic acid
Schiff) stain, respectively [9, 32; Figure 6]. In consequence of the
focal ischaemia, necrosis and malacia develop in the grey and
white matter of the spinal cord. These changes are clearly visible
with low magnification as vacuolization of the parenchyma
(Figure 4b). Further characteristic histopathological features
are vascular necrosis, axonal degeneration and regenerative
processes of different degree with lipid-laden macrophages and
neutrophilic infiltration [26, 32].
The differential diagnoses of FCE are markedly reduced after MR
imaging. They were evaluated for the first time by this study.
Explosive intervertebral disc herniations which have some features
in common with FCE, such as an acute to peracute onset of
signs, frequently asymmetric and non-progressive paresis/plegia,
and often without obvious pain [18, 10] could not definitely be
differentiated from FCE with MRI. The distinction of the four
cases with explosive intervertebral disc herniation was performed
on the basis of intraoperative or histopathologcial findings.
According to Bagley [4] the acute explosive non-compressive disc
herniation is of particular importance as a differential diagnosis
of FCE, and a frequent source of misinterpretation. Furthermore,
spinal cord contusion constitutes a differential diagnosis as it
shows a focal T2 hyperintensity and no contrast enhancement [4,
9]. The distinction of these pathological spinal cord conditions is
particularly challenging to impossible as they all classically show
an intramedullary oedema [4, 28]. The diagnosis of FCE therefore
clinically remains a tentative diagnosis – despite the use of MRI.
Conclusions
The study presented here comprising 22 dogs with the
presumptive diagnosis of ischaemic myelopathy due to FCE
provides new information about the findings on MRI. It
describes for the first time the occurrence of histopathologically
confirmed FCE without signs of T2-hyperintensity. Therefore, the
absence of a hyperintense lesion on T2-weighted images does
not exclude the existence of FCE, and conversly the detection of
a T2-hyperintensity does not necessarily confirm the existence of
FCE. Explosive intervertebral disc herniations can display similar
characteristics on MRI as FCE. Characteristic neurological signs
in line with history, and signalment in combination with the
185
Magnetic resonance imaging findings in dogs with suspected ischaemic myelopathy ... - V.M. Stein, et al
findings of MRI can strongly support a presumptive diagnosis
of FCE whereas explosive intervertebral disc herniation is still
an important differential diagnosis. The presence or absence
of an intramedullary hyperintensity on T2-weighted images
could be influenced by the time interval between initiation of
neurological signs and MR imaging, but the size and localization
of the embolized blood vessels could also have an impact on the
MRI appearance.
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cord ischemia diagnosed by MRI. J Neuroradiol, 1995; 22: 11522.
[17] GANDINI (G.), CIZINAUSKAS (S.), LANG (J.), FATZER (R.), JAGGY
(A) - Fibrocartilaginous embolism in 75 dogs: clinical findings and
factors influencing the recovery rate. J Small Anim Pract, 2003;
44: 76-80.
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[19] GRÜNENFELDER (F.I.), WEISHAUPT (D.), GREEN (R.), STEFFEN (F.)
- Magnetic resonance imaging findings in spinal cord infarction in
three small breed dogs. Vet Radiol Ultrasound, 2005; 46: 91-6.
[20] HAWTHORNE (J.C), WALLACE (L.J.), FENNER (W.R.), WATERS (D.J.)
- Fibrocartilaginous embolic myelopathy in Miniature Schnauzers.
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[21] JUNKER (K.), VAN DEN INGH (T.S.G.A.M.), BOSSARD (M.M), VAN
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features of tumors of the spine and spinal cord in dogs. Vet Radiol
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embolism. Comp Cont Educ Pract Vet, 1980; 2: 402-6.
[24] MACKAY (A.D.), RUSBRIDGE (C.), SPARKES (A.H.), PLATT (S.R.)
- MRI characteristics of suspected acute spinal cord infarction in
two cats, and a review of the literature. J Fel Med Surg, 2004; 7:
101-7.
[25] MIKSZEWSKI (J.S.), VAN WINKLE (T.J.), TROXEL (M.T.) Fibrocartilaginous embolic myelopathy in five cats. J Am Anim
Hosp Assoc, 2006; 42: 226-33.
[26] NEER (T.M.) - Fibrocartilaginous emboli. Vet Clin North Am: Small
Anim Pract, 1992; 22: 1017-25.
[27] NICKEL (R.), SCHUMMER (A.), SEIFERLE (E.), BÖHME (G.) - Lehrbuch
der Anatomie der Haustiere Band 4. Nervensystem, Sinnesorgane,
Endokrine Drüsen. Berlin und Hamburg: Parey 2004.
[28] SANDERS (S.G.), BAGLEY (R.S.), GAVIN (P.R.) - Intramedullary
spinal cord damage associated with intervertebral disk material in
a dog. J Am Vet Med Assoc, 2002; 1594-6, 1574-95.
[29] SCOTT (H.W.), O´LEARY (M.T.) - Fibrocartilaginous embolism in a
cat. J Small Anim Pract, 1996; 37: 228-31.
[30] SEBASTIAN (M.M.), GILES (R.C.) - Fibrocartilaginous embolic
myelopathy in a horse. J Vet Med A, 2004; 51: 341-3.
[31] SHARP (N.J.H.), WHEELER (S.J.) - Fibrocartilaginous embolism. In:
Small Animal Spinal Disorders. London, New York: Elsevier Mosby,
2005; 332.
[32] SUMMERS (B.), CUMMINGS (J.F.), DELAHUNTA (A.) - Veterinary
Neuropathology. St. Louis: Mosby, 1995.
[33] TARTARELLI (C.L.), BARONI (M.), BORGHI (M.) - Thoracolumbar
disc extrusion associated with extensive epidural haemorrhage:
a retrospective study of 23 dogs. J Small Anim Pract, 2005; 46:
485-90.
[34] TESSARO (S.V.), DOIGE (C.E.), RHODES (C.S.) - Posterior paralysis
due to fibrocartilaginous embolism in two weaner pigs. Can J
Comp Med, 1983; 47: 124-6.
[35] UENO (H.), SHIMIZU (J.), UZUKA (Y.), KOBAYASHI (Y.), HIROKAWA
(H.), UENO (E.), SUZUKI (A.), YAMADA (K). - Fibrocartilaginous
embolism in a chondrodystrophoid breed dog. Aust Vet J, 2005;
83: 142-4.
[36] WEIDAUER (S.), NICHTWEISS (M.), LANFERMANN (H.), ZANELLE
(F.E.) - Spinal cord infarction: MR imaging and clinical features in
16 cases. Neuroradiology, 2002; 44: 851-7.
Acknowledgements
The authors would like to thank all referring veterinarians, and
Dres. Irene Böttcher and Thilo von Klopmann for their supportive
care of hospitalized patients. The study was funded by the
Frauchiger Stiftung, Berne, Switzerland.
References
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186
URINOGENITAL SYSTEM
ORIGINAL WORK
Urethral sphincter mechanism
incompetence in spayed bitches: new
insights into the pathophysiology
and options for treatment
I. Reichler (1), M. Hubler (1), S. Arnold (1)
INTRODUCTION
Incidence of USMI after ovariectomy
Urinary incontinence is the involuntary loss of urine [1]. In intact bitches urinary incontinence is rare (0-1 %) [2],
whereas in spayed bitches the incidence is up to 20% [3].
The underlying pathophysiological mechanism is mainly an acquired insufficient closure of the urethra after spaying
[4]. Therefore urinary incontinence after spaying is called urethral sphincter mechanism incompetence (USMI).
Within one year after spaying the urethral closure pressure is significantly reduced. Because many bitches may only
become incontinent years after surgery it took a long time until the causal relationship between ovariectomy and the
occurrence of incontinence was proven [5]. In one study, 83 of 412 (20%) bitches became incontinent 3 to 10 years after
surgery [3].
As long as 40 years ago urinary incontinence was described as a rare side effect of spaying [6]. However, it took 20
years to verify the causal relationship between the removal of the ovaries and urinary incontinence [5]. The triggering
mechanism is still unclear.
Neuronal damage can most likely be disregarded, as the risk of urinary incontinence is the same in ovariectomised
and ovariohysterectomised bitches [3].
The role of oestrogen deficiency
becoming continent [3, 11, 12]. Also, the plasma oestrogen
concentration of spayed incontinent bitches is the same [13] or
slightly lower [14] than that of intact, continent bitches.
It is generally assumed that USMI after spaying is due to an
oestrogen deficiency [7, 8]. In view of other facts it appears
unlikely that oestrogen deficiency alone accounts for USMI after
spaying. For example, bitches treated with long acting gestagens
to suppress the sexual cycle, have no increased risk for urinary
incontinence, although this treatment leads to suppressed
ovarian function [9] with a serum oestradiol concentration
remaining at a basal level [10]. In addition, daily supplement
of oestrogen only results in 61-65% of incontinent bitches
Treatment of USMI
Dogs with USMI have a higher risk of urinary tract infection,
that can result in polyuria and detrusor instability of the bladder.
Urinary tract infection and other diseases causing polyuria
such as decreased renal function, Cushing’s disease, diabetes
mellitus, or corticosteroid treatment can lead to overt urinary
(1) Small Animal Reproduction,Vetsuisse Faculty University Zurich, Winterthurestr. 260
CH-8057 Zürich E-mail: ireichler@vetclinics.uzh.ch
187
Urethral sphincter mechanism incompetence in spayed bitches - I. Reichler, M. Hubler, S. Arnold
incontinence in dogs with USMI. Thus urinary tract infection
and polyuric diseases should always be ruled out or treated
adequately.
to endogenous and exogenous catecholamines [26]. If therapy
with alpha-adrenergic agonists is unsatisfactory, a combination
with oestrogens may potentiate the effect.
Medical treatment of USMI
GnRH depot analogues
As mentioned before not all the observations can be explained
by oestrogen deficiency as being the sole underlying cause of
urinary incontinence after spaying. In addition, it is not the only
endocrine hormonal change after spaying. By removing the
ovaries the feedback function of the gonadal hormones on the
hypothalamic-pituitary system is abolished [27], which in turn
results in a several fold increase of the initial plasma levels of
the two gonadotropins (follicle stimulating hormone FSH, and
luteinizing hormone, LH) [28, 29]. The question arises, if the
elevated FSH and LH concentrations are responsible for the high
incidence of urinary incontinence in spayed bitches. If this was
the case suppression of the gonadotropin secretion would result
in continence in affected bitches. GnRH depot preparations are
suitable for the suppression of FSH and LH secretion. These
are subcutaneously administered implants, which continuously
secrete GnRH and, dependant on the preparation, result in an
elevated blood concentration over weeks or months. This leads to
a down-regulation of the GnRH-receptors in the pituitary gland
and thereafter to a decrease of the FSH and LH concentrations
to a low level.
Medical treatment of USMI is the method of choice and should
always precede surgical therapy. The aim of medical treatment
is to increase the urethral closure pressure.
Alpha-adrenergic drugs
In the first line alpha-adrenergic agonists are used. The effect of
these sympathomimetic drugs is explained by the fact that 50%
of the urethral closure pressure is generated by the sympathetic
nervous system. Alpha-adrenergic agonists improve the urethral
closure pressure by stimulation of the alpha-receptors of the
smooth urethral musculature [13, 15-19]. The treatment with
alpha-adrenergic agonists results in continence in 75% of
incontinent bitches.
The alpha-receptors are divided into alpha-1 and alpha-2
subtypes. These receptor subtypes are distributed differently
in each single effector. Alpha-1 receptors are found in many
target organs of the sympathetic nervous system. With a few
exceptions, alpha-2 receptors are not present in target organs
of the sympathetic nervous system, but in neuronal synapses.
It is now known, that the alpha-receptors at the bladder neck
and proximal urethra of the bitch, which are responsible for
continence, belong to the subtype 1 [20].
Eighteen of thirtyfive bitches with USMI after spaying did indeed
become continent, for an average period of 229 days [30, 31],
after receiving depot preparations of GnRH-analogues. However,
it is questionable if the therapeutic success is due to a decrease
of the gonadotropin concentrations as there was no difference
in concentrations between responders and non-responders [31].
It is possible that the success of the treatment is not based on a
decrease in the FSH and LH, but instead on a direct effect of the
GnRH on the lower urinary tract. This idea is quite conceivable
as our working group has recently been able for the first time to
prove the presence of LH, FSH and also GnRH receptors in the
bladder and urethra of bitches [32]. Apart from that, it has been
shown that the effect of GnRH is not limited to the regulation
of pituitary hormones, but GnRH is also produced outside the
hypothalamus and may have a direct effect on the target organs
[33].
The side effects of alpha-adrenergic agonists is explained by the
fact that alpha-1 receptors are not just found at the bladder
neck, but also in other organs, especially in blood vessels.
Phenylpropanolamine (PPA) acts selectively on alpha-1 receptors.
The older substance Ephedrine is less selective than PPA. It also
stimulates beta-receptors, and therefore has more side effects
[21]. In contrast to PPA a habituation to Ephedrine occurs.
Because of these reasons PPA is the therapy of first choice [21].
In humans treatment with PPA sometimes causes side effects,
such as an increase in blood pressure and headache. It may
occasionally trigger a stroke or a heart attack and is therefore no
longer used. When PPA was used in dogs at the recommended
dose of 1.5 mg/kg BW bid or tid, an increase in blood pressure
was not observed [18, 22]. The side effects observed in dogs were
never life threatening and usually were self-limiting; diarrhoea,
vomiting, anorexia, apathy, nervousness and aggression [3, 19,
23].
The fact that GnRH, FSH and LH receptors are expressed in the
lower urinary tract and other organs supports the assumption
that GnRH performs specific functions in the tissue and that
a widely distributed paracrine or autocrine regulatory system
exists.
Oestrogens
An alternative is the treatment with oestrogens, which is
successful in 65% of the incontinent dogs [3, 12, 24]. However,
with oestrogens unwanted side effects can occur such as
swelling of the vulva and attraction of male dogs [12]. Nowadays
only short-acting oestrogens (Estriol, Incurin®, Intervet,
Netherlands) are used [11]. The depot preparations used in the
past are obsolete, in part because they can potentially cause
bone marrow depression [25]. Oestrogens indirectly increase
the urethral closure pressure by sensitizing the alpha-receptors
In about 50% of bitches with urinary incontinence treatment
with GnRH-analogues was successful [30, 31]. Based on the
proposed pathophysiology of USMI, that after spaying the
decrease in urethral closure pressure is the underlying cause
for urinary incontinence, it seems reasonable to assume
that the therapeutic success is due to a normalization of the
urethral sphincter mechanism. However, this hypothesis was
clearly disproved by the recording of urethral pressure profiles
of incontinent bitches before and after GnRH treatment. The
application of GnRH had no significant effect on the urodynamic
188
EJCAP - Vol. 18 - Issue 2 October 2008
parameters, even in successfully treated bitches [31]. Recent
studies in Beagle bitches may assume that GnRH modulates
bladder function [34]. In 10 spayed Beagle bitches cystometric
examinations were performed before and after treatment with
depot formulations of GnRH analogues. The results showed a
doubling of the difference between the medium and maximum
bladder filling volume at the same bladder pressure after GnRH
treatment.
Urethropexy [37]
A caudal midline celiotomy is performed. Blunt dissection
in the midline is used to visualise the ventral aspect of the
urethra at the level of the cranial pubic brim. A suture of 2/0
or 0 polypropylene is placed caudal to one prepubic tendon so
that it enters the caudal abdomen. While traction is applied to
the bladder neck and urethra via the bladder neck stay suture,
the polypropylene suture is passed transversely through the
muscular layers of the adjacent urethra. Once placed through
the urethra, the suture is passed caudal to the opposite prepubic
tendon and out of the abdominal cavity. The suture ends are
held together with a pair of haemostatic forceps. The procedure
is repeated, with a second polypropylene suture being placed
through the urethral wall approximately 3 to 5 mm cranial to the
first. Both the polypropylene sutures are now tied. This results in
the closure of the most caudal aspect of the celiotomy incision
and fixation of the urethra to the ventral abdominal wall at the
end of the cranial pubic brim. The mechanism of action remains
uncertain, although re-location of the bladder neck into an intraabdominal position and the production of a localised increase in
urethral resistance are likely consequences of the procedure.
Tricyclic antidepressant agents
Tricyclic antidepressant agents such as imipramine (0.5 to 1 mg/
kg tid per os) increase bladder capacity, along with the urethral
sphincter closure pressure [35]. These drugs may be beneficial
to dogs with urinary incontinence due to USMI and detrusor
instability or as postoperative treatment of USMI.
Surgical treatment of USMI
For refractory cases at least three different surgical therapies
are available. However, before considering surgery, urinary tract
infection should be ruled out or be initially treated. Polyuric
diseases should also be evaluated and managed. Colposuspension
[36], urethropexy [37] and endoscopic injection of collagen [38]
are mainly used as surgical therapy, with a success rate of 50 –
75%. With all three techniques a deterioration in the response
rate was seen over time. At our clinic, we prefer the endoscopic
injection of collagen as this method is least invasive with a
minimal rate of complications, and the results are as good as
the more invasive techniques [39].
Urethral submucosal injection of collagen [38]
The goal of treatment is to enhance the closure of the proximal
urethra. For endoscopic injection of collagen the dogs are placed
under general anesthesia and positioned in dorsal recumbency
with the hind limbs extended cranially. A human cystoscope is
passed into the urethra via the external orifice. Approximately
1.5 cm caudal to the neck of the bladder, 3 injections of collagen
are made into the submucosa at 2, 6 and 10 o’clock positions,
respectively [38]. The procedure is considered complete when,
on viewing through the cystoscope, the urethral lumen is closed
by the collagen deposits.
Colposuspension [36]
The bitch is placed in dorsal recumbency with the hind limbs
flexed. A Foley catheter is used to empty the bladder. The
catheter cuff is inflated with air and drawn into the neck of the
bladder. A caudal midline, abdominal skin incision is made. The
prepubic tendon is exposed on both sides of the mid-line. The
external pudendal vessels are identified and avoided. Traction
on the bladder allows the bladder neck to be identified due to
the presence of the inflated Foley catheter cuff. An index finger
is inserted through the vulva and used to displace the vagina
cranially. The fat and fascia around the ventral bladder neck and
proximal urethra are separated until the vaginal wall is exposed
dorso-lateral to the urethra. The vaginal wall is grasped with Allis
tissue forceps on each side of and approximately one centimetre
away from the proximal urethra. The surgeon withdraws the
finger from the vagina and changes his gloves. The vagina on
each side of the proximal urethra is anchored to the prepubic
tendon using two 0 or 1 monofilament nylon sutures. Sutures
are taken through the full thickness of the vaginal wall and are
pre-placed. Before tying, tension is placed on the sutures to
determine that strangulation of the urethra between the vagina
and pubis would not occur. Once the sutures are tied, a final
examination is performed to confirm that the urethra is freely
moveable between the vagina and pubis and is not compressed
in any way. The beneficial effect of the operation may be the
resultant re-location of the bladder, bladder neck and proximal
urethra into an intra-abdominal position.
Comparison of the surgical techniques for USMI
With the collagen injection, incontinence initially resolved in 83
% of 40 bitches, by injection alone in 68 % and with additional
medication in the remaining 15 % [39]. Up to 12 months after
the injection, there was a deterioration in the initial result in
16 dogs, thereafter the results remained unchanged. Among
these 16 dogs, 13 dogs were reclassified from the continent
group to one of the other 3 groups (continent with additional
medication, incontinence improved by approximately 80 % after
collagen injection and with additional medication, incontinence
remained unchanged after collagen injection) up to 12 months
after the injection. This corresponded to the period necessary
for resorption of collagen deposits as seen in women [40].
However, the fact that the success rate categories stabilized 1
year after treatment suggested that the collagen deposits are
not resorbed in dogs. Also, histologic examinations of collagen
deposits 12 months after injection in dogs revealed that they
were still in place as cell-free masses surrounded by a connective
tissue capsule [38]. Flattening of the deposits was likely the
cause of reoccurrence of incontinence.
Collagen injections compare well to the other established
surgical methods for the treatment of canine USMI. After
urethropexy, 56 % of affected dogs were continent and 27 %
had an improvement in continence [37]. A similar success rate
189
Urethral sphincter mechanism incompetence in spayed bitches - I. Rechler, M. Hubler, S. Arnold
was observed after colposuspension, with 53 % of the female
dogs continent and a further 38 % experiencing a marked
improvement (41). However, a serious complication with both
these techniques is an increased risk of urinary retention, a postoperative condition not seen in dogs injected with collagen.
[18] HENSEL (P.), BINDER (H.), ARNOLD (S.) - Influence of phenylpropanolamine and ephedrine on the urethral closure pressure
and the arterial blood pressure of spayed bitches. Kleintierpraxis,
2000 Aug, 45(8): 617-+.
[19] WHITE (R.A.), POMEROY (C.J.) - Phenylpropanolamine: an alphaadrenergic agent for the management of urinary incontinence
in the bitch associated with urethral sphincter mechanism
incompetence. Vet Rec., 1989 Nov 4, 125(19): 478-80.
[20] SHAPIRO (E.), LEPOR (H.) - Alpha 1 adrenergic receptors in
canine lower genitourinary tissues: insight into development and
function. J Urol., 1987 Oct, 138(4 Pt 2): 979-83.
[21] BYRON (J.K.), MARCH (P.A.), CHEW (D.J.), DIBARTOLA (S.P.) Effect of phenylpropanolamine and pseudoephedrine on the
urethral pressure profile and continence scores of incontinent
female dogs. J Vet Intern Med., 2007 Jan-Feb, 21(1): 47-53.
[22] SCOTT (L.), LEDDY (M.), BERNAY (F.), DAVOT (J.L.) - Evaluation
of phenylpropanolamine in the treatment of urethral sphincter
mechanism incompetence in the bitch. J Small Anim Pract., 2002
Nov, 43(11): 493-6.
[23] BLENDINGER (C.), BLENDINGER (K.), BOSTEDT (H.) -[Urinary
incontinence in spayed female dogs. 2. Therapy]. Tierarztl Prax.,
1995 Aug, 23(4): 402-6.
[24] NENDICK (P.A.), CLARK (W.T.) - Medical therapy of urinary
incontinence in ovariectomised bitches: a comparison of the
effectiveness of diethylstilboestrol and pseudoephedrine. Aust
Vet J., 1987 Apr, 64(4): 117-8.
[25] TESKE (E.), FELDMAN (B.F.) - [Bone marrow depression following
oestrogen therapy]. Tijdschr Diergeneeskd., 1984 May 1, 109(9):
357-60.
[26] SCHREITER (F.), FUCHS (P.), STOCKAMP (K.) - Oestrogenic
sensitivity of alpha-receptors in the urethra musculature. Urol Int.,
1976, 31(1-2): 13-9.
[27] CONCANNON (P.), COWAN (R.), HANSEL (W.) LH releases in
ovariectomized dogs in response to oestrogen withdrawal and its
facilitation by progesterone. Biol Reprod., 1979 Apr, 20(3): 52331.
[28] OLSON (P.N.), MULNIX (J.A.), NETT (T.M.) - Concentrations of
luteinizing hormone and follicle-stimulating hormone in the
serum of sexually intact and neutered dogs. Am J Vet Res., 1992
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[29] REICHLER (I.M.), PFEIFFER (E.), PICHÉ (C.A.), JÖCHLE (W.), ROOS
(M.), HUBLER (M.), et al. - Changes in plasma gonadotropin
concentrations and urethral closure pressure in the bitch during
the 12 months following ovariectomy. Theriogenology. 2004 Nov,
62(8): 1391-402.
[30] REICHLER (I.M.), HUBLER (M.), JÖCHLE (W.), TRIGG (T.E.), PICHÉ
(C.A.), ARNOLD (S.) - The effect of GnRH analogs on urinary
incontinence after ablation of the ovaries in dogs. Theriogenology.
2003 Oct 15, 60(7): 1207-16.
[31] REICHLER (I.M.), JÖCHLE (W.), PICHÉ (C.A.), ROOS (M.), ARNOLD
(S.) - Effect of a long acting GnRH analogue or placebo on plasma
LH/FSH, urethral pressure profiles and clinical signs of urinary
incontinence due to sphincter mechanism incompetence in
bitches. Theriogenology. 2006 Apr 29, 66: 1227-36.
[32] WELLE (M.M.), REICHLER (I.M.), BARTH (A.), FORSTER (U.),
SATTLER (U.), ARNOLD (S.) - Immunohistochemical localization
and quantitative assessment of GnRH-, FSH-, and LH-receptor
mRNA expression in canine skin: a powerful tool to study the
pathogenesis of side effects after spaying. Histochemistry and cell
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[33] SRIDARAN (R.), LEE (M.A.), HAYNES (L.), SRIVASTAVA (R.K.),
GHOSE (M.), SRIDARAN (G.), et al. - GnRH action on luteal
steroidogenesis during pregnancy. Steroids. 1999 Sep, 64(9):
618-23.
References
1] First report on the standardization of terminology of lower urinary
tract function. Incontinence, cystometry, urethral closure pressure
profile and units of measurement. Urol Int. 1977, 32(2-3): 81-7.
[2] THRUSFIELD (M.V.), HOLT (P.E.), MUIRHEAD (R.H.) - Acquired urinary
incontinence in bitches: its incidence and relationship to neutering
practices. J Small Anim Pract. 1998 Dec, 39(12): 559-66.
[3] ARNOLD (S.), ARNOLD (P.), HUBLER (M.), CASAL (M.), RÜSCH
(P.) - Incontinentiae urinae bei der kastrierten Hündin: Häufigkeit
und Rassedisposition. Schweiz Arch Tierheilkd., 1989, 131(5):
259-63.
[4] ROSIN (A.E.), BARSANTI (J.A.) - Diagnosis of urinary incontinence in
dogs: role of the urethral pressure profile. Journal of the American
Veterinary Medical Association, 1981, Apr 15, 178(8): 814-22.
[5] THRUSFIELD (M.V.) - Association between urinary incontinence and
spaying in bitches. Vet Rec., 1985 Jun 29, 116(26): 695.
[6] JOSHUA (J.O.) - The Spaying of Bitches. Vet Rec., 1965 Jun 5, 77:
642-6.
[7] FINCO (D.R.), OSBORNE (C.A.), LEWIS (R.E.) - Non neurogenic
causes of abnormal micturition in the dog and cat. Vet Clin North
Am., 1974 Aug, 4(3): 501-16.
[8] OSBORNE (C.A.), OLIVER (J.E.), POLZIN (D.E.) - Non-neurogenic
urinary incontinence. In: Kirk RW, editor. Current Veterinary
Therapy. Philadelphia: WB Saunders, 1980. p. 1128-36.
[9] EL ETREBY (M.) - Effect of cyproterone acetate, levonorgestrel and
progesterone on adrenal glands and reproductive organs in the
beagle bitch. Cell Tissue Res., 1979, 200(2): 229-43.
[10] DE BOSSCHERE (H.), DUCATELLE (R.), TSHAMALA (M.), CORYN
(M.) - Changes in sex hormone receptors during administration of
progesterone to prevent estrus in the bitch. Theriogenology, 2002
Oct 1, 58(6): 1209-17.
[11] JANSZEN (B.), VAN LAAR (P.), BERGMAN (J.) - Treatment of
urinary incontinence in the bitch: a pilot field study with Incurin®
Veterinary Quarterly, 1997, 19((Suppl)): 42.
[12] MANDIGERS (R.J.), NELL (T.) - Treatment of bitches with acquired
urinary incontinence with oestriol. Vet Rec., 2001 Dec 22-29,
149(25): 764-7.
[13] RICHTER (K.P.), LING (G.V.) - Clinical response and urethral pressure
profile changes after phenylpropanolamine in dogs with primary
sphincter incompetence. Journal of the American Veterinary
Medical Association, 1985 Sep 15, 187(6): 605-11.
[14] NICKEL (R.) - Studies on the function of the urethra and bladder
in continent and incontinent female dogs [PhD thesis]. Utrecht:
University Press, 1998.
[15] AWAD (S.A.), DOWNIE (J.) - The effect of adrenergic drugs and
hypogastric nerve stimulation on the canine urethra. A radiologic
and urethral pressure study. Invest Urol., 1976 Jan, 13(4):
298-301.
[16] AWAD (S.A.), DOWNIE (J.W.), KIRULUTA (H.G.) - Alpha-adrenergic
agents in urinary disorders of the proximal urethra. Part I.
Sphincteric incontinence. Br J Urol., 1978 Aug, 50(5): 332-5.
[17] GILLBERG (P.G.), FREDRICKSON (M.G.), OHMAN (B.M.), ALBERTS
(P.) - The effect of phenylpropanolamine on the urethral pressure
and heart rate is retained after repeated short-term administration
in the unanaesthetized, conscious dog. Scand J Urol Nephrol.,
1998 May, 32(3): 171-6.
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[34] REICHLER (I.M.), BARTH (A.), PICHÉ (C.), JÖCHLE (W.), ROOS (M.),
HUBLER (M.), et al. - Urodynamic parameters and plasma LH/FSH
in spayed Beagle bitches before and 8 weeks after GnRH depot
analogue treatment. Theriogenology, 2006, 66(9): 2127-36.
[35] STONE (E.A.), BARSANTI (J.A.) - Postoperative management
and surgical complications of congenital disorders. In: Stone
EA, Barsanti JA, editors. Urologic surgery of the dog and cat.
Philadelphia: Lea & Febiger, 1992. p. 210-1.
[36] HOLT (P.) - Urinary incontinence in the bitch due to sphincter
mechanism incompetence: surgical treatment. J Small Anim
Pract., 1985, 26: 237-46.
[37] WHITE (R.N.) - Urethropexy for the management of urethral
sphincter mechanism incompetence in the bitch. J Small Anim
Pract., 2001 Oct, 42(10): 481-6.
[38] ARNOLD (S.), HUBLER (M.), LOTT-STOLZ (G.), RUSCH (P.) Treatment of urinary incontinence in bitches by endoscopic
injection of glutaraldehyde cross-linked collagen. J Small Anim
Pract., 1996 Apr, 37(4): 163-8.
[39] BARTH (A.), REICHLER (I.M.), HUBLER (M.), HASSIG (M.), ARNOLD
(S.) - Evaluation of long-term effects of endoscopic injection of
collagen into the urethral submucosa for treatment of urethral
sphincter incompetence in female dogs: 40 cases (1993-2000).
Journal of the American Veterinary Medical Association, 2005 Jan
1, 226(1): 73-6.
[40] MONGA (A.K.), ROBINSON (D.), STANTON (S.L.) - Periurethral
collagen injections for genuine stress incontinence: a 2-year
follow-up. Br J Urol., 1995 Aug, 76(2): 156-60.
[41] HOLT (P.E.) - Long-term evaluation of colposuspension in the
treatment of urinary incontinence due to incompetence of the
urethral sphincter mechanism in the bitch. Vet Rec., 1990 Dec 1,
127(22): 537-42.
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PRACTICE MANAGEMENT
The Helsingborg
Referral Animal Hospital:
A Swedish Foundation Practice
Alexandra Vilén (1)
INTRODUCTION
The Helsingborg Referral Animal Hospital was the first animal hospital to be founded in Sweden. The concept of
Veterinary Hospitals being owned by a foundation is interesting and probably unique to Sweden. It is situated in the
outskirts of the city of Helsingborg, Skåne county, in the south of Sweden. From the city one has a beautiful view over
the waters of Öresund to the Danish coast. The Helsingborg Referral Animal Hospital consists of both small animal
and large animal departments. The hospital provides a 24 hour service and receives 30 000 patients each year, of which
23 500 are small animals and 6 500 horses.
The veterinarians at The Referral Animal Hospital are highly motivated. The hospital attracts veterinarians that are
interested to work at a high level and want to nourish their academic skills. The hospital motto is “Veterinary medical
leading competence and qualified care – our everyday routine”.
The Swedish situation
about 80% of all dogs and 50% of all cats have healthcare
insurance.
There is one university for veterinary studies – the Swedish
University of Agricultural Sciences (SLU). It is situated in Uppsala,
an ancient city in the middle of Sweden. Every year approximately
one hundred new Swedish veterinarians graduate.
SLU also has a nursing school in the small town of Skara. This
educational course is accredited by ACOVENE (accreditation
committee for veterinary nurse education). It is a two year course
Sweden has approximately 2100 qualified veterinarians. It is
difficult to assess how many of these work exclusively with small
animals but there are about 540 members of the Swedish Small
Animal Veterinary Association (SSAVA).
Approximately 26% of the Swedish households own a pet. The
total number of dogs and cats is in the region of 730,000 and
1,3 million, respectively. Pet insurance is well developed and
(1) Regiondjursjukhuset i Helsingborg, Bergavägen 3, Box 22097, S-250 23 Helsingborg
E-mail: alexandra@vilen.se
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The Helsingborg Referral Animal Hospital: A Swedish Foundation Practice - Alexandra Vilén
and each year 40 nurses graduate. It is still possible to work as a
nurse and be trained at a hospital and practice even without the
formal education. To function as a nurse or a nurse’s assistant
(i.e. to be allowed to give injections) there is one basic
requirement and that is to attend a specific one day course
followed by an exam.
Currently there is a great interest amongst Swedish veterinarians
to participate in continued education (CE). There are limited
opportunities to attend programmes to become European
Diplomates in Sweden. To meet the need for CE in Sweden,
there is a Swedish specialist degree level called “Step I”.
This is a three year programme which terminate in a written
and oral exam. When passed, the Veterinarian can use the title
“Swedish specialist in diseases of dogs and cats”. Recently an
even more specialised CE programme started called the “Step
II”. This is an organ- or discipline specific specialist degree.
The Swedish Board of Agriculture is the authority controlling
veterinary issues in Sweden. They have the responsibility to
appoint veterinarians to cover emergencies. There are four
appointed 24 hour small animal referral hospitals in Sweden, three
in the middle and one in the south of Sweden. They are each run
by foundations. In addition to the requirement of ‘keeping open’,
there are certain other requirements regarding the number of
Swedish specialists that need to work in these hospitals in order
to retain their special status. The appointed referral hospitals
are not financially supported by the government to maintain
emergency cover. The veterinary school which is supported by
the government is also open for 24 hours. Besides this there are
a few private hospitals that are also open for 24 hours.
scientific continuing education and research in general as well
as providing specialised animal medicine and healthcare. The
function of the Referral Animal Hospital of Helsingborg is to
function as a local hospital as well as an important referral
animal hospital in the south of Sweden.
Investors in People (IIP) is an International standard to improve
the quality of an organisation by development of its workforce.
In 2007 the hospital was the first Swedish animal hospital to be
IIP certified.
Staff
Veterinarians
Twenty three veterinarians work in the small animal department.
Seven of these are Swedish specialists in diseases of dogs
and cats. There is one Swedish specialist in surgery, one in
ophthalmology and one in internal medicine. One veterinarian
is a Dipl.DEVDC (odontology). Only three veterinarians are male
which reflects the current trend seen in students undertaking
Swedish veterinary education.
A full time working veterinarian (40 hour /week) has in addition
an average of 4 night- or weekend day shifts per month. The
compensation for daytime duty at weekends is two full days
off the following week. Extra salary is paid, in the form of
commission on the fee paid, for work done during the night.
As Sweden has very generous maternity leave conditions it is
possible to stay at home with children for 18 months after the
birth. As our veterinarians find participation in hospital activities
stimulating, most mums on maternity leave start working 3 - 6
months after delivering their child but on a part time basis, often
just a few hours a week. This flexible attitude is appreciated by
both the hospital as well as the veterinarians.
‘The Foundation of Swedish Animal
Healthcare’ and it’s history
The Helsingborg Referral Animal Hospital was founded by Dr
Fritz Sevelius in 1954. He served as a military veterinarian in the
cavalry and realised the need for a hospital in order to properly
treat the military horses. Since the government did not consider
that it was in the interest of the general public to pay for the
running of such an animal hospital, Dr Sevelius persuaded
the Household Society of Malmöhus County to finance the
hospital. The Household Society represented Swedish farmers
and it became the hospital owner. In 1993 the Animal Hospital
of Malmö, which was founded in 1958 was also Incorporated
by the Household Society. The hospitals are situated in two
different cities approximately 70 km apart. In 1999 both of
these hospitals were sold by the Household Society and the
Helsingborg Referral Hospital and the Animal Hospital of Malmö
both became part of a joint-stock company with a ‘foundation’
as owner. The foundation was formed to prevent the hospital
becoming privately owned. It was named ‘The Foundation of
Swedish Animal Healthcare’.
Nurses
There are approximately 30 nurses and usually four trainees
working in the practice. Seven of the nurses have a degree from
the Swedish nursing school.
Each nurse is usually allotted to a particular department. As the
work is becoming more specialised the nurses wishing to do
so can choose to work in a certain team (for example intensive
care unit, exotics, reproduction, dermatology etc). This gives the
experienced nurse an opportunity to specialise and to gain more
knowledge of, and responsibility for, patients in their care.
The nurses have a rolling schedule that includes evenings and
weekends.
Receptionists
The reception is staffed by a total of 8 receptionists with different
backgrounds. A few of them are former nurses and a couple are
recruited from hotel management.
Cleaning
There are two professional cleaners daily, including weekends.
The foundation’s current board of five directors was chosen
by the Household Society. The chairman is supported by two
veterinarians, the chairman of the municipal executive committee
and a representative from the former owner, the Household
Society.
Maintenance and technical assistance
The hospital is served by two highly efficient staff members
that help out with everything technical that is malfunctioning
including the computers.
The purpose of the foundation is to promote development,
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Management
The hospital management consists of a Chief Executive and two
clinical directors, one for each department. The small animal
director, Louise Blomquist, is a former nurse and responsible for
the staff and the operation of the clinic. The small animal head
veterinarian, DVM Linda Toresson is responsible for medical
matters. In addition there is a financial controller with two
assistants.
Financial aspects
Since the hospital is owned by a Foundation, there is no pressure
to return a high profit. The only requirement is that the hospital
produces a surplus of 5% which then is used for re- investment
in the practice (such as equipment, renovations and education).
The turnover in 2007 was € 9 000,000. Some of the hospitals’
clinical activity is financed through private donations. In 2006
the hospital received approximately €1100,000 and in 2007
€ 150,000.
Care nurse Maria discusses dental cleaning with a cat owner.
Hospital Organization
The hospital is open 24/7. Clients can book a consultation
between 8 am - 9 pm Mondays – Thuisdays and 8 am - 5 pm
Fridays. It is always possible to see a veterinarian in an emergency
without booking an appointment. Clients are welcome to sit
down and wait for an opportunity to see the ‘emergencies’ vet
even if theirs is not emergency case, though they may not be
seen quickly. The nurses undertake the primary triage.
The veterinarians on night call work between 5 pm-8 am. An
experienced nurse works alongside the veterinarian for the
whole night. Apart from assisting in emergency cases, the nurse
answers the phone and attends to hospitalised animals.
During the weekends there is one veterinarian on duty from
8 am-5.30 pm. Since the the beginning of 2008 an additional
veterinarian works between 10 am – 2 pm. This addition was
necessary to meet demand as there are an increasing number
of patients during weekends. There are three nurses on rotation
working the nightshift.
Nursing ward
The daily work on the nursing ward starts at 7 am when the
night personnel hand over patients over to the day staff.
On average there are 25 patients in the nursing ward. There
Plan of clinic.
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The Helsingborg Referral Animal Hospital: A Swedish Foundation Practice - Alexandra Vilén
Dr Larsen assisted by two nurses examines a patient in the
nursing ward.
The morning rounds provide an excellent opportunity to discuss
difficult cases.
are three to four nurses who start the day by cleaning the
ward, walking the dogs and giving medication. There are two
veterinarians in the ward that are on duty between 7 am - 4 pm.
These veterinarians are responsible for arranging the common
rounds in the morning, in which all veterinarians on duty
participate. The rounds start at 8 am and last 20 minutes. After
this all veterinarians proceed to their respective departments.
The veterinarians on the ward continue with the daily examination
of all patients in the ward and prepare to undertake necessary
tasks and arrange discharges.
Feline patients have their own section within the ward. Canine
patients are separated according to the type of their complaint.
For instance all neurological and orthopaedic patients are
separated from the internal medicine cases. Exotics also have a
small separate section.
There is a compact but well equipped intensive care unit (ICU)
in the centre of the ward. To develop and manage intensive
care there is an intensive care team consisting of dedicated
veterinarians and nurses.
A separate and isolated part of the ward is used for patients with
established or suspected contagious diseases. It is also possible
to isolate hyperthyroid cats for treatment with radioactive
iodine.
All pet owners with animals in the ward get a daily phone call
regarding their pet´s condition. When an animal is discharged
this usually takes place in the afternoon and each pet owner
receives an appointment with the responsible veterinarian. They
also receive written instructions regarding the pet’s illness as
well as an individual treatment plan. All dogs going home from
the ward are bathed and groomed.
To support the veterinarians in the ward there is a nurse with
the title “ward secretary” who is responsible for checking that
client’s bills are correct. She also arranges with clients when pets
can be collected and calls them if needed to give a report on their
pet’s progress. When necessary she contacts the referring vets
if more information is required. The pet owners also appreciate
a phone call from her or the veterinarian a couple of days after
discharge. This also enables advice and support to be given if
any problems have occurred.
Surgical department
All patients are admitted for surgery in the morning. The
veterinary surgeon has a brief talk with the owner on admission.
The animals are usually prepared for surgery beforehand, having
had a pre-operative clinical consultation. At this visit, preoperative
blood samples and X-rays can be taken if required. Most types
of emergency surgery outside normal hours, including necessary
advanced surgery such as neurosurgery can be performed.
Pre arranged surgery takes place between 9 am and 5 pm.
The operating theatre is very well stocked with all the
necessary equipment needed to perform advanced orthopaedic
procedures, neurosurgery and all fibreoptic examinations (eg.
arthro-, laparo- and thora-scopy) currently used by veterinarians.
There are usually two to four surgeons working in the operating
theatre. A large preparation room is central to the three separate
theatres and the room for dental procedures and gastrointestinal
endoscopies.
Policlinic
There are three veterinarians with pre booked patient lists and
one veterinarian that sees all emergency cases. Each veterinarian
is assisted by one nurse. The nurse takes all blood samples
and X-rays. In total there are 12 examination rooms. Five of
The reception with waiting room and shop.
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the veterinarian on call is allowed to dispense
initial drugs which are needed urgently.
Laboratory
The hospital has its own in house laboratory
with three biomedical scientists. They
serve both the small animal as well as the
large animal department. They also receive
considerable numbers of external samples
from veterinarians all around the southern
part of Sweden.
Physiotherapy
The physiotherapy department was built in
2003 and is equipped with a treadmill as well
as a swimming pool with an aqua jet. The
A recovering patient taking a plunge in the pool. Physiotherapy to improve balance.
physiotherapist, who is certified for human as
well as animal treatment, is assisted by two
nurses. The patients are given orthopaedic
these have special purposes - one for ultrasound, one specially
and neurological rehabilitation, pain relief and muscle stimulation
equipped for emergency cases, one for contagious diseases, one
such as massage and stretching.
“clean” room for reproduction consulting and blood donors,
Physical exercise is encouraged in patients suffering from
one for the care nurse on duty at the policlinic, one room for
arthrosis, obesity and post-operatively after orthopaedic and
the exotics, and one room used only for euthanasia with an
spinal surgery. In addition it is helpful in patients with muscle
outer door so the owners can leave whenever they wish without
atrophy secondary to other causes. Owners are able to board
passing through the rest of the hospital. All cadavers are placed
their animals at the hospital during periods of intensive rehab/
in discrete cardboard coffins. The grieving pet owner is offered
training.
an individual cremation if required. They then get their pet’s
It is popular for dog owners to rent the pool for an hour of
ashes in an urn.
exercise. The police, for instance, appreciate this facility as a part
On a daily basis there is a “Care Nurse” on duty in the policlinic
of the weekly training schedule for their service dogs.
who has her own list with pre booked patients. These patients
are in for simple treatments such as weight control, suture
Diagnostic imaging
removal after spays and castrations, second dose vaccinations in
There are several veterinarians at the hospital interested in
puppies and kittens or nail trimming.
diagnostic imaging. The hospital is equipped with digital x-ray,
There is a care nurse who specialises in behavioral problems
fluoroscopy, ultrasound and an MRI scanner. In the operating
who can see patients when required.
theatre there is a separate x-ray and fluoroscopy facility frequently
The hospital tries to meet the specific needs of feline patients
used during surgery. There is also a dental x-ray machine.
and has a separate waiting room for cats with high shelves for
the transportation cages which help to minimise stress. Every
Blood bank
other week there is one evening specifically devoted to cats.
The hospital has its own blood bank with approximately 50
registered canine donors. One day every week dogs come in
Reception
Reception is open between 7:30 am - 9 pm on weekdays
Nurse Erika prepares a patient for an MRI scan of the
and between 9 am – 3 pm on Saturdays and Sundays. The
neurocranium.
receptionists are responsible for answering the phone, the
booking of appointments, the shop and for all payments
including contact with the insurance companies.
In Sweden there are several companies that insure pets (dogs,
cats, parrots, rabbits, and guinea pigs). To facilitate matters
for the pet owner payment by the insurance company can be
arranged by e-mail while the owner is waiting. In this way the
owner only pays the part of the bill that is not covered by the
insurance. The hospital gets the remainder immediately by
electronic transfer from the insurance company. This service is
much appreciated by owners.
The shop in the reception area mainly deals with prescription
diets. As the Swedish government still retains a monopoly
for the sale of prescription drugs, pet owners have to visit an
outside pharmacy to have prescriptions dispensed. Out of hours
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The Helsingborg Referral Animal Hospital: A Swedish Foundation Practice - Alexandra Vilén
to donate blood. For cats there is a register of cats that can
be brought in to donate blood at any time. The blood donors
get their vaccinations free of charge and are given yearly blood
screening as a token of our appreciation..
The staff regularly participate in different events outside the
hospital such as dog and cat shows.
This summer Swedish television followed the daily routines at
the hospital in a documentary called “The Animal Hospital”. This
type of programme is very popular in Sweden and programmes
have been recorded before at the hospital as well as at other
large hospitals in Sweden. It is of course fabulous PR for any
hospital.
Education
Education is something that is emphasised at the hospital. This
is one of the reasons why morning rounds are mandatory. Twice
a week one hour is set aside for meeting when veterinarians
sit down and discuss difficult cases and exchange experiences
or give reports from courses they have attended. This is much
appreciated and is sometimes attended even by those vets who
are off duty. All veterinarians are encouraged to enroll for the
Swedish specialist qualification programme. Twice a year there
is an afternoon training session in oral presentation skills. Each
veterinarian is asked to make a 15 minutes presentation in a
topic of their choice. Some of the veterinarians are especially
skilled in for instance gastrointestinal diseases and orthopaedics
and lecture nationally as well as abroad.
There is a joint agreement to standardise treatment plans for
different medical conditions. This is considered important for
three reasons. As treatment plans are put together by the most
experienced veterinarians, supported by reference to the most
recent scientific literature, patients are more likely to receive
the “best possible care”. Secondly,it makes it easier for a new
employee or an inexperienced veterinarian to quickly get in
to hospital working routines . Finally, it also makes sure that
treatment and charging at the hospital is consistent. It has been
particularly noticed that different veterinarians have a tendency
to charge differently. A couple of years ago the largest insurance
company noticed that generally the less experienced veterinarian
performs a more extensive diagnostic work up, and thus the
owner is charged more.
There are two study groups created by the veterinarians. One is
called the “Ettinger club” where we a chapter is read and then
all the vets meet over dinner to discuss it. A corresponding study
group for surgery also exists. Both groups are voluntary but they
are usually well attended.
In 2006 a two year in house educational programme for all our
nurses was started. This was to meet their need for CE and to
help further motivate them. It is based on lectures given by the
veterinarians as well as different aspects of practical training. It
ends with a written examination. The topics covered are wide
and include medicine as well as laboratory practice and how to
deal with pet owners in distress.
Referrals
A fairly large number of clients are referred cases. It is important
for the hospital to have a good cooperation with referring
colleagues. The clinical director organises most of the referral
appointments in order to simplify the process for both parties.
As many referred clients have to travel a long way the aim is,
if possible, to maximise the benefit of their visit by fitting in
all possible necessary examinations. The goal is to try not to
perform examinations or analyses that have already been
carried out by the referring veterinarians practice. This is also a
requirement of the insurance companies. The aim is to send a
written report to the referring veterinarian within two weeks.
To engender the goodwill of referring veterinarians as well
as improve their continuing education the hospital organise
“Referral vets meetings”. An invitation is extended to all referring
veterinarians to visit the hospital to enjoy some good food and
a lecture given either by an invited speaker or sometimes by one
of the veterinarians at the hospital. This usually takes place at
least twice a year and is much appreciated. The hospital has a
new lecture hall which can seat 80 people.
Future and Vision
In a few years there are plans to rebuild some parts of the
hospital. The policlinic received a facelift two years ago. There
are plans to increase the Intensive care unit and a make it
more closely connected and accessible to the operating rooms.
The isolation unit also needs some modernisation in order to
function more efficiently.
The Referral Animal Hospital is a stimulating and dynamic
workplace which is pervaded by a tremendous team spirit.
Compared to most other countries, Swedish veterinarians
generally have more assistance from nurses and nurses are
given more responsibilities. At The Referral Animal Hospital
for example each department has a nurse who is given major
responsibilities. The cooperation between Swedish veterinarians
and nurses might appear causal and too informal in some
countries. This is however something though that suits both the
veterinarians and the nurses at our hospital.
The unique way that the Foundation run the hospital permits
investments in education as well as in technical equipment.
When working as a veterinarian at The Referral Animal Hospital
one is given the opportunity to specialise in an area of interest.
This of course improves the level of quality and at the end this
must be considered a “win / win” situation for the staff as well
as for the patients.
Clinical Research
There are currently preparations to start a research project on a
new method for assessing liver function but there is still some
administrative work to be done as the requirements from the
Swedish Medical Products Agency are extensive.
Public relations
We frequently meet requests from the general public or
different kennel clubs to visit the hospital. In conjunction with
this, lectures are often given on topics such as emergency care
for pet owners, prophylactic measures regarding how to control
parasites etc.
200
GENERAL
FECAVA SYMPOSIUM PAPER*
Suicide and the veterinary
profession
R.J. Mellanby(1)
SUMMARY
It has recently been shown that the veterinary profession in England and Wales has one of the highest incidences of
suicide of all occupations [1, 2]. The alarmingly high incidence of suicide within the veterinary profession has attracted
a tremendous amount of attention in the veterinary press and has also instigated a discussion in the wider media as
to why a profession with such a positive public profile had a so strikingly high incidence of suicide [3]. Whilst it is
widely agreed that the veterinary profession needs to address the issue of suicide, there is no industry wide, clear
consensus as to what the response should be. Arguably, the most appropriate response is to further explore the issues
of suicide through high quality research which will provide the foundation for objective, evidence based initiatives
and programmes aimed at reducing the incidence of suicide in the profession. Specifically, there is a need to explore
why the veterinary profession has such a high incidence of suicide through a variety of research approaches as well
as examining whether this statistic is a reflection of poor mental health well being across the profession. A number of
key questions which warrant further research will be highlighted and the ongoing work in some these areas will be
reviewed.
will enable the profession to establish whether veterinarians
have a widespread problem with mental health well being as
well as suicide. In addition, greater knowledge of these topics
will establish what factors, both work and non-work related,
predict poor mental health amongst veterinarians. In the UK, the
RCVS (Royal College of Veterinary Surgeons), VBF (Veterinary
Benevolent Fund) and SPVS (Society of Practising Veterinary
Surgeons) have funded a collaborative proposal by Professor
Halliwell, Dr Harrison, Dr Mellanby, Ms Dean and Dr Adams to
explore these issues by sending a questionnaire to 20% of RCVS
registered veterinarians. This work began in the spring and the
findings will be published in the next 18 months. David Bartram
and David Baldwin have also initiated a similar project utilising a
different methodology [4].
*This paper is based on a lecture given as part of the
Fecava Symposium held during the FECAVA/WSAVA/
VICAS Congress, Dublin August 2008
Do veterinarians have poor mental health well being?
The observation that the veterinary profession has a high
incidence of suicide may simply reflect ease of access to
lethal substances or a difference in attitudes towards human
euthanasia. It also however represents the ‘tip of the iceberg’
of a much broader problem of poor mental well being amongst
veterinarians. Consequently, one of the most important questions
the profession needs to address is what is the incidence of poor
mental well being amongst veterinarians and how does this
compare with the general population and other health care
professions? Furthermore, what particular socio-demographic,
personality and work related features predict poor mental wellbeing in veterinarians? A deeper understanding of these issues
What is the background of veterinarians who commit
suicide?
Very little is known about the demographics and background
of veterinarians who died by suicide. A previous study has
(1)Royal (Dick) School of Veterinary Studies,Division of Veterinary Clinical Studies, University of Edinburgh,Hospital for Small Animals,
Easter Bush Veterinary Centre,Roslin, Midlothian, GB-EH25 9RG.
E-mail : Richard.Mellanby@ed.ac.uk
203
Suicide and the veterinary profession - R.J. Mellanby
identified that 10 of the 26 male veterinarians who committed
suicide between 1991 and 2000 were younger than 45 years of
age but little other information is available on the demographic
background and circumstances of veterinarians who take their
own life [1]. Consequently, it is important to clarify these issues
so that it can be established if there are particular subsets of the
profession, and whether these groups can be defined as being
at particular risk by age, personal or work-related parameters.
A well established approach to address these questions is the
use of a psychological autopsy where the coroners’ reports of
people who have died by suicide are systematically reviewed
[5]. Similar studies have been undertaken in other professions
which have a high incidence of suicide and when carried out
in a sensitive manner have been extremely useful in clarifying
the background and circumstances of individuals who commit
suicide [6-8]. A review of coroners’ reports of veterinarians who
have committed suicide is currently being carried out by Belinda
Platt at the University of Oxford. It is supervised by Dr Mellanby,
Ms Simkin and Professor Hawton. This study has been funded
mainly by Hill’s Pet Nutrition with additional support from the
RCVS Trust and the VBF. It is important to highlight that this
approach will only review coroners’ reports and will not attempt
to contact family or friends of veterinarians who have died.
The data will be anonimised and the project will undergo strict
ethical review and approval by an NHS Ethics Committee. In
addition, this collaboration will also publish a systematic review
of the current literature on suicide in the veterinary profession.
the attitudes of recent qualified graduates on their personal
transition from student to vet and how this transition can be
optimised to the benefit of the graduate, their employers,
their clients and animals under their care. Research should also
investigate how current support mechanisms aimed at easing the
transition, are performing. To address this topic, the RCVS Trust
Fund has recently awarded a grant to Dr Mellanby, Professor
Halliwell, Dr Harrison, Ms Dean and Dr Adams to undertake
a questionnaire based survey of recent graduates’ attitudes
to mental health well being, job satisfaction, key workplace
stressors and the efficacy of current support structures. It is
hoped that this questionnaire will provide objective data which
will allow the profession to develop strategies to ensure that the
transition from student to vet is optimised.
Is a high incidence of suicide amongst veterinarians a
global phenomenon?
From the studies currently available which have investigated
the relationship between occupation and suicide, it appears
that veterinarians have an almost universal higher incidence
of suicide regardless of the country studied. It is hoped that as
many countries as possible will examine the incidence of suicide
within their veterinary profession; the identification of a country
which does not have a higher incidence of suicide amongst its
veterinarians offers the global veterinary community an excellent
opportunity to develop a comparative research programme
which would hopefully tease apart the work and non work
related factors which may be protective in certain countries.
Is the incidence of alcohol and drug misuse higher in the
veterinary profession?
Alcohol and drug misuse are commonly linked to both poor
mental health well being and suicide [9]. Given the clear evidence
of increased mortality by suicide in veterinarians, it is important
to establish whether alcohol and/or drug misuse is commonplace
within the veterinary profession. This could be investigated
using a number of approaches, notably through consumption
questionnaires of veterinary students and veterinarians. A
different approach to establish the incidence of severe, lethal
alcohol misuse in specific occupations can be undertaken by
establishing the incidence of alcohol related deaths in specific
professions [10]. Interestingly, recent work found that there was
no evidence of increased mortality due to alcohol related deaths
within the veterinary profession [Mellanby et al, in press [13]].
However, this finding should not diminish the need to establish
the incidence of sub-lethal alcohol misuse in the veterinary
profession as well as exploring the incidence of drug misuse.
How can the veterinarians engage more effectively with
and ultimately protect high risk colleagues?
One of the greatest challenges facing the veterinary profession
is developing specific strategies aimed at reducing the incidence
of suicide in the profession. This is obviously a formidable and
highly challenging long term goal which bodies such as VetLife,
VBF, Vet Helpline and the VSHSP (Veterinary Surgeon’s Health
Support Programme) aim to address. Nonetheless, educating
veterinarians to recognise and engage colleagues who might
be having thoughts of suicide and to connect them with
community resources which specialise in suicide intervention
is widely considered to be crucial in the professions’ attempt
to reduce the problem. However, ensuring that all veterinarians
have these skills is difficult and consequently, the veterinary
schools need to play a leading role in ensuring that their
undergraduates acquire such skills. The RCVS Trust has recently
awarded Dr Mellanby and Professor Rhind a grant to enable the
Scottish Association for Mental Health to present a safeTALK
half day workshop, which aims to instil basic suicide awareness
in its participants, the first year veterinary undergraduates at
the University of Edinburgh. Furthermore, funding has been
secured for 6 Director of Veterinary Studies to undertake the
ASIST (Applied Suicide Intervention Skills Training) two day
workshop which gives further training in suicide awareness
and intervention. This approach will ensure that a large number
of people have basic skills in suicide awareness (completed
safeTALK) who can refer concerns to colleagues who have
further training in suicide intervention (completed ASIST). The
efficacy of this approach will be evaluated by questionnaires and
the results published in a peer-reviewed journal and if successful
How can the transition from undergraduate to practising
veterinarian be optimised?
It is widely acknowledged that the transition from undergraduate
to practising veterinarian can be difficult and stressful. Recent
work has shown that many recently qualified veterinary
graduates work with little supervision or support and that
many make clinical mistakes which can be extremely stressful
to the veterinarian involved [11]. Therefore, it is crucial that the
veterinary profession develops strategies which aim to optimise
this transition and reduce the stress faced by veterinarians
beginning their clinical careers. Despite the importance of this
subject, surprisingly little work has been undertaken to establish
204
EJCAP - Vol. 18 - Issue 2 October 2008
this initiative will hopefully become a permanent fixture in the
veterinary curriculum.
link interested parties within the veterinary profession with
leading academic authorities in disciplines such as psychology,
sociology and psychiatry. It is hoped that this research led
approach will yield a definitive evidence base on which to build
initiatives and programmes which will tackle the high incidence
of suicide within the veterinary profession.
Is job satisfaction lower in the veterinary profession than
other healthcare professions?
The veterinary profession is widely considered by the public and
prospective students to be associated with high job satisfaction
yet anecdotal evidence suggests that is far from a universal
experience. Consequently, it is important for the veterinary
profession to assess how satisfied veterinarians are with their
jobs, to establish what factors influence job satisfaction and to
investigate whether job satisfaction influences well being. The
medical profession regularly audits job satisfaction amongst
its GPs and their initiative affords the veterinary profession
an opportunity to compare the satisfaction of its members to
their GP counterparts [12]. This analysis will be undertaken
in collaboration with Professor Sibbald of the University of
Manchester as part of the larger survey of the well being of the
profession which has been outlined above.
Acknowledgements
The author would like to thank the large number of people who
are actively engaged in this area in the various collaborations
described. Particular thanks are due to Professor Halliwell, Dr
Adams, Dr Harrison, Ms Dean, Professor Hawton, Ms Simkin,
Ms Platt, Ms Romeri, Mr van Galen, Ms Neumann, Professor
Rhind, Professor Gunn-Moore, Professor Platt, Ms Byrne, Mr
Kirwan, Professor Sibbald and Professor Lee. I am indebted to
the various funders of the studies described in this report which
include RCVS, SPVS, VBF and Hill’s Pet Nutrition.
References
Do veterinarians have a different attitude towards
euthanasia?
Veterinarians often have the responsibility of ending an animal’s
life through euthanasia and it has been postulated that the
routine association with the process of euthanasia may alter the
attitudes of veterinarians towards the expendability of human
life. A study by Austin Kirwan suggested that this may be the
case and his work clearly highlights the need to further expand
research in this area.
[1]
[2]
[3]
[4]
Is the mental well-being of veterinary students different
from the wider student population?
As well as considering the well-being of the wider veterinary
profession, it is important not to neglect the undergraduate
veterinary population. We are in the processing of developing
a framework to assess the well being amongst our students
at Edinburgh which we plan to develop into a long term,
longitudinal study which will continue following graduation.
This approach will allow us to establish how the well being of
students varies during the course and what aspects of the course
are particularly stressful leading to the development of evidence
based alterations to the curriculum which will optimise student
well being. Furthermore, this approach will yield crucial data on
a wide range of issues such as career aspirations, movement
between jobs following graduation as well as identifying factors
which may lead to veterinarians leaving the profession.
[5]
[6]
[7]
[8]
[9]
[10]
Summary
[11]
This presentation discusses some of the work which has recently
being undertaken in the field of mental well-being within the
veterinary profession as well as highlighting some ongoing
research in this area. It is hoped that this article will encourage
further discussions about future areas of research and promote
novel collaborations which will investigate the issues surrounding
the mental well-being of the profession. In addition, it is hoped
that funding bodies will be encouraged to support future high
quality research proposals and initiatives especially ones which
[12]
[13]
205
MELLANBY (R.J.) - Incidence of suicide in the veterinary profession
in England and Wales. Vet Rec. 2005 Oct 1; 157(14):415-7.
KELLY (S.), BUNTING (J.) - Trends in suicide in England and Wales,
1982-96. Popul Trends. 1998 Summer(92):29-41.
HALLIWELL (R.E.), HOSKIN (B.D.) - Reducing the suicide rate
among veterinary surgeons: how the profession can help. Vet
Rec. 2005 Oct 1;157(14):397-8.
BARTRAM (D.M.J.), BALDWIN (D.S.) - Veterinary surgeons and
suicide: influences, opportunities and research directions. Vet
Rec. 2008 Jan 12;162(2):36-40.
HAWTON (K.), APPLEBY (L.), PLATT (S.), FOSTER (T.), COOPER
(J.), MALMBERG (A.) et al. - The psychological autopsy approach
to studying suicide: a review of methodological issues. J Affect
Disord. 1998 Sep;50(2-3):269-76.
HAWTON (K.), MALMBERG (A.), SIMKIN (S.) - Suicide in
doctors. A psychological autopsy study. J Psychosom Res. 2004
Jul;57(1):1-4.
MALMBERG (A.), HAWTON (K.), SIMKIN (S.) - A study of
suicide in farmers in England and Wales. J Psychosom Res. 1997
Jul;43(1):107-11.
HOUSTON (K.), HAWTON (K.), SHEPPERD (R.) - Suicide in young
people aged 15-24: a psychological autopsy study. J Affect Disord.
2001 Mar;63(1-3):159-70.
SHER( L.) - Alcoholism and suicidal behavior: a clinical overview.
Acta Psychiatr Scand. 2006 Jan;113(1):13-22.
ROMERI (E.), BAKER (A.), GRIFFITHS (C.) - Alcohol-related deaths
by occupation, England and Wales, 2001-05. Health Stat Q. 2007
Autumn(35):6-12.
MELLANBY (R.J.), HERRTAGE (M.E.) - Survey of mistakes
made by recent veterinary graduates. Vet Rec. 2004 Dec
11;155(24):761-5.
WHALLEY (D.), BOJKE (C.), GRAVELLE (H.), SIBBALD (B.) - GP job
satisfaction in view of contract reform: a national survey. Br J Gen
Pract. 2006 Feb;56(523):87-92.
MELLANBY (R.J.), PLATT (B.), SIMKIN (S.), HAWTON (K.) (in press)
- Incidence of alcohol-related deaths in the veterinary profession
in England and Wales, 1993-2005. The Veterinary Journal.
BOOK REVIEWS
Diagnostic Cytology and
Hematology of the Dog and
Cat, 3rd Edition
Rick L. Cowell, Ronald D. Tyler, James H.
Meinkoth and Dennis B. DeNicola
Published by Mosby Elsevier
(http://intl.elsevierhealth.com.vet)
474 pages, approx 1030 illustrations
Hardback,(2008)
ISBN: 978-0-323-03422-7, € 95.99/
£ 63.99
25 page index, which gives fast access to
the different topics. Each chapter is provided with a large reference list. Most of
the references however cover American
literature only and it is disappointing that
articles in European journals are less often
quoted.
The book is produced on high quality paper and at a very modest price. Everybody
in companion animal clinics who is interested in cytology should have this book
on his or her bookshelf. Those who have
an earlier version should consider upgrading to this new edition.
Erik Teske DVM, PhD, Dip ECVIM-CA,
Assoc Memb ECVCP (The Netherlands)
Manual of Exotic Pet Practice
Mark Mitchell, DVM, PhD, MS, Thomas N
Tully Jr. DVM, MS
This book is now in its 3rd edition. In comparison to the 2nd edition a fourth editor
has been added and the number of pages has been increased from 383 to 474.
Although the second edition was a very
good cytology book, in this edition it has
been improved even further. Apart from
the editors 31 other people have contributed to the book. It has become one of
the standard books of veterinary diagnostic cytology. The contribution of haematology, including bone marrow cytology,
is however limited to only 60 pages.
The chapters on collecting material, on cell
types and malignancy criteria, on cutaneous and subcutaneous lesions, on lymph
nodes, and on cerebrospinal fluid have
many new pictures and have largely been
rewritten. Several algorithms are provided
which give helpful guidelines summarising the text. New chapters on selected
infectious agents, round cell tumours, the
gastrointestinal tract, and pancreas have
been added.
The book is a nice mixture giving information by descriptive text and hundreds of
colour pictures. The quality of these pictures has further improved and is generally excellent. A pleasing detail is that those
topics that could be part of different chapters are discussed on each appropriate occasion often using different pictures, e.g.
mast cell tumours are included as part of
the chapter on round cell tumours as well
as in the chapter on cutaneous lesions.
In contrast to earlier editions there is no
longer a section with separate colour
plates. However, no one will miss this as
there are so many pictures included in the
separate chapters. There is an extensive
Published by Elsevier Saunders (http://
intl.elsevierhealth.com.vet and www.
elsevierhealth.com) 560 pages, approx.
400 illustrations, Hardback, (2008)
ISBN: 9781416001195 € 71.99 £ 47.99
when faced with any of these species, especially as some of them such as the sugar
gliders and African pygmy hedgehogs are
increasingly being kept in Europe.
The chapter on invertebrates gives good
information on this subject and once
again rather more informative than most
other books on exotic pets. It inevitably
covers a broad cross-section of species
that are kept as pets, and therefore does
not cover other invertebrates that are kept
for commercial reasons, such as bees.
The other chapters are probably about
the same length as most of the afore
mentioned chapters, but a single chapter
cannot cover all avian species, so this is
therefore restricted to passerine and psittacine birds and does not attempt to cover
pigeons or raptors. The chapter on rabbits
cannot hope to cover the wealth of material that is now available on this species,
but it does provide a good introduction to
treating the commonly encountered conditions seen in rabbits.
This is a book that will find a place in my
own library. It is certainly worth considering if you only intend to have one book on
exotic pets, and is a good and reasonably
comprehensive introduction to the subject. If you have an interest in one particular species or group of species then there
are more specialist texts available, and this
is recognised by the authors, who do provide guidance on further reading.
Owen Davies BVSc MRCVS(UK)
The stated aim of this 546-page text is
to allow you to treat all exotic pets confidently, using the most cutting-edge information and all within one comprehensive resource. The pages are all glossy and
there are over 400 colour pictures and the
page edges are colour coded to allow the
relevant sections to be readily accessed.
Differential Diagnosis in Small
Animal Medicine
Alexander Gough
Published by Wiley-Blackwell (http://
eu.wiley.com) 480 pages, 85 illustrations.
Paperback ISBN: 9781405132527
ISBN10: 1405132523, £ 29.99 / € 40.50
The first two chapters give an introduction to the subject and help in preparing
the veterinary surgery to treat these patients.
The rest of the nineteen chapters each
cover a separate species or linked group
of species. It is inevitably biased to exotic
pets kept in North America, so that it includes chapters on crocodilians, marsupials, hedgehogs (African pygmy) and North
American wildlife. This results in rather
more information on husbandry, diagnosis and treatment of these species than
is usually found in books written by European authors, and this could be useful
207
The differential diagnosis list is one of the
most important aspects of the problemorientated approach to clinical diagnosis.
Alex Gough says he always missed one
BOOK REVIEWS
easy to find reference to help him formulate a differential diagnosis list from the
information gathered from the history
and physical examination of a patient. For
this reason he has assembled multiple differential diagnosis lists for various signs
of illnesses for dogs and cats as well as
for laboratory findings. He presents these
lists in his book in an orderly fashion. The
book is especially written for veterinary
students, veterinary practitioners, and
specialists, who, as he mentions in his
book, like him cannot fully carry these lists
around in their heads.’
The book certainly lives up to expectations, since the structure of the book simplifies looking up a differential diagnosis
list. There are seven chapters the first
five of which consist of extensive differential diagnosis lists for historical , physical and radiographic signs together with
laboratory findings and electrodiagnostic
testing. These chapters are subdivided
in signs from the various organ systems.
The sixth chapter presents a very clear
and structural enumeration of diagnostic
procedures, varying from the fine-needle
aspiration to cerebrospinal fluid collection
and MRI. For each procedure the indications, required equipment, technique
and interpretation are detailed. The last
chapter consists of diagnostic algorithms
for bradycardia, tachycardia and for some
laboratory findings such as regenerative
anaemia, non-regenerative anaemia and
hypoalbuminaemia.
I personally think the book provides a
good diagnostic aid for both veterinary
students and practitioners due to its clear
structure and the very detailed differential
diagnosis lists. In addition common diseases as well as diseases occurring only in
dogs or cats are separately detailed.
There are a few points to criticise in this
book. Unfortunately some differential
diagnosis lists are very extensive, such as
the one for weakness, due to the vagueness of the symptoms. Furthermore the
sub lists of the drugs and toxins in some
differential diagnosis lists are sometimes
extremely elaborate. Although veterinary
practitioners should always consider drugs
and toxins as a cause of disease, enumerating these in detail ,sometimes filling a
whole page, seems inconsistent with the
otherwise well-ordered structure of the
book.
In my view there’s also a catch when using this book. The lists are so detailed that
some clinicians could easily ‘drown’ in the
many possibilities for causes of a particu-
lar disease. For example, some of the funguses mentioned in the book, are nonexistent in many parts of the world, such
as The Netherlands. Therefore it’s still very
important to complete the historical and
physical examination of a patient and to
stay alert when using the differential diagnosis list.
In conclusion I’m very pleased someone
has finally composed an overview of
the various differential diagnostic possibilities in small animal medicine. I would
highly recommend this book to veterinary
students to facilitate working with the
problem-orientated approach, but also
to veterinary practitioners when dealing
with complicated or difficult cases. I am
absolutely certain that it will be very rewarding to work up a case on your own
with the diagnosis lists or the algorithms
in this book.
Annette Boer, DVM (The Netherlands)
Small Animal ECGs:
An introductory guide
(2nd edition)
Mike Martin
Published by Wiley- Blackwell (http://
eu.wiley.com) 136 pages, Paperback
(November 2007) ISBN: 978-1-40514160-4 € 33.80 £24.99
easy-to-read
This is an eas
to read book of a convencon
ient size concerning ECG analysis. It is written by a well-known expert in veterinary
cardiology. Despite the rather small size of
the book it provides a comprehensive and
thorough guide to ECG interpretation.
The book is divided into five parts as follows: Part 1: Understanding the electricity of the heart and how it produces an
ECG complex, The origins of the P-QRS-T
complex and the normal rhythms of sinus
origin are discussed. Part 2: Abnormal
electricity of the heart, The origins and
pathophysiology of ectopic complexes as
well as disturbances of the conduction
system and changes in P-QRS-T morphology. Part 3: More advanced electrocardiography The different ECG leads, the
mean electrical axis, intraventricular conduction defects, ventricular pre-exitation,
atrial flutter and idioventricular rhythms
208
are explained. Part 4: Management and
treatment of arrhythmias includes discussion of whether or not medical treatment
is indicated in different situations, as well
as a fairly comprehensive list of different
drugs and their dosages and pacemaker
implantation. Part 5: Recording and interpreting ECGs encompasses the actual
recording of an ECG, different artifacts
and the advantages and disadvantages of
different equipment.
The book provides an excellent introduction to ECG interpretation for the veterinary student and the practitioner wanting
to begin ECG recording and analysis.
Anna Tidholm, DVM, PhD, Dipl. ECVIM
(Sweden)
Essential facts of blood
pressure in dogs and cats
A Reference Guide
Beate Egner DVM, Anthony Carr
DACVIM, Scott Brown DVM PhD,
DACVIM
Published by VBS VetVerlag, Babenhausen, Germany ( www.be-vetverlag.
com). Available from www.lifelearn.co.uk
256 pages 118 Illustrations Paperback/
DVD with videos
ISBN: 978-3-938274-15-6 € 69.95 £50.
This book is available in English and
German
This book is an essential for
fo all clinicians
involved in blood pressure monitoring. It
is a highly practical and clinically relevant
book containing a wealth of information
on all aspects of blood pressure, including
all the essential facts, as the title of the
book suggests. The book has managed to
reach just the right balance between providing depth information yet presenting
things in a very clear format which is easy
to read and extremely user friendly.
It certainly meets its aims of providing the
information needed to successfully integrate an understanding of blood pressure
into every day clinical practice. It is very
BOOK REVIEWS
practical and clinically orientated, containing short bullet pointed sections, making
good use of diagrams, pictures, tables,
flow charts and frequent highlighted
summary boxes to illustrate important details. In addition it features multiple case
examples throughout, which nicely demonstrate the clinical importance of specific
points made in the text.
The book is logically split into five sections. Each section is divided into chapters
with small subsections within each chapter which contribute to its user friendliness, making it quick to look up specific
points of interest.
The first section, ‘Importance of blood
pressure measurement’ contains a brilliant overview of blood pressure physiology and why monitoring blood pressure
is important, followed by detailed explanations with diagrams describing the
techniques for direct and indirect (Doppler, conventional oscillometry and high
definition oscillometry) measurement of
arterial blood pressure, and measurement
of central venous pressure. A large section
of the final chapter has been dedicated to
the new technology of high definition oscillometry (HDO), with explanation of the
technology, how to use it and how to interpret results. This section is further supported by an enclosed DVD which gives a
practical demonstration of blood pressure
measuring, in particular using HDO.
The only real criticism of this book is that it
focuses largely on the oscillometric measuring techniques. In cats conventional oscillometry has been shown to be unreliable
and this is not really made clear to readers.
Whilst the HDO has many theoretical benefits, as far as the reviewer is aware, peer
reviewed published data to support these
claims is lacking. There are also some reference values quoted in tables which do not
appear to be backed up by published data
in peer reviewed journals, which makes it
difficult for the reader to interpret. The focus on the oscillometric technique also extends to the DVD which although it does
illustrate the Doppler technique it does
not demonstrate its use in as much detail
as the oscillometric techniques. The Doppler technique is extremely useful when
used correctly and is frequently used in
clinical practice, so it is just a shame that
the authors did not include more detail
on Doppler blood pressure monitoring,
with practical tips and an evidence based
approach to the clinical usefulness of the
different methodologies. Having said this,
the description and explanation of using
the HDO machine and interpreting results
is excellent, and a crucial aid for any clinicians using this equipment.
Section 2 ‘Pathologic changes in blood
pressure’ reviews the pathophysiology of
diseases causing hyper- and hypo-tension,
including heart disease, renal disease,
endocrine disorders, and shock. This is a
really useful section for recapping pathophysiological mechanisms covering all the
essentials without going into too much
depth. It also contains a chapter on controlling blood pressure under anaesthesia.
This is a great chapter and a vital read
for anyone involved with anaesthetising
patients. It includes details on effects of
commonly used sedation and anaesthetic agents, other factors affecting blood
pressure and how to manage intra-operative hypotension. This chapter finishes
nicely with a well presented flow diagram
of guidelines to work through when hypotension is encountered during general
anaesthesia.
Section 3 ‘End-organ damage’ reviews effects of hypertension on the heart, eye,
kidney and brain. It again includes the
pathophysiology of blood pressure regulation by these end-organs, fundamental information required for understanding and
treating end-organ damage due to alteration of blood pressures. It also contains
information on diagnosing and treating
end-organ damage. The enclosed DVD is
very useful to use in conjuction with this
chapter, with practical illustrations and
tips on how to evaluate the eye and heart
for end-organ damage.
Section 4 ‘Therapy’ is a really detailed
section on the pharmacology of treating
both hypertension and hypotension. Once
again the layout makes this section very
209
user friendly with tables and highlighted
boxes to make it much easier for clinicians
to formulate treatment plans without
needing to read a large amount of text.
The section also contains a useful table of
drugs with haemodynamic side effects,
clearly of listing whether they increase or
decrease blood pressure.
The authors had a great idea to include
Section 5 on ‘Economics’, as this is an
area so often missed from textbooks,
and yet so important to veterinary practices. Whilst the preceding chapters will
persuade all veterinarians of the value of
blood pressure monitoring, this chapter
is sure to persuade the most sceptical of
practice managers, that blood pressure
measuring is not just good for the patients,
but is good for the practice’s image, work
environment and profitability! If anyone
has problems persuading their boss that
blood pressure monitoring is important,
just make them read this chapter!
Finally, an appendix includes important
clinical information from the ACVIM
Consensus statement, on guidelines for
the identification, evaluation, and management of systemic hypertension with
particularly useful guideline interpreting
blood pressure readings and when to
treat.
Despite the criticism regarding the focus
on oscillometric blood pressure measuring, this really is the only negative point
to make. Otherwise, this is an excellent
book in all respects and remains an essential guide for anyone in clinical veterinary
practice.
Andrea Harvey (UK)
Calendar of main European National Meetings
and other continuing education opportunities
WSAVA & FECAVA Congresses (Red)
Principal annual meetings (blue)
A list of the addresses and telephone numbers of the Secretariat or person holding information is attached.
2008
10-11 October
TSAVA
Istanbul
3rd Tsava “Anadolum” Continuing Education Congress
English / Turkish
11 October
BASAV
Stara Zagora
WSAVA CE Ophthalmic surgery
English
11-12 October
AIVPA
Modena
National Congress-Dermatology and infectious diseases
of dogs and cats with associated meetings on October
12th
AIVPAFE “Feline dermatology”
AIVDAO “Veterinary dermatology a holistic approach”
SITOV “News from the orthopaedic field
Italian
17-19 October
AVEPA
Barcelona
Annual Congress -(A Southern European Veterinary
Conference )
English and Spanish
18-19 October
AIVPAFE/AIVPA
Perugia
“Ematology and cytology in dog and cat”
English
18-19 October
PSAVA
Wisla
Annual Congress-current techniques in imaging
Polish and English
20-31 October
ESAVS
Luxembourg (LUX)
Ophthalmology Course I
English
24-26 October
CSAVA
Hradec Kralove
Annual Congress
Czech and English
28 October
BSAVA
BSAVA HQ
Gloucester
Urinary Tract II “Clinical evaluation of lower
urinary tract.
English
29 October
BSAVA
BSAVA HQ
Gloucester
GIT I “Clinical evaluation of Liver and Pancreas”
English
14-16 November
SASAP
Belgrade
Annual Symposium SIVEMAP
Serbian , English
16 November
AIVPA
Pesaro
“Melanoma and mastocytoma: innovative therapies”
Italian
17-28 November
ESAVS
Utrecht (NL)
Internal Medicine I
English
19-22 November
WCVD
Hong Kong
World Congress of Veterinary Dermatology
English (in part Mandarin,
Korean and Japanese)
22-23 November
FAVP
Helsinki
CE Hypertension
Finnish and English
22-23 November
AIVPAFE/AIVPA
Grugliasco (TO)
“Radiology in cat and dog”
Italian
25 November
BSAVA
BSAVA HQ
Gloucester
Endocrinology II “Endocrine pancreatic disorder
including Insulinomas and diabetes mellitus”
English
26 November
BSAVA
BSAVA HQ
Gloucester
GIT II “ Clinical evaluation conditions affecting
Oesophagus, stomach and intestines.
English
27-30 November
AFVAC
Strasbourg
Annual Congress Including a FECVA Day) Details on
page 143
French
English and German on
FECAVA Day
1-5 December
ESAVS
Halmstadt (S)
Oral Surgery Course
English
1-5 December
ESAVS
Lisbon (P)
Excellence in Veterinary Therapy:
Oncology and Internal Medicine Course
English
VICAS
Galway
Annual Winter Conference
English
English
2009
30 Jan -1st Feb
5-6 March
FAVP/AVA
???
Congress
March
FAVP
???
Annual Congress
???
2-5 April
BSAVA
Birmingham
Annual Congress
English*
23-25 April
NACAM
Amsterdam
Voojaarsdagen
Dutch/ English and others
7. - 9. May
SVK/ASMPA
St. Gallen
National Congress
German, French, English
17-19 September
ECVD-ESVD
Bled (Slovenia)
Annual Congress
English
19-20 September
VÖK
Salzburg
24th VÖK-Annual-Meeting
German, English
26-29 November
AFVAC
Lille (F)
15th FECAVA/AFVAC/LAK/ SAVAB Eurocongress
French, English-possibly
others
* 60 Veterinary surgeons or 70 Nurse registrations required for simultaneous translation to be provided
ADVANCE NOTICE
2010
FECAVA/WSAVA/SVK Geneva 2-5 June
VÖK Salzburg
25 - 26 September
2111
SVK/ASMPA Interlaken 18-21 May
2012
FECAVA /WSAVA/BSAVA April
210
Secretariat or address to contact for information
(Full Association names are given at the front of the Journal)
AFVAC
AIVPA
APMVEAC
AVEPA
BASAV
BHSAVA
BSAVA
CSAVA
CSAVS
DSAVA
ESAVA
FAVP
GSAVA
Contact Address for Information
Secretariat: 40 rue de Berri – F-75008 Paris
Segretariat: AIVPA - Medicina Viva, Via Marchesi 26D - I-43100 Parma,
Italy
Director: Dr. José H. Duarte Correia/ Secretariat: Rua Américo Durão,
18D, 1900-064 Lisboa, PORTUGAL
Secretariat: Paseo San Gervasio 46-48, E7, E-08022 Barcelona Spain
Director: Dr. Boyko Georgiev, Institute of Biology and Immunology
of Reproduction, Tzarigradsko shousse 73 Sofia 1113, Bulgaria
Contact: Dr. Josip, Krasni-Alipasina St. 37 7100 Sarajeva – Bosnia and
Herzegovina
Secretariat: Woodrow House 1 Telford Way, Waterwells Business Park
Quedgeley, Gloucester GB-GL2 AB
Director: Dr. Jiri Beranek, University of Veterinary and Pharmaceutical
Sciences – Palackého 1/3 – 612 Brno Czech Republic
Director: Dr. Davorin Lukman, Specijalizirana Ambulanta Varazdin
Trnovecka 6, 42000 Varazdin, Croatia
Secretariat: Emdrupvej 28 A, DK 2100 Copenhagen
Director: Dr. Tiina Toomet, Vabriku 45 Tallinn, EE- 10 41.Estonia
Director: Dr. Kaj Sittnikow, Ykskoivuntie 32, FIN-23500 Uusikaupunki
PSAVA
PVA
RSAVA
SAVAB
SkSAVA
Secretariat: Dr. Birgit Leopold-Temmler, Gneisenaustr. 10, D- 30175
Hannover
Director: Fereac Biró, Isvan u. 2 Budapest H-1078
Director: Dr. Katerina Loukaki, Protopapa 29, Helioupolis, GR- 163 43
Athens
DIirector :Dr. Katia Di Nicolo, Médecin Véterinaire, 36 rue des Redoutes,
L-6476 Echternach
Director: Dr. Lita Konopore, Zvaigznáju Gatve 2 Riga, LV-1082
Contact: Dr. Saulius Laurusevicius, Tilzes 18, LT-47181 Kaunas
President: Dr Predrag Stojovic Ul.Ilije Plamenca lamela 103 bb,
(Montvet), 81000 Podgorica, Montenegro
Director: Marin Velicovski, Ul. Lazar Ppo Trajkov 5-7 Skopje, Fyrom
Director: Dr. C.L. Vella, Blue Cross Veterinary Clinic Msida Road,
Birkirkera, Malta
Secretariat: NACAM, KNMvD, PO box 421, 3990 GE, Houten,
The Netherlands
Secretariat: SVF v/Dr. Ellef Blakstad, PO Box 6781 St. Olavs Plass N-0130
Oslo
Director: Dr.Roman Aleksiewicz, Secretariat PSAVA 20-934, Lublin
Director: Dr. Yiannis Stylianov, PO Box 5284, 1308 Nicosia Cyprus
Contact: Dr. A. Tkachov-Kuzmin, V-Kojinoi, 23 – 121096 Moscow, Russia
Director: Dr. J van Tilburg, Ernest Claeslaan 14 B-2500 Lier Belgium
Director: Dr. Igor Krampl, Sibirska 41, 83102 Bratislava, Slovak republic
SASAP
Director: Denis Novak, Dr Ivana Ribara 186/30, 11070 Belgrade, Serbia
HSAVA
HVMS
LAK
LSAPS
LSAVA
MASAP
MSAVA
MVA
NACAM
NSAVA
SSAVA
Director: Dr. Alexandra Vilén, Regiondjursjukhuset i Helsingborg,
Bergavägen 3, Box 22097, S-250 23 Helsingborg, Sweden
SVK/ASMPA Director: Dr. Peter Sterchi, Mühlegrund – CH-3807 Iseltwald
SZVMZ
Director: Dr. Zorko Bojan, Veterinary Faculty, Gerbiceva 60, SLO-1000
Ljubljana, Slovenija
TSAVA
Director: Akif Demirel, Istanbul Animal Hospital, Eceler sokak.
16/1 Florya, Istanbul,Turkey
USAVA
Director: Dr. Vladimir Charkin, 8 Filatova str., Apartement 24, Odessa
65000, Ukraine
Tel/Fax
Tel: (33) 1 53 83 91 60 – Fax: (33) 1 53 83 91 69
Tel: (39) 0521-290191 - Fax: (39) 0521-291314
Tel: +351 218 404 179 – Fax: +351 218 404 180
Tel: (34) 93 2531522 – Fax: (34) 93 4183979
Tel: (359) 888 272529 – Fax: (359) 2 866 44 50
E-mail/Website
www.afvac.com
segreteria@aivpa.it
www.aivpa.it
geral@apmveac.pt
www.apmveac.pt
www.avepa.org
boykog@netbg.com
veterins@bih.net.ba
Tel: (420) 603 272 796 – Fax: (420) 549246974
customerservices@bsava.com
www.bsava.com
MED.PROD@tiscali.cz
Tel/Fax: (385) 42 331 895
dr.lukman@vz.htnet.hr
Tel: (45) 38 71 08 88 – Fax: (45) 38 71 03 22
Tel: (372) 6413 11 – Fax: (372) 641 3110
Tel: (358) 2 844 2580 Fax: (358) 2 844 2589
Mob (358) 0400 602 081
Tel: (49)511-85 80 60 0r 99 Fax : (49)511-85 80 45
ddd@ddd.dk
kevade@uninet.ee
kaj.sittnikow@uusikaupunki.fi
Tel: (36) 305950750
Tel/Fax: (30) 2109932295
biro.fari@freemail.hv
loukaki1@otenet.gr
Tel: (352) 691711795
katiadinicolo@gmx.net
Tel: (371) 7546 366 – Fax: (371) 7606 202
Tel: (370) 698 45876 – Fax: (370) 373 63490
Tel: 00382 69 014 726 – Fax: 00382 81 662 584
lita@tl.lv
sac@lva.lt
montvet@cg.yu
Tel: (389) 91 115 125 – Fax: (389) 91 114 619
Tel: (356) 225 363 – Fax: (356) 238 105
marin@yahoo.com
carmel.lino.vella@magnet.mt
Tel : (31) 30 63 48 900 – Fax: (31) 30 63 48 909
moniquemegens.ggg@knmvd.nl
www.gggknmvd.nl
Ellef.blakstad@vetnett.no
Tel: (44) 1452 726700 – Fax: (44) 1452 726701
Tel: (47) 22 994600 – Fax: (47) 22 994601
Tel: (81) 44 56 158
Tel: (357)99603 499
Tel/Fax: (7) 095 921 6376
Tel: (32) 3 489 2309 – Fax: (32) 3 480 1942
Tel: (421) 905 511971
info@tierpraxis.de
Tel: (46) 421 68 000 – Fax: (46) 421 68 066
www.pslwmz.org.pl
drstylianou@cytanet.com.cy
movet01@mail.ru
Vtilb001@skynet.be
info@savlmz.org
www.savlmz.org
novak@ptt.yu
www.smasap.org.yu
alexandra@vilen.se
Tel: (41) 33 845 11 45
Tel: (386) 14779277 – Fax: (386) 647007111
peste@bluewin.ch
Bojan.zorko@vf.uni-lj.si
Tel/fax: (381) 11 2851 923; (381) 11 382 17 12;
drdemirel@ttmail.com
www.tsava.org
Tel.: (380) 503369810 - Fax: (380) 482 606726
v.charkin.hotmail.com or
usava@ukr.net
www.usava.org.va
VICAS
Director: Dr. Peter A. Murphy, Summerhill Veterinary Hospital, Wexford,
Tel: (353) 5391 43185 – Fax: (353) 5391 43185
drpamurphy@eircom.net
Co. Wexford Ireland
by request
www.veterinary-ireland.org
VÖK
Director: Dr. Silvia Leugner, Schönbrunnerstraße 291/1/1/3, A-1120 Wien Tel. (43) 664/8212318 or (43) 1 8791669 - 18 or (43) silvia.leugner@royal-canin.at
office@voek.at www.voek.at
1 8132983 - Fax (43) 1 8791669 - 33
Associate members
ESAVS
Contact: ESAVS Office Birkenfeld, Schadtengasse 2, D-55765 Birkenfeld Tel: (49) 6782 980650 – Fax: (49) 6782 4314
ewelina.skrzypecka@esavs.org
www.esavs.org
ECVD
Contact: Dr. Dominique Héripret, Clinique Vétérinaire Frégis 43, avenue
Tel: (33) 149 85 83 00 – Fax: (33) 149 85 83 01
dheripret@fregis.com
Aristide-Briand F-94110 Arcueil
Tel: (41) 44 635 84 08 – Fax: (41) 44 313 03 84
ECVS
Contact: Executive Secretary – ECVS Office Vetsuisse Faculty University
ecvs@vetclinics.uzh.ch
Zürich Winterthurerstrasse 260, CH-8057 Zürich
www.ecvs.org
ESFM
Contact: Claire Bessant, Taeselbury, High Street, Tisbury, Wiltshire, GB Tel: (44) 1747 871872 - Fax: (44) 1747 871873
claire@fabcats.org or
SP3 6LD, UK
esfm@fabcats.org
ESVC
Contact: Dr.Nicole Van Israël, Rue Winamplanche 752,
Tel: +32-(0)87-475813 – Fax + 32-(0)87-776994
nicolevanisrael@acapulco-vet.be
B-4910 ,Theux, Belgium
www.acapulco-vet
ESVCE
Contact: Dr. Sarah Heath, 10 Rushton, Upton, Chester GB-CH2 1RE
Tel: (44) 1244 377365 – Fax: (44) 1244 399288
heath@brvp.co.uk or admin@
brvp.co.uk
ESVD
ESVD President, Dr Aiden P. Foster, VLA Shrewsbury, Kendal Road,
Tel +44 (0) 1743 467621 – Fax +44 (0)1743 441060 a.foster@vla.defra.gsi.gov.uk
Harlescott, Shrewsbury, Shropshire, SY1 4HD UK
www. esvd.org
ESVIM
Tel: (+44) 141 330 5848 - Fax: +44 141 330 3663
Contact: Dr. Rory Bell, Department of Veterinary Clinical Studies
r.bell@vet.gla.ac.uk
University of Glasgow, Bearsden, Glasgow, GB- G61 1QH
ECVIM-CA
For Congress: Sharon Green Avenue du Guéret 1 B-1300 Limal
Tel: (+32) 10 400 603 - Fax: +32 10 400 703
www.ecvimcongress.org
congress@ecvim-ca.org
ESVN
Tel: (44 )141 330 5738 - Fax: (44) 141 330 3663
Contact: Dr. Jacques Penderis, Division of Companion Animal Sciences,
J.Penderis@vet.gla.ac.uk
Faculty of Veterinary Medicine, University of Glasgow, Bearsden,
www.esvn.org
Glasgow, GB- G61 1QH
ESVOT
Contact: Dr. Aldo Vezzoni, via Massarotti 60/A, I-26100 Cremona
Tel: (39) 0 372 23451 - Fax: (39) 0 372 20074
www.esvot.org
EVDS
Tel: (+33) 2 40 68 78 09 (76 72) –
President: Olivier Gauthier – Unite de Chirurgie Anesthesie – Ecole
gauthier@vet-nantes.fr
Nationale Veterinaire de Nantes – Atlanpole La Chantrerie – BP 40706
Fax: (+33) 2 40 68 77 73
– F-44307 Nantes cedex 3
EVSSAR
Contact/President: Dr Gaia Cecilia Luvoni, Dept Veterinary Clinical
Tel: +39 02 50318147 - Fax: (+39) 02 50318148
cecilia.luvoni@unimi.it
Sciences, Obstetrics and Gynaecology,University of Milan,Via Celoria10,
I-20133, Milan
211