REVIEWER

FOR

VETERINARY SMALL ANIMAL MEDICINE AND SURGERY

University Review Center LEYTE STATE UNIVERSITY Visca, Baybay, Leyte 6521-A

Prepared by: AGNES M. TAVEROS, D.V.M. 2003 1

TABLE OF CONTENTS

UNIT NO. PRELIMINARIIES TITLE PAGE TABLE OF CONTENTS 1 2

TITLE

PAGE

1 2 3 4

FACTORS INFLUENCING DISEASE ENVIRONMENTAL CONTROL OF INFECTIOUS DISEASES

3 4 5 6 7 8 9 10 11 12 13 14 15

SKIN DISEASES DISEASES OF THE EARS AND EYES DISEASES OF THE MUSKULOSKELETAL SYSTEM BLOOD, LYMPHATIC AND CARDIOVASCULAR SYSTEMS RESPIRATORY SYSTEM DIGESTIVE SYSTEM REPRODUCTIVE AND URINARY SYSTEMS NERVOUS SYSTEM ENDOCRINE SYSTEM IMMUNE SYSTEM INFECTIOUS DISEASES ZOONOTIC DISEASES PRINCIPLES OF SURGERY

7 13 14 16 19 19 26 28 30 32 33 40 41

UNIT1 FACTORS INFLUENCING DISEASE

Agent (virus, bacteria, parasite, etc.) + host + environment are involved in a complex interplay that determines incidence, severity and distribution of infectious diseases in an animal population. TERMINOLOGY Reservoir of an infectious agent is its natural habitatwhere it survives (ex. soil, water, etc.). Animal reservoirs are known as carriers. They can be clinical (showing disease) or subclinical (no outward signs of disease). The infected animals shed (spread) the disease. Latent carriers shed intermittently (sporadically). A pathogenic organism must evolve a mechanism by which to spread from the reservoir or carrier to other animals in order to perpetuate it. Respiratory infections are usually spread by aerosol produced by coughing and sneezing. Gastrointestinal infections are usually spread through vomit and feces. Genitourinary infections are transmitted via urine, semen, and vaginal and fetal fluids. Occasionally, infectious organisms may be shed by open, draining wounds. Clinical illness is not always seen in animals that are shedding. A carrier may be apparently symptom-free, yet still be spreading the disease. Infection potential generally varies inversely with the length of time over which the disease is communicable. Acute, severe illness is associated with highly contagious secretions, but the period of time over which the animal is contagious will be fairly short. The transmissibility of a disease is its communicability. The ability to spread from an infected to a susceptible host. Transmission can occur between members of the same population ( horizontal) or to succeeding generations (vertical) via the placenta or milk. Not all infectious diseases are transmissible (ex. systemic mycotic infections originate from the soil). The four major routes by which infectious agents spread between hosts include 1) direct contact 2) vehicle or fomite 3) airborne and 4) vector transmission: Direct contact is the most common means of transmission. This would include any situation where the susceptible animal comes into direct contact with the infectious agent or ill host. Vehicles or fomites are often involved in transmission of disease. They are inanimate objects that may carry or contain the infectious organism. Examples would include using the same food dishes for a sick animal and a healthy one and spreading the disease via the food pans. Airborne transmission occurs all the time as with feline upper respiratory infections and human colds or influenza. Generally, airborne transmission is most likely to occur at distances of less than one meter. However, some diseases are known to be transmitted over distances of up to several miles. Vector transmission requires a living creature to transmit the disease. The vector is usually an arthropod or insect such as a mosquito or tick. On some occasions the vector may be a mammal such as raccoons and their role in the transmission of rabies.

ADDITIONAL DEFINITIONS Epizootiology: the study of occurrence and distribution of disease within a population of animals Epizootic: an acute outbreak of a disease Enzootic: constant incidence of disease in a defined geographical area and population Sporadic: single or random occurrence of disease

UNIT 2 ENVIRONMENTAL CONTROL OF INFECTIOUS DISEASES

Factors that must be considered when attempting disinfection or sterilization include the microorganism or agent involved the disinfecting agent, the amount of organic matter present and the temperature. Physical Agents boiling Heat kills cells by denaturing cellular protein 121 degrees C at 15 pounds/cubic inch for 13 minutes 126 degrees C at 20 pounds/cubic inch for 10 minutes Dry heat requires a much longer time period and higher temperature Radiation Gamma radiation is used to sterilize some foods (strawberries) and surgical supplies (gloves, suture material) that can not tolerate high temperatures. The technology involved is costly. Ultraviolet light is used in surgery suits but has limited application because of poor penetration. It only affects surface areas Filtration Heat and humidity Steam under pressure creates a higher temperature than can be achieved by

Filtration involves separating bacteria (particulate matter) from liquids or gases using some kind of selective barrier. This method is commonly used for pharmaceutical products.

Chemical Agents Alcohols Do not kill spores Are viricidal with increased exposure time Are only effective during contactno residual effect Are primarily an antiseptic agent Approximately 50% effective Will dissolve cements (lens cement) and harden plastics Evaporate Effectiveness is inhibited by organic debris

Chloride Chlorine(Clorox) is an example Is inactivated by organic matter Activity is pH dependent Corrosive Unstable. Solutions should be made fresh daily Forms a carcinogen (trihalomethane) in the presence of organic debris Is sporicidal, viricidal and fungicidal Is harsh on tissues in high concentrations

Iodine Povidone-iodine (Betadine) is an example Antimicrobial 5

Some formulations stain Inactivated by organic matter Cytotoxic at high concentrations Can cause skin irritation and contact dermatitis Iodophores = iodine + surfactant (povidone-iodine)

Aldehydes Formaldehyde and glutaraldehyde (Cidexplus) are examples Tissue toxic, irritating and carcinogenic Contraindicated for use with living tissue Used for cold sterilization and preservation of tissue samples

Phenols Hexachlorophene and carbolic acid are examples Can be irritating to tissues Undesirable reactions by cats Is only bacteriostatic not bactericidal Some compounds neurotoxic and hepatotoxic Replaced by more effective compounds

Surfactants (surface-active compounds) Quaternary ammonia. (Benzalkonium chloride) is an example Algecidal, bactericidal, viricidal, fungicidal They are not effective against spores and some viruses Bland, non-toxic to tissues Some forms are inactivated by soaps, organic matter, hard water (anionic)

Bigaunides 6

Chlorhexidine is an example Low tissue toxicity Does not affect gram + cocci or spores Effective against bacteria, viruses, fungi and yeast May have decreased efficacy in the presence of organic matter, hard water and anionic compounds

Ethylene Oxide Ethylene oxide gas is the most effective chemical agent for sterilization It is used extensively on surgical equipment that can not tolerate heat exposure It is carcinogenic and requires specialized equipment and ventilation systems for proper use Flammable, explosive, irritating to skin and mucous membranes

When trying to control the spread of a disease, all the discussed factors (microorganism, disinfecting agent, presence of organic debris, how the agent is spread, susceptibility of the host, etc.) must be taken into consideration. Addressing only one or two of the factors involved will lead to an inability to control the disease. Remember: AGENT + HOST + ENVIRONMENT = DISEASE A few examples: Even though a dog may be vaccinated for kennel cough it still comes down with the disease. Why? There are multiple agents involved in causing the disease complex known as "kennel cough". We do vaccinate for some of the causative agents BUT not all of them. Animals that are vaccinated may still come down with "kennel cough" but it will be a much milder form than if they had not been vaccinated. (AGENT) A cat with feline leukemia is caged directly across from healthy cats, yet none of them develops feline leukemia. Why? Feline leukemia is spread by direct and prolonged contact. By having the cats caged so that they do not have contact with each other you prevent the spread of the disease by controlling the surroundings. (ENVIRONMENT) Your practice takes care of quite a few stray cats from the animal shelter and they all seem to have upper respiratory infections. Why? 7

There are lots of contributing factors to this situation but one of the factors is probably the poor condition (health status) of the stray cats. They are under continuous stress and usually have a number of other health problems that cause them to have an impaired immune status making them much more susceptible to upper respiratory infections. (HOST) ADDITIONAL DEFINITIONS Sterilization: all life forms are destroyed including spores. Sterilization is absolute. Applied to inanimate objects. Disinfection: destruction of most pathogenic organisms. The risk of infection is reduced to a "safe" level. Applied to inanimate objects Antiseptic: compound that decreases the population of pathogenic organisms. Resident bacteria are still present. Applied to living tissue. Sanitation: decrease the level of bacteria to a safe level of cleanliness Bacteriostatic (inhibition of growth) vs. bactericidal (killing of bacteria) Asepsis: freedom from infection

UNIT 3 SKIN DISEASES

Some important points to remember when dealing with skin problems and questions that should be asked of EVERY patient that comes in with a skin problem in his dog or cat so that there is less likelihood that a diagnosis will be missed:

Take a complete history including when the problem started, duration, diet, any other health problems, etc. Ask specifically if the problem is seasonal or if it occurs year round. Is the animal pruritic or non-pruritic? (Does the animal itch?) What is the distribution of the lesions? Are the lesions only on one small area or is the whole body affected? What do the lesions look like? Are other animals affected? Any human family members with symptoms? Are there any observable parasites like fleas lice or ticks?

In addition, EVERY patient that presents with a skin problem should have the following diagnostic tests performed:

Skin scraping Wood lamp Fungal culture (Dermatophyte Test Media-DTM) 8

Additional tests that may be indicated depending on initial findings and/or response to therapy:

Skin biopsy Blood work Thyroid and/or cortisol tests Autoimmune test(s) Bacterial culture and sensitivity Intradermal skin test or serologic allergy test Cytology Diet trial to determine food allergies Provocative exposure for contact allergies

Likewise, the following are the most common lesions of skin diseases: 1. Pustule 2. Crust 3. Excoriation 4. Pruritus 5. Bulla 6. Alopecia 7. Papules 8. Epidermal collarettes 9. Urticaria 10. Ulceration 1) PYODERMA

Pyoderma is an infection of the skin usually caused by the bacteria, Staphylococcus intermedius. Pyoderma is common in dogs and uncommon in cats. Pyodermas are usually classified as superficial or deep and primary or secondary. Most pyodermas are secondary and predisposing causes include allergies, parasitic infestations, some other primary health problem and seborrhea. In cats the disease is rare so pyoderma should be suspected to be secondary to a primary health problem such as feline leukemia or feline immunodeficiency virus. Clinical signs:

alopecia, papules, crusts, excoriations and epidermal collarets animal may or may not be pruritic areas of involvement: armpits, skin folds, lips, interdigital spaces or any other area that remains moist is predisposed to infection. However, lesions may be wide spread and involve the whole body.

Diagnosis is based on history and clinical signs. Skin scrapings and fungal cultures should be performed to rule out Demodecosis and Dermatophytosis. Other rule outs include Malezzia dermatitis and other uncommon crusting diseases. Treatment consists of appropriate long-term antibiotic therapy (oxacillin, erythromycin, chloramphenicol, cefadroxil, cehpalexin, amoxicillin/clavulanate, trimethoprim-sulfadizine) 2) DERMATOMYCOSIS/DERMATOPHYTOSIS

A fungus causes dermatomycosis or ringworm. There are three main groups of fungi responsible for causing this disease: Tricophyton, Microsporum and Epidermophyton. Dermatophytosis is a zoonotic concern and it can affect all domestic animals. The main mode of transmission is via direct contact or through fomites such as shared bedding, tack or grooming equipment. Not all animals or humans that are exposed will contract the disease. Host factors such as age, nutritional status, level of stress, etc. are important in determining susceptibility. Ringworm grows only in keratinized tissue. As the host mounts an immune response and inflammation occurs, further spread of the fungus is inhibited. For most healthy individuals, the disease is self-limiting although it may take several weeks for the infection to resolve. Persistent infections can occur among immune-compromised individuals and longhaired cats. Asymptomatic carriers exist, especially cats. Diagnosis is based on physical examination and laboratory tests. Clinical lesions usually appear as round areas of alopecia. The animal may or may not be pruritic. Wood lamp is helpful in diagnosing cases of M canis, but only 80% of the cases will fluoresce. Other fungi do not fluoresce so a negative response to the Wood lamp is insignificant. Other tests include using Dermatophyte Test Media (a positive culture turns the media red), identifying hyphae and spores using lactophenol blue and the potassium hydroxide digestion test. Treatment consists of topical antifungal ointments and shampoos. In generalized cases, systemic antifungals are indicated.
AGENT SHAMPOOS 1) Chlorhexidine Few side effects; antibacterial Occasional ulcers irritation; corneal COMMENTS SIDE EFFECTS

2) Povidone-iodine

Not recommended for cats or lighthaired animals Bathe first with a keratolytic shampoo if necessary

Iodine toxicity may occur; stains white or light coats

3) Ketoconazole

DIPS

10

1) Chlorhexidine

Few side effects; antibacterial

Occasional ulcers

irritation;

corneal

2) Captan 3) Lime-sulfur

Contact sensitizer in people Antipruritic, antiparasitic, malodorous

Vomiting in cats Stains white or light occasional irritation coats;

4) Povidone-iodine

Staining common

Iodine toxicity (esp in cats); occasional irritation Occasional irritation; will bleach dark haircoats

5) Sodium hypochlorite

PRODUCTS FOR LOCAL THERAPY 1) Miconazole 2) Clotrimazole 3) Ketoconazole 4) Thiabendazole Available as cream, lotion and spray Available as cream Cream with few side effects Should be refrigerated; antipruritic, antibacterial Available as cream Occasional reactions contact allergic Occasional local irritation Occasional local irritation

5) Econazole SYSTEMIC ANTIFUNGAL DRUGS 1) Griseofulvin

Divide dose q12h; administer with a fatty meal

Nausea, vomiting, diarrhea; idiosyncratic myelotoxicity (esp in cats); ataxia, pyrexia, icterus, angioedema Gastric irritation, anorexia, hepatotoxicity; idiosyncratic lightening of haircoat

2) Ketoconazole

Admisniter the dose divided q12h if nausea or anorexia occurs

3)

ATOPY

Atopy or allergic inhalant dermatitis is very common in dogs. 10% -15 % of the population may be affected with predisposition for this disease seen in certain breeds (Terriers, Golden Retrievers, German Shepherds, Labradors, Shar-peis, etc.). It is an infrequent disease in cats. The disease usually manifests itself by the time the animal reaches adulthood (3 years old). It usually starts off as being seasonal in nature but as the animal becomes sensitized to more and more 11

allergens, the symptoms will be present year round. Main clinical signs include muzzle rubbing, foot licking and chewing, pruritus, excoriations from self-mutilation, hyperpigmentation of the skin and abnormal behavior due to intense itching. Secondary otitis and/or pyoderma may occur. Diagnosis is based on clinical signs. Pruritus and the seasonal nature (initially) of the disease are characteristic. The diagnosis is confirmed via intradermal skin test or serologic allergy test. Treatment can be symptomatic such as the use of corticosteroids and histamines to control itching. Immunotherapy (hyposensitization) via allergy shots gives the best long-term results. It may also be possible to avoid or decrease exposure to some allergens once the allergens are identified via skin or serologic testing. 4) FOOD ALLERGY/FOOD HYPERSENSITIVITY

Food allergies are not as common as atopy, but they do occur. The terms are used interchangibly and describe symptoms induced by food ingestion in which there are donstrable or highly suspected immunologic reactions. It seems to be primarily a problem in dogs but can occur in cats. Symptoms may be confusing and non-specific. The animal will be pruritic and the symptoms will be nonseasonal. The age at onset of clinical signs varies. Clinical signs may include otitis, blepharitis, pruritus, alopecia, and muzzle rubbing. Cats may show signs of miliary dermatitis. The terms food intolerance or food sensitivity are used when immunologic etiology is unlikelyl Diagnosis is difficult because the clinical signs are not specific ( although pruritus is the most common sign) and there is no definitive diagnostic test. Diagnosis is based on history, clinical signs and response to an elimination diet or hypoallergenic test diet. The animal should be fed the trial diet for 3 months and NO other foods added to the diet. Animals normally respond to the diet within two weeks. Elimination diets may be difficult to use in cats because they often refuse to eat the new diet. The most commonly identified allergens are beef and chicken for dogs and fish, beef and chicken in cats. It is possible that the animal may have more than one allergic syndrome. This may further complicate diagnosis and treatment. Treatment is based on avoiding exposure to the allergens by feeding specialized diets. Response to symptomatic treatment is variable but corticosteroids and antihistamines may help in some cases. 5) CONTACT ALLERGY

Occurs as a result of chemicals reacting with skin proteins. The classic example is poison ivy rash in humans. This problem has been reported in dogs and is usually due to sensitization to plastics (feed dishes or collars) or substances applied to the skin (dips, etc.). Diagnosis is based on localized signs and treatment consists of avoiding the allergen. 6) FLEA ALLERGY

Flea allergy dermatitis is the most common skin disease of dogs. Cats are also commonly affected. The cat flea, Ctenocephalides felis, is the main cause of the problem; less likely, by Pulex irritans (human flea) and Ctenocephalides canis. It will bite humans. In dogs typical signs include 12

chewing. Licking and biting at the tailhead, legs and flanks. "Hot spots" are commonly seen. Crusts, papules, hyperpigmentation, staining from saliva and sores will develop. The animal will chew until it self-mutilates. It will be restless, anxious and uncomfortable. Cats develop small, round scabs and crusts especially around the neck, face and back legs (miliary dermatitis). The condition is usually worse in the summer months, but can be a year round problem if fleas become established in the home. Diagnosis is based on typical clinical signs and the evidence of fleas on the animal (fleas or flea dirt[digested blood excreted by the flea] in the coat of the dog) which changes to a reddish-brown colour on contact with water.). Treatment usually consists of any of a number of excellent topical or oral anti-flea medications now available on the market. All animals in the household must be treated. Environmental controls may be indicated if the infection is severe. If the animal is in intense discomfort or if secondary infections exist, corticosteroids, antihistamines or antibiotics may be indicated. Below is the treatment suggested by Birchard and Sherding: 1) Decreasing Allergic load (Flea Control) a. Environmental indoors and outdoors) treatment using the following compounds that have activity against flea eggs, larvae and pupae: chlorpyrifos, permethrin, or pyrehtrin in conjunction with a growth hormone regulator such as methoprine, fenoxycarb) Note: Cats are very sensitive to organophosphates b. Treatment of unaffected pets with adulticidal flea products lacking flea repellent effects: chlorpyrifos and permethrin as dips or sprays or foams Note: (permethrin dips can cause toxicity in cats) c. Treatment of Affected pets also with adulticidal flea products; use of systemic parasiticidal agents is not recommended as flea bites are required for their effectiveness 7) SARCOPTIC MANGE

Sarcoptic mange or scabies is caused by the mange mite, Sarcoptes scabiei var canis. It is a zoonotic disease, although infestations in humans are usually self-limiting. Sarcoptic mange can infect other animals including cats and ferrets. Sarcoptes is spread by direct contact. The adult mites burrow in the skin causing severe irritation and itching. Clinical signs include pruritus, papules, crusts, excoriations and secondary bacterial infections. The lesions usually develop on the legs, elbows, ears and face. The condition can become generalized. Asymptomatic carriers exist. Diagnosis is based on clinical signs and skin scrapings. Repeated deep scrapings must be performed in multiple location in order to discover mites. In some cases mites may not be found and based on clinical signs alone a therapeutic trail may be indicated. Treatment consists of dips that are effective against mites or Ivermectin (not an approved drug for this use). All animals and humans in the household may need to be treated

13

8)

DEMODECTIC MANGE

When found in large numbers, the mange mite, Demodex canis, causes demodecosis. The mites are normal inhabitants of the canine skin and usually do not cause disease. In individuals that are immunosupressed, the mites overpopulate and cause clinical signs of disease. There is evidence that there is a genetic predisposition for this problem. It is not a contagious disease. Clinical signs take on two manifestations, localized and generalized. Localized lesions usually occur on the head or feet and is seen in animals less than one year old. Alopecia, redness, crusts and papules characterize the lesions. The prognosis for localized demodecosis is good. Most cases resolve spontaneously. Generalized demodecosis has a much graver prognosis. Localized demodecosis can spread and become generalized. Generalized demodecosis affects the whole body and is characterized by alopecia, crusts, papules and pustules. Animals may be very ill with secondary pyoderma and lymphadenopathy. Some underlying systemic illness should be suspected. Diagnosis is based on clinical signs and skin scrapings. The mites are easily found. Treatment for localized lesions can be topical. Treatment for generalized demodecosis consists of whole body dips with amitraz. Success has been reported with ivermectin and milbemycin oxime. If secondary pyoderma exists, appropriate antibiotic treatment is indicated. Corticosteroids should be avoided. Demodecosis has been reported in cats. It is an uncommon disease. It is not caused by the same mite as demodecosis in dogs. Cats have their own species of mite, Demodex cati. 9) CHYLETIELLA

Chyletiella or walking dandruff causes dorsal scaling and itching in dogs and cats. It can spread to humans so it is a zoonotic disease. There are several mites involved; Chyletiella yasguri is the main culprit. Diagnosis is based on skin scrapings and the use of a flea comb or clear sticky tape to trap the mites. Treatment consists of weekly dips or oral Ivermectin. 10) NOTOEDRES CATI

Notoedres cati causes mange in cats. It is an uncommon disease. The mites will infest other animals including man so it is considered a zoonotic disease. The mite causes severe itching. Crusts and hair loss are seen mainly around the head and neck. Diagnosis is via skin scrapings. Treatment consists of lime-sulfur dips or oral Ivermectin. 11) OTODECTES CYANOTIS

Otodectes cyanotis causes otitis externa in dogs, cats and ferrets. In theory humans can also be infected although clinical cases have not been reported. Signs include head shaking, scratching, alopecia and erythema. Secondary trauma (hematomas) and infections are common. Diagnosis is based on cytology. The mites will be easily visible. Treatment consists of topical insecticides. 14

Unit 4 DISEASES OF THE EARS AND EYES

There are many diseases that affect dogs and cats. Only the three most common problems are included. Some eye and ear problems are symptoms or complications of a particular disease. Each disease will be discussed under the primary systems that they affect, for example, respiratory system. 1) ENTROPION

Entropion is an inherited problem of the eyelids. The lid margins roll inwards towards the cornea causing irritation, tearing and in some cases corneal ulceration and permanent eye damage. Diagnosis is based on physical exam findings. Surgical correction of the defect is usually required. It is a disease primarily seen in certain breeds of dogs such as Chows, Akitas and Shar-peis. 2) OTITIS EXTERNA

Otitis externa is an inflammation of the external ear canal. It is seen in both dogs and cats. It may be caused by a number of factors including parasites, allergies, autoimmune diseases, endocrinopathies, chemical irritation, yeast and bacterial infections. Clinical signs include redness, pain, swelling, itching, discharge, and foul smell of the ear. Diagnosis is based on clinical signs, cytology, culture and blood work. Treatment is based on the underlying cause. 3) GLAUCOMA

Glaucoma is a disease seen mainly in dogs. Dogs have the highest incidence of glaucoma, second only to man. It can be a primary problem or occur secondarily to an eye injury. The disease is characterized increased intra-ocular pressure that can lead to progressive damage of the retina and optic disk. The animal will eventually become blind. Clinical signs vary. The eyeball may be enlarged and painful. The sclera will have prominent blood vessels. The pupil will be dilated or respond sluggishly to light. The animal may be extremely painful. Diagnosis is based on tonometry, opthalmoscopy, goniospcopy, electroretinogram, and visual evoked potential. Treatment may include medical or surgical treatment or both.

UNIT 5 DISEASES OF THE MUSKULOSKELETAL SYSTEM

15

1)

PATELLAR LUXATION

Patellar luxation is a problem that is seen in both dogs and cats. Miniature breeds of dogs are especially affected. The patella (kneecap) slips out of place causing the animal pain. This slippage makes the joint unstable and, long-term, will lead to arthritic changes in the knee. There are a number of predisposing factors including trauma, obesity and a genetic predisposition. Diagnosis is based on clinical signs. The animal will be reluctant to bend its leg at the knee joint. On palpation, the knee can be manually popped in and out of the patellar groove. The knee may be very painful on palpation. The animal may have a "skipping" gait as the patella pops out of place on flexion and back into place on extension. Ideal treatment would consist of surgical correction of the defect known as: trochleoplasty; chondroplasty; wedge recession; patelloplasty or DeAngelis Technique (fabella to patella tendon). In some cases, medical management might be an option. Weight control and use of antiinflammatory and joint fluid modifying drugs may help. 2) CRUCIATE RUPURE

This is primarily a problem of dogs. Rupture of the cruciate ligament in the knee usually occurs post-trauma. The ligament that is torn is usually the anterior/cranial cruciate ligament. This ligament is responsible for stabilizing the knee. When the ligament is ruptured the knee becomes unstable leading to secondary osteoarthritis. Diagnosis is based on physical exam. The animal will be lame. The joint may show evidence of swelling and pain on palpation. While the animal is lying on its side the clinician should be able to elicit a cranial drawer sign. This is diagnostic for an ACL rupture. Treatment should consist of surgical correction. There are a number of surgical options available but the purpose of the procedure is to stabilize the knee, hopefully by mimicking the action of the ACL as closely as possible. The operations are: patellar tendon procedure; Fibular head transposition procedure; Fascial Strip Over-the-Top Procedure and the Imbrication Procedure. In some situations medical management may be attempted. This would consist of weight reduction, rest and the use of anti-inflammatory and joint modifying drugs. This may not be the ideal choice because even after the initial pain subsides the knee still remains unstable and arthritis will be a problem in the future. 3) HIP DYSPLASIA

Hip dysplasia is a complex disease that primarily affects middle to large sized breeds of dogs. Hip dysplasia has a genetic basis and the incidence of this disease in some breeds is very high. The main problem is that the hip (femoral head) does not fit properly into the hip socket (acetabulum). Because of the instability that is present, over time, arthritis develops. This leads to the clinical signs that most people are familiar with. The animal will have difficulty getting up, going up stairs and jumping up on to higher surfaces. The hind end may wobble or weave as the animal walks. There may be muscle wasting of the hind legs due to lack of use. The gait of a dyplastic dog is described as a "bunny hop". The animal is painful and so is reluctant to stride out. On physical 16

examination the clinician may find that the animal is very painful when the hip joint is manipulated. There may be a grating sound or feeling when the hip is swung through the range of motion. Range of motion may be limited. The hip may be so unstable that the clinician can actually "pop" the hip out of the socket (Ortolanis sign). Radiographs may help with making the diagnosis. It is important to note that clinical signs and radiographic findings do not always correlate. The animal may be extremely painful and show minimal radiographic changes while an animal that is not painful may have horrible hips radiographically. Treatment consists of several options. Medical management with anti-inflammatory and joint fluid modifying drugs, exercise restriction and weight control is a possibility in older animals that are not too severely affected. In younger animals a surgical option should be considered. Pelvic osteotomy (5-13 months old dogs), femoral head and neck excision arthroplasty (all ages but most successful in dogs <18 kg) pectineal myectomy (dogs of all ages); intertrochanteric osteotomy for dogs nearing skeletal maturity (6-8 mos);shelf orthoplasty and total hip replacement are all possibilities. The purpose of the surgery is to correct the instability that is present in the joint in order to prevent secondary osteoarthritis. In older animals that can not be managed medically, a total hip replacement or in some cases, a femoral head ostecotmy should be considered. Many conscientious breeders are attempting to reduce the incidence of this disease in their breeds. Animals of breeding age have ventral-dorsal (VD) radiographs of their hips taken and evaluated prior to including them in a breeding program. Breeding animals are re-evaluated every two years (Orthopedic Foundation for Animals or OFA). A newer radiographic procedure (Penn Hip) allows evaluation of puppies prior to purchase. Even with these precautions, there will be dysplastic animals. The gene that causes hip dysplasia is a multiple allele gene. This means that the parents can be totally normal radiographically and yet still produce dysplastic puppies! Most reputable breeders will offer a replacement guarantee knowing that despite their best efforts, some animals may still have problems. 4) OSTEOMYELITIS

Osteomyelitis is an infection of the bone and soft tissue elements of marrow, endosteu;m, periosteum and vascular channels. There are two main ways that this can occur. The first is thorough trauma to the bone (such as in the case of an open fracture) and infection develops. The second most common cause of osteomyelitis is iatrogenic. This means that we cause the infection. It would occur secondary to surgery and the use of improper sterile technique. Osteomyelitis is difficult to treat and requires long-term antibiotic therapy. In situations where bone is exposed surgically, very careful attention to proper technique should be observed. The etiology are: bacteria predominantly with beta-lactamase-producing Staphylococcus organisms; fungi after pulmonary inoculation; corrosion of implants that cause a sterile inflammatory response with localized bone lysis and a draining tract occur. 5) OSTEOCHONDROSIS

17

Osteochondrosis is a problem of development of the cartilage. It can be seen in the hock, shoulder, elbow and stifle. It is a disease seen in middle to large breed rapidly growing dogs. It is believed to have a genetic basis. Defects in cartilage development lead to an uneven joint surface and many fragments. This uneven surface and the presence of debris in the joints causes arthritis to develop. The animal will be lame and painful on manipulation of the joint. Radiographs of the affected joint may help to establish the diagnosis. More than one joint may be affected. Treatment consists of surgically removing any cartilage debris or loose cartilage flaps. The use of anti-inflammatory and joint fluid modifying drugs also helps.

UNIT 6 BLOOD, LYMPHATIC AND CARDIOVASCULAR SYSTEMS

1) CARDIAC INSUFFICIENCY AND CARDIAC FAILURE

The most common cause of cardiac insufficiency in dogs is mitral valve disease. The valves fail to properly close causing regurgitation (back flow) of blood. This regurgitation will cause turbulence and the clinician should be able to hear a holosystolic murmur. The back flow of blood will also cause increased pressure in the left atrium and ventricle and the pulmonary veins. This increased pressure will cause fluid to accumulate in the lungs causing pulmonary edema. The animal may cough, have exercise intolerance or in some cases, syncope. Its mucous membranes may be blue or gray colored and it will have a delayed capillary refill time. Diagnosis is based on history, physical exam, chest radiographs, electrocardiogram and echocardiography. There are definite breed predisposition for certain cardiac diseases so patient signalment may be extremely helpful. Treatment depends on the stage of the disease. Diuretics may be used to decrease pulmonary edema. Digitalis glycosides are used to help increase the force of cardiac contraction. After-load reducers such as Enalapril are used to decrease hypertension. Antiarryhtmics may be indicated as well. Many animals survive for years with appropriate medical therapy. 2) CARDIOMYOPATHY

Cardiomyopathy is a disease of the heart muscle itself. The heart looses its ability to contract effectively. There are many different causes of cardiomyopathy. The cause of dilated cardiomyopathy in most cases is unknown. This form of the disease is seen most frequently in large breed dogs. Hypertrophic cardiomyopathy is seen most frequently in cats. The cause is also unknown. Clinical signs include weakness, exercise intolerance, coughing and collapse. A murmur may be heard. In cats a gallop rhythm may develop (third heart sound). Diagnosis is based on history, physical exam, chest radiographs, electrocardiogram and echocardiography. Echocardiography can be especially helpful because it allows visualization of the heart chamber walls and valves. 18

Treatment consists of the use of diuretics, digitalis glycosides and vasodilators. Prognosis is guarded. Survival rates are usually brief even with aggressive treatment and range from two months to two years. 3) LYMPHOMA/LYMPHOSARCOMA

Lymphosarcoma occurs in both dogs and cats. In cats, the underlying cause is infection with Feline Leukemia Virus. In dogs the cause is not known. There is an increased incidence of this disease in certain breeds such as Golden Retrievers, Boxers and Basset Hounds. A genetic predisposition or basis for this disease in dogs is suspected. Clinical signs are extremely variable and depend on the anatomical site affected by the malignancy. In dogs, the most common form is the multi-centric. The dog will present with generalized enlarged lymph nodes. In cats, the gastrointestinal and mediastinal forms predominate. With the gastrointestinal form the cat may present with weight loss, anorexia, vomiting, diarrhea and abdominal distention. With mediastinal form, respiratory signs will be seen. Diagnosis is based on clinical signs. Further tests that might be indicated include biopsy, cytology, blood work, radiographs and ultrasonography. Treatment depends on the location and stage of the disease. Surgical excision is an option if the malignancy is limited to a single site. Chemotherapy helps but survival time is limited to 6-12 months. 4) HEMANGIOSARCOMA

Hemangiosarcoma is an aggressive soft tissue tumor that may arise spontaneously or due to sun exposure. They metastasize easily. This type of tumor is common in large breed dogs especially German Shepherds and Golden Retrievers. Th most common sites for occurrence include the extremities and the spleen. Diagnosis is based on physical exam, radiographs and biopsy. Excision is the treatment of choice. Survival rates depend on the presence or absence of metastasis. 5) VON WILLEBRANDS DISEASE

Von Willebrands disease is an inherited deficiency of Factor VIII related antigen. Factor VIII related antigen aids in platelet adhesion and slows clearance of Factor VIII from circulation. It is a genetic disease that has been described in many animal species. It is seen most frequently in dogs and has been described in over 54 breeds. There is a high incidence of this problem in Dobermans, Shelties and Scottish Terriers. The animal usually does not exhibit clinical sign until after a surgery or trauma when prolonged bleeding occurs. The animal will have an adequate platelet count and normal clotting times. The buccal mucosa bleeding time may be used as a screening test or as a diagnostic test. Affected animals will have a prolonged bleeding time, however, this test is not always accurate. VonWillebrands Factor assay is the best way to detect and quantify the problem. Treatment, if necessary, consists of fresh or fresh frozen plasma transfusion or if the animal has bled profusely, whole blood transfusion.

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6)

HEMOPHILIA

Hemophilia is a deficiency of either Factor VIII (hemophilia A) or Factor IX (hemophilia B). It is a genetic disease that has been reported in dogs, cats, humans, and horses. The defect is carried on the X chromosome so it is a sex-linked trait. Females are usually asymptomatic carriers and males are affected with clinical signs. Carriers are difficult to detect. Animals with hemophilia can not clot and will spontaneously bleed. Bleeding may not occur until after an injury or surgery. Clotting times are prolonged (ACT & APTT). Treatment consists of transfusion of fresh or fresh frozen plasma or whole blood. The animal is transfused 2-3 times a day until the bleeding stops. 7) CONGENITAL DEFECTS OF THE HEART

The most frequently detected cardiac defects are septal defects (atrial or ventricular) and patent ductus arteriosus (PDA) and are reported mainly in dogs. Patent ductus arteriosus is the most common problem and occurs when the shunt between the aorta and pulmonary trunk fails to close at birth. Abnormal shunting of blood from the left side of the heart to the right side of the heart leads to a volume overload, pulmonary congestion and ultimately heart failure. A continuous "machinery murmur" may be detected by the clinician Echocardiography will help to determine the diagnosis. Animals may survive for years with medical management depending on the severity of the defect. Surgical correction is the best choice for long-term survival.

Unit 7 RESPIRATORY SYSTEM

Most common respiratory diseases of cats and dogs are of viral or bacterial etiology and will be discussed in detail under the unit on infectious diseases. Here are some important definitions: Hemothorax: blood in the chest. Seen most commonly post-trauma such as a hit-by car. Pyothorax: pus in the chest. Seen most commonly after a penetrating injury to the chest. This is a frequently seen syndrome in intact male cats post cat-fights. Pneumothorax: air in the chest. Seen most commonly post-trauma. Chylothorax: chyle or lymph in the chest. This occurs because of a rupture of the thoracic duct often after being hit-by-car or in the case of cats, being kicked.

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Unit 8 DIGESTIVE SYSTEM

1) EOSINOPHILIC GRANULOMA COMPLEX

Eosinophilic granuloma complex is a hypersensitivity reaction that has been reported in cats, dogs and horses. It is most commonly seen in cats. Sensitivities to insects, foods, bacteria and other environmental factors have been documented. There is a genetic predisposition to this disease although the cause of many cases remains undetermined (idiopathic). Cats may develop ulcers, plaques or granulomas. Common sites include the lips, thighs and pads of the feet. In dogs most lesions are seen in the mouth. Siberian Huskies are the breed most likely to be affected. Diagnosis is based on the typical appearance (ulcer, plaque or granuloma) and location of the lesions. Biopsy of the lesion with histopathology is helpful. Histopathology will show inflammation with a high number of monocytes, plasma cells and neutrophils. Eosinophils may or may not be present on the tissue biopsy. There is usually a peripheral eosinophilia. Like any disease of an allergic nature, the emphasis should be on eliminating the allergen from the environment if possible. Insect control and dietary trials are indicated. Allergy testing and hyposensitization would be the next step if necessary. Antibiotics should be utilized in nonresponsive cases. If the cause remains undiagnosed the use of steroids and other anti-inflammatory drugs can be used to treat the symptoms.

2)

GASTRIC DILATATION-VOLVULUS

Gastric dilatation-volvulus occurs primarily in large breed dogs such as German Shepherds, Great Danes, Irish Setters, Doberman Pinschers and Standard Poodles. It is a life-threatening emergency that involves the torsion (twisting) of the stomach on its axis and the accumulation of gas in the stomach. This twisting and bloating can cut off the blood to supply to vital organs and lead to death. The exact cause of this disease is not known. There may be a genetic or familial predisposition but this has not been proven. Diagnosis is based on physical examination and radiographs. The animal will show signs of restlessness and pain. The abdomen may be grossly distended. The dog may drool, gag and have dry heaves. As the disease progresses the animal will go into shock. Heart rate will be elevated, body temperature will fall, mucus membranes will be gray or muddy and capillary refill time will be delayed. Radiographs will show a rotation of the stomach over to the right side of the body (the right lateral abdominal view is preferred). Treatment is geared towards the treatment of shock and stabilization of the patient before taking it to surgery. This includes the placement of catheters, fluid administration, decompression of the 21

stomach, administration of steroids and other anti-shock therapy. Surgical correction of the volvulus is indicated (gastropexy). Several different methods of surgical correction are used and all seem to have approximately the same success rate. If the animal is only managed medically the chances of reoccurrence are about 75%. Surgical correction offers a 5-11% reoccurrence rate. This is a serious disease. Approximately 70% of the animal die even with aggressive therapy. 3) PANCREATITIS

Pancreatitis is a disease that is seen most often in middle aged, obese, female dogs. It is also reported in cats. The exact cause of this disease is not known. It is thought that a high fat diet predisposes an animal to developing pancreatitis. Basically there is a change in cell membrane and vascular permeability and pancreatic enzymes leak out. The enzyme causes tissue damage and necrosis and the pancreas digests itself. Signs of this disease are extremely variable and often non-specific. The animal may have vomiting, diarrhea, abdominal pain, abdominal distention, depression, anorexia, fever, dehydration and icterus. Diagnosis is based on clinical signs and confirmed with a hemogram, blood chemistries (amylase and lipase levels), radiographs and ultrasonography. Therapy Fluid therapy and pain relief are the cornerstones in supportive care. Concurrent problems (such as lipidosis or enteritis) need to be addressed. Feed; do not fast, unless animal is vomiting. Even with the vomiting animal, designing a nutritionally supportive protocol is of great importance especially to cats due to this species predisposition for developing lipidosis. Thus, cats should be fasted for no longer than 48 hours utilizing anti-emetics as necessary. In the few intractably vomiting cats, total parenteral nutrition or jejunostomy tube feeding may be advisable for 710 days. Trickle feeding: For animals requiring nutritional support, but who are vomiting, it is useful to know about trickle feeding. This is a spin-off of the technique of parenteral/IV feeding that has been adapted to enteral (i.e., GI) feeding. If an animal with an esophageal or gastrostomy tube vomits whenever the volume fed is more than a ridiculously small amount then trickle feeding is the answer. Anti-emetics: When the use of anti-emetics is being considered it should be noted that the liver metabolizes these agents, so their clearance rates may be decreased. Doses should be reduced accordingly. Generic Name Product Dose (feline) Chlorpromazine Thorazine, Largactil0.5 mg/kg q8h IM ProchlorpromazineCompazine 0.1 mg/kg q6h IM Diphenhydramine Benadryl 2.04.0 mg/kg q8h PO, 2.0 mg/kg q8h IM Dimenhydrinate Dramamine 8.0 mg/kg q8h PO ProchlorpromazineDarbazine 0.50.8 mg/kg q12h IM, SQ + Isopropamide 22

Metoclopramide Ondansentron Dolasetron

Reglan Zofran Anzemet

12 mg/kg constant rate infusion IV over 24 hours 0.10.15 mg/kg slow push IV q612 hours prn 0.6 mg/kg IV q24h

Also of critical importance are: analgesics for the comfort of the patient, a test dose of 0.10.2 mg/kg oxymorphone IV to see if the patient improves over the approximately four hour effective period. If that is the case, then constant rate infusion of a narcotic may be considered or a transdermal fentanyl patch (Duragesic) for continuous relief. Corticosteroids are indicated in an acute shock presentation. Other anti-inflammatories are not currently recommended; nor have any benefits been seen with the use of antacids, anticholinergics, GI hormones (somtostatin, glucagon), or calcitonin. Dopamine has been useful in acute experimental feline pancreatitis. Metronidazazole may be useful for both its immunomodulatory and antimicrobial effects. Antibiotics are only indicated if the diagnosis of a suppurative pancreatitis has been made. In this case, antimicrobial selection is best made with the knowledge of a sensitivity spectrum. Note that a suppurative pattern may be seen on histology in a sterile pancreatitis caused by enzyme damage. Complications of ACUTE pancreatitis that may arise include DIC, thromboembolism, cardiac arrhythmia, sepsis, acute tubular necrosis, pulmonary edema, and pleural effusion. It has been suggested that a low dose of dopamine (5 mcg/kg/min) diminishes the severity of the disease. To prevent bacterial translocation, cover these patients with broad-spectrum antibiotics.

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Prognosis Prognosis depends on the type of pancreatitis as well as the degree of duration and severity. Many cats have chronic, low-grade smoldering pancreatitis and with accurate diagnosis and appropriate therapy, can live long lives. Treatment is geared towards resting the pancreas and supportive care. The patient should not be given anything to eat or drink for at least several days depending on the severity of the disease. If necessary the animal can be kept off of food for weeks and supported with parenteral nutrition or a jejunostomy tube that by passes the pancreas. Intravenous fluids, histamine blockers, analgesics and antibiotics should be provided. The prognosis can be very poor. If the animal is caught in the early stages, the chances for survival improve. Relapses are common. 4) INTESTINAL PARASITES

Roundworms are common especially in puppies and kittens. They are a zoonotic disease and can cause visceral larval migrans and occular larval migrans in humans. Toxocara canis is the most important because of its pathogenicity. T canis can be transferred transplacentally, via ingestion and transmammary. T cati can only be transmitted via ingestion or transmammary while T leonina is transmitted only by ingestion. With T. canis, puppies as young as 1 week of age will already have parasites present in their intestinal tracts. Puppies and kittens typically develop a pot-bellied appearance and are "poor doers". They may vomit worms or pass them in their feces. The animals may have diarrhea and coughing (from migrating larvae). The parasites may cause intestinal blockage, pneumonia and death. Diagnosis is based on clinical signs, the presence of worms in the vomitus or stool or the detection of eggs on fecal examination. There are numerous excellent worming medications available. Puppies and kittens should be dewormed starting at 2 weeks of age and dewormed every 2 weeks until they reach 12-16 weeks of age. Adult animals should have a fecal check performed every six months and dewormed if necessary. Hookworms are common in warmer climates. Ancylostoma caninum is the main culprit. Uncinaria stenocephala, Ancylostoma tubaeforme and Ancylostoma braziliense can also cause problems. A. caninum is transmitted via ingestion, skin penetration and transmammary. Hookworm larvae can also penetrate the skin of man causing coetaneous larval migrans or eosinophilic enteritis. These parasites are blood suckers so infected animals become anemic, hypoprotenimc, lethargic malnourished and may have tarry stool. Dermatitis and pneumonia may also be seen. Diagnosis is based on clinical signs and the detection of parasite eggs on fecal examination. Treatment is with any one of a number of deworming medications. The same schedule should be followed as is recommended for the treatment of roundworms.

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Whipworms are not as common a problem as hooks and roundworms. Transmission of Trichuris vulpis is by ingestion. These parasites cause GI upset with weight loss, diarrhea and occasional fresh blood in the stool. Although These parasites have occasionally been associated with eosinophilic enteritis in man. The eggs of this parasite can survive in the environment for up to 5 years so environmental control is essential. Whipworms have a long life cycle (12 weeks) so effective control depends on giving the patient medication at least twice at 6-12 week intervals. Tapeworms are often seen in dogs and cats. All rely on an intermediate host for transmission. Dipylidium caninum is the most common tapeworm and is transmitted by fleas. Taenia taeniaefomis is seen in cats and depends on mice and rats for transmission. Echinoccocus may be seen in dogs that have access to carcasses. Tapeworms rarely cause any signs of disease in dogs or cats. Owners often report the problem when they see white egg packets in their pets stool. Echinoccocus is a major zoonotic concerm as humans can develop metacestodes (Hydatid Cyst Disease) from these tapeworms. Treatment can be accomplished with a one-time administration of a deworming medication such as Praziquantel. Owners should limit their pets access to the intermediate host. Flea control is indicated as well. Feline GI Pearls Inflammation is often characterized by infiltration of lymphocytes and plasma cells in many feline conditions: inflammatory bowel diseases, pancreatitis, cholangiohepatitis, triaditis, and stomatitis. Inflammation of any of these tissues may also be suppurative in nature or even granulomatous, but lymphocytic/plasmacytic (l/p) infiltrates are most common. This implies the presence of antigenic stimulation chronically and has implications in the therapeutic approach to any of these conditions. 6) IBD Inflammatory Bowel Disease may cause vomiting, diarrhea, both or neither in cats. Symptoms seen depend on the degree of inflammation and impairment of absorption as well as the location (where and how much) of the inflammatory lesions. Gastric inflammatory changes and those in the upper small intestines will be likely to cause vomiting. Colitis in the cat may also cause vomiting. Occasionally cats will be asymptomatic other than weight loss. Palpably thickened intestinal loops may be present and enlargement of the mesenteric lymph node may be noted. Mild dehydration may be evident. Folate and cobalamin. Cats, unlike dogs, do not appear to develop small intestinal bacterial overgrowth (SIBO), rather, the normal cat has a much higher population of GI flora than does that of dogs. Thus, subnormal folate levels are not indicative of SIBO in cats; however, folate deficiency may occur with severe, chronic malabsorptive proximal small intestinal disease. In addition, 50% of cats with exocrine pancreatic insufficiency (EPI) have subnormal folate levels. Cobalamin deficiency is most likely the result of malabsorption secondary to EPI in cats. Some cats with 25

chronic intestinal disease (e.g., triaditis or "IBD" may be deficient in either of these vitamins and may benefit by supplementation if their assays verify subnormal levels. 7) CHOLANGITIS/CHOLANGIOHEPATITIS COMPLEX (CCHC) Inflammation of the biliary tree and/or liver parenchyma may be suppurative or non-suppurative. The non-suppurative form is more common and is often lymphocytic/plasmacytic in character. The clinical presentation includes a vague history of inappetance/anorexia OR polyphagia, lethargy, as well as possibly nausea, vomiting, diarrhea and weight loss. The signs may have a chronic intermittent occurrence. On physical examination, signs of dehydration, weight loss, muscle wasting, icterus, salivation, palpable liver margins, cranial abdominal tenderness or firmness may be present. Suppurative and non-suppurative CCHC cannot be differentiated based on history and physical examination alone; both forms may or may not present with an elevated temperature. Biopsy is required for differentiation. Wedge biopsy provides necessary architectural information that a Tru-cut or fine needle aspirate doesnt. Cats with CCHC often have hyperbilirubinemia and bilirubinuria, but these do not differentiate the conditions from other hepatic, pre-hepatic or post-hepatic causes of icterus. In patients with bilirubinuria, lack of urobilinogen should increase suspicion of extra-hepatic bile duct obstruction. Increases in activities of serum alkaline phosphatase (ALP), alanine transferase (ALT), and gamma glutamyl transferase (GGT) may be present to varying degrees but do not distinguish between suppurative and non-suppurative CCHC. Cats with hepatic lipidosis usually have markedly increased ALP activity compared to ALT activity and have normal GGT activity. In contrast, cats with CCHC usually have ALP and ALT increases of equal magnitude or the increase in ALT is greater than ALP; GGT activity is usually increased as well. Bilirubinuria is ALWAYS significant in the cat. It is important to realize that some patients may have chronic CCHC resulting in decreased functional liver mass and therefore no increases in ALT, ALP, or bilirubin may occur. There may be variable changes in albumin, glucose, BUN, and cholesterol. If you believe that liver disease is possible, a liver function test is indicated. Use the combination of pre- and post-prandial serum bile acid measurement to assess liver function. With cirrhosis, penacillamine or methotrexate may be beneficial in reducing the progression of fibrosis. Hepatic biopsy is preferred over FNA or Tru-cut biopsy. With FNA, not only are you restricted in what you harvest, but also the condition of that sample is mutilated by the aspiration action and slide preparation. Some types of cells do not exfoliate readily (mesenchymal neoplasias such as fibrosarcoma, for example); with FNA, you only get a cytological diagnosis of whatever cells are sampled easily and may not get a real picture of the underlying disease process. Additionally, orientation of the cellular reaction within tissue is critical in differentiating what role neutrophils or lymphocytes play. For example, peribiliary inflammation and periportal inflammation define different disease processes and may indicate different therapy and different prognosis. Vitamin K1. Fifty percent of cats with HL have prolonged PIVKA (Proteins Induced in Vitamin K Absence or Antagonism) times or other prolonged coagulation tests and require vitamin K1 therapy. It takes cats < 7 days to become vitamin K deficient. Cats who have been on antibiotics may have fewer organisms in their bowels to make vitamin K. Vitamin K is absorbed in the proximal small bowel and recycled by the liver (via the vitamin K epoxidase cycle). Thus, in small 26

bowel disease (such as IBD induced fat malabsorption), as well as in liver diseases (especially in hepatic lipidosis), low vitamin K levels may predispose to occult coagulopathies. Factors II, VII, IX and X, as well as protein C and protein S (antithrombotic proteins), are vitamin K dependent. If the patient is jaundiced or nauseous, then the vitamin K1 must be given SC rather than orally because intestinal absorption is poor (0.51.0 mg/kg q24h X 34 days or until coagulation normalizes). If too much vitamin K1 is given, an oxidative toxicity may develop and supplementation of vitamin E as an antioxidant may be required. 8) TRIADITIS Unlike the dog, in the cat, the pancreatic duct enters the common bile duct before it opens into the duodenum. When there is disease (e.g., inflammation, infection, neoplasia, stasis) in the small bowel, it may ascend into the common bile duct and, from there, affect the pancreas and the rest of the biliary tree. Similarly, disease in the biliary tree or pancreas may affect the other two regions. When this occurs, it is termed triaditis. This complex is so common, that ultrasonographic evaluation of the abdomen is very helpful to try to determine which organs are involved. 9) CHOLECYSTITIS Cholecystitis generally presents as a vague malaise with inappetance and dehydration, (pretty much like everything else in the cat). Vomiting may be present. While this too may involve a lymphocytic/plasmacytic inflammatory infiltrate of the gall bladder wall, it more often is suppurative. If surgical evaluation occurs, and the gall bladder looks inflamed or if it does not compress and empty normally, or if ultrasound is suggestive of cholecystitis, bile aspiration and culture (aerobic and anaerobic) should be performed. 10) EXTRA HEPATIC BILE DUCT OBSTRUCTION (EHBDO) This is a cause for acute onset of vomiting and malaise in a patient. Plain radiographs may show a radiodense object in the region of the gall bladder; ultrasound confirms that the location is the bile duct, as well is able to detect inspisations that are not radiodense. A urinalysis detects this problem early, as there will be the presence of bilirubin but a lack of urobilinogen in the sample. Blood work will show a marked increase in bilirubin and eventually cholestasis and some hepatocellular injury (increased ALT). This constitutes an emergency and requires surgical correction. 11) GASTROINTESTINAL (GI) LYMPHOMA

Lymphoma is the most common form of GI neoplasia in cats. In the past, alimentary lymphoma has been given a poor/grave prognosis in most of the literature. LymphoCYTIC GI lymphoma is readily treated using prednisone and clorambucil. The median disease free interval was 20.5 months (range 5.849 months). Rescue is achieved with cyclophosphamide. Cats with lymphoBLASTIC lymphoma respond poorly to chemotherapy using either CVP (cyclophosphamide, vincristine, pred) or ACOPA (CVP + doxorubricin and Lasparaginase). Of interest also is the observation that cats with lymphoBLASTIC lymphoma are more likely to have recurrences of abdominal masses. GI biopsies. Good quality biopsy samples are essential. Diagnostically, more is better. Endoscopy is a tool with advantages and disadvantages. The biggest problem with endoscopy is the limited 27

areas one can visualize and the limitations of partial thickness biopsy. GI lymphoma may be patchy, may be limited to the serosal and muscularis layers of the bowel, can be missed, and the remaining tissue may have lymphocytic/plasmacytic infiltrates and be interpreted as IBD. In addition, it is important to recognize that severe IBD may progress to lymphoma. Thus, it is important to make a definitive diagnosis of IBD early on and suppress the inflammatory response. Endoscopy. In a retrospective study comparing radiographic, ultrasonographic and endoscopic findings in cats with upper GI IBD, it was found that the clinical signs and ultrasound findings correlated best with histologic grade of IBD and that ultrasound identified more abnormalities than upper GI endoscopy.

Unit 9 REPRODUCTIVE AND URINARY SYSTEMS

1) PYOMETRA

Pyometra is a bacterial infection of the uterus characterized by a purulent discharge from the vulva. I t can affect both dogs and cats but is much more common in dogs. Animals that are prone to pseudopregnancy, that are older or that have received mismating shots (estrogen) are more likely to be affected. The organism that is most often involved in uterine infections is E. coli. Diagnosis is fairly easy when the condition is "open" with actual pus draining from the open cervix. The diagnosis can be much more difficult if it is a "closed" pyometra with no visible uterine discharge. Animals will be anorectic, depressed and may have abdominal distention. They may exhibit signs of polyuria, polydypsia and vomiting. They may or may not have a fever. Leukcoytosis is common. Treatment involves providing supportive care and performing an ovariohysterectomy as soon as it is safe for the animal to undergo anesthesia. In animals that must be salvaged for breeding purposes, prostaglandins may be used to empty the uterus and antibiotics initiated based on culture and sensitivity. There is increased risk to the patient with medical management and a reoccurrence of the pyometra is likely. 2) PSEUDOPREGNANCY OR FALSE PREGNANCY

Pseudopregnancy occurs at the end of diestrus and is caused by lowered progesterone levels. It is common in dogs. Bitches may actually lactate, act restless, exhibit nesting behavior and "adopt" an object to take the place of a pup. Medical treatment is not recommended nor is it necessary. Pseudopregnancy will resolve spontaneously within 2-3 weeks. If the owner is distressed by the changes in their pets behavior, they should have an ovariohysterecotmy performed. There is some evidence that pseudopregnancy predisposes the animal to pyometra.

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3)

CRYPTORCHIDISM

Cryptorchidism is a hereditary condition seen in dogs and cats. It is a more common problem in dogs. One (unilateral) or both (bilateral) testes may fail to descend. In order for propre sperm production to occur, the testis must be at temperatures 1-8 degrees lower than normal body temperature. Bilateral cryptorchidism renders the male infertile. Unilateral cyrptorchids can still produce viable sperm from the one descended testis. The testicles continue to produce testosterone no matter what their anatomical location, so cryptrochid males will have normal secondary sexual characteristics and mating behavior. The location of the undescended testis can be anywhere from immediately caudal to the kidney to just outside the scrotum in the inguinal ring. These animals should not be used for breeding, as the condition is hereditary. In addition, there is an increased risk of cancer developing in the undescended testis (Sertoli Cell Tumor). These animals should be castrated. 4) FELINE UROLOGIC SYNDROME (FUS) OR FELINE LOWER URINARY TRACT DISEASE (FLUTD) This is a common problem of cats characterized by straining to urinate (stranguria), blood in the urine (hematuria) and urinating in small quantities, frequently (pollakiuria). Cats may also urinate in unusual places (kitchen sink, bathroom floor, etc). The causes of lower urinary tract diseases are numerous and often the actual underlying cause may not be identified. There is however, a wellknown syndrome in cats that involves the presence of sand and stones (urolithiasis) in the urine. Feline urolithiasis occurs in both male and female cats but males are at greater risk of obstruction due to the longer and narrower diameter of their urethra. The uroliths are usually composed of struvite crystal with a variable amount of gelatinous material mixed in. A smaller percentage is composed of calcium oxalate. Diagnosis is based on clinical signs and confirmed with a urinalysis. Additional diagnostics may be required for refractory cases and would include chemical testing of the uroliths, radiographs and ultrasonography. Treatment consist of supportive care, antibiotics IF an infection is present, reduction of magnesium in the diet and reducing the urine pH to less than 6 (prescription diets). If the animal is blocked, more aggressive therapy will be required to remove the urethral plug and restore urinary output. Blocked cats can rapidly become extremely ill and die.

5)

RENAL FAILURE OR INSUFFICIENCY

Renal failure can be acute (anti-freeze toxicity) or chronic (any one of numerous causes of renal disease). The goals in acute renal failure is to prevent further damage to the kidneys while supporting the patient long enough to allow recovery. The goal in chronic renal failure it to treat what ever the underlying cause was that precipitated the event while trying to re-establish homeostasis. 29

Signs include polyuria, polydipsia, vomiting, weight loss, anorexia, dehydration, diarrhea and oral ulceration. Blood work will show increased blood urea nitrogen (BUN), creatinine and phosphorous. In some chronic cases, anemia may be present. Urinalysis will show a decreased specific gravity. Care must be taken to rule out any one of a number of diseases that can cause similar clinical signs. Prognosis depends on the underlying cause. In acute renal failure the prognosis is good if the underlying cause can be identified quickly enough and treatment initiated. In chronic renal failure, the prognosis is dependent on the rate of progression of the disease. Some animals live comfortably for years. 6) PROSTATITIS

Enlargement of the prostate gland may be due to benign hyperplasia, bacterial infection or occasionally cancer. Bacterial infection is most commonly associated with E. coli. Clinical signs include tenesmus (straining to defecate), hematuria, difficulty urinating (stranguria), depression, pain and fever. Diagnosis is based on clinical signs, abdominal and rectal palpation, aspirates of the prostate, evaluation of ejaculate, culture and sensitivity, blood work, radiographs and ultrasonography. Treatment consists of long-term antibiotics that have been selected based on culture and sensitivity. Castration may help by promoting involution of the prostate. Prognosis is guarded. Prostatitis can be difficult to resolve.

Unit 10 NERVOUS SYSTEM

1) INTERVERTEBRAL DISK DISEASE

Intervertebral disk disease affects primarily dogs. There is a genetic predisposition for this disease in certain breeds such as Dachshund, Corgis, Shih Tzu, Pekingese, Lhasa Apso and Basset Hounds (dogs with long backs). The signs are variable but include pain at the herniation site, paresis, flaccid or rigid paraplegia, arched back, reluctance to move, weakness, fecal and/or urinary retention. Diagnosis is based on clinical signs and a through neurologic examination. Radiographs and/or a myelogram can help in establishing the diagnosis. Treatment for mild cases may include cage rest, anti-inflammatory drugs and pain medication. In severely affected animals, surgery is the only option. If the animal is caught early enough before spinal cord damage has occurred, the prognosis is good.

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2)

CERVICAL INSTABILITY "WOBBLER"

Wobbler is caused by spinal cord compression from cervical vertebrae instability. It is a disease primarily of large breed dogs such as Great Danes and Dobermans. There is a suspected genetic predisposition to this problem. Clinical signs include inability to properly place feet (proprioceptive deficits), paresis and paralysis (may affect front, back or all four feet). Animals may be painful in the neck and resist neck manipulation. Diagnosis is based on clinical signs. Radiographs and/or a myelogram may be helpful. Treatment is symptomatic and includes anti-inflammatory drugs and pain medication. The dog should be restrained using a chest harness and not a halter or collar. If the condition is severe, surgery to stabilize the cervical vertebrae may be the only option. The prognosis is guarded. 3) EPILEPSY

Epilepsy is a disease characterized by recurrent seizures. There is usually no detectable brain lesion. The cause of the disease is unknown. It is known to be inherited in many breeds of dogs including Golden Retrievers, Labrador Retrievers, German Shepherds, Shetland Sheepdogs, Saint Bernards and many other breeds. Males appear to be more commonly affected than females. Typically animals will have generalized convulsive seizures. The seizures are more likely to occur when the animal is resting at night or early in the morning. The dog will become stiff, fall over, paddle, vocalize, chomp, urinate, defecate and salivate. The seizure may last for seconds or for minutes. Diagnosis is based on clinical signs and the ruling out of all other possible causes of "seizures". Realize that the owner may inaccurately identify collapse from cyanosis, renal failure, etc. as "seizures". A complete medical work up including bloodwork should be performed on these animals. Treatment is based in the severity of the seizures. If the dog only seizes occasionally (1x/3 months) then treatment may not be indicated. If the seizures occur on a regular basis, treatment with Phenobarbital +/- potassium bromide is indicated. Treatment is for the life of the animal. In some situations an animal may have prolonged or repeated seizures (clusters). These animals may require emergency treatment with intravenous anti-seizure drugs to control the seizures. Animals that begin seizing after 2 years of age and that do not exhibit cluster seizures usually respond well to treatment and have a good prognosis. Animals that begin seizing before 2 years of age or that have cluster seizures have a much more guarded prognosis.

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Unit 11 ENDOCRINE SYSTEM

1) HYPOTHYROIDISM

Hypothyroidism is the most commonly diagnosed endocrinopathy in dogs. It is caused by a deficiency of thyroid hormones and is characterized by a low metabolic rate. It is seen primarily in dogs. There is a breed predisposition to this disease. Breeds most commonly affected include Golden Retrievers, Shetland Sheepdogs, Schnauzers as well as others. Females are more likely to be affected than males. The actual cause of the disease is suspected to be immune mediated. Clinical signs include weight gain, heat seeking behavior, exercise intolerance, hair loss, dull hair coat and increased incidence of pyoderma. Bloodwork may show anemia and hyperlipidemia. Diagnosis is based on clinical signs and the result of thyroid hormone assays. Treatment consists of thyroid hormone replacement therapy and treatment of any underlying infections with antibiotics. Response to treatment is gradual and may take up to 3 months before improvement is noted. Prognosis is excellent but treatment must continue for the life of the dog. 2) HYPERTHYROIDISM

Hyperthyroidism is the most commonly diagnosed endocrinopathy of cats. It is caused by excess production of thyroid hormone from hyperfunctioning nodules in the thyroid gland. These nodules are benign in 98% of the cases. Clinical signs include poor appearance and body condition, hyperactivity, tachycardia, gallop rhythm and heart murmur. Blood work may show evidence of elevated liver and kidney values associated with some of the more severe complications of hyperthyroidism. There are several treatment options. Medical treatment involves the use of methimazole (Tapazole) to shrink the thyroid gland. Methimazole is associated with undesirable side effects. Radiotherapy involves the use of radioiodine to shrink the thyroid gland. Access to appropriate facilities for this treatment may be a problem. Surgical therapy involves the surgical removal of the thyroid gland. This procedure involves some risk form anesthesia as well as possible surgical complications. Radiotherapy is the best choice for the patient. Prognosis depends on the stage at which the disease is diagnosed. The earlier treatment is received the better the prognosis. In uncomplicated cases the prognosis is excellent. 3) DIABETES MELLITUS

Diabetes mellitus is a fairly common endocrinopathy that affect both dogs and cats. It is usually caused by a deficiency of insulin. It is seen more commonly in certain breeds of dogs such as

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Terriers, Poodles Dachshunds and Schnauzers. Diabetes is more common in female dogs and in male cats. Clinical signs include polyuria, polydipsia, inappropriate urination, weight loss, polyphagia, vomiting, anorexia, depression, obesity, muscle wasting, jaundice, cataracts and hepapatomegally. Diagnosis is based on clinical signs. Blood work will help in establishing the diagnosis. Fasting blood glucose levels will be greater than 200mg/% in the dog and 250mg/% in the cat. Glucosuria will also be present. Treatment consists of twice a day administration of injectable insulin administered subcuataneously. Diet should be a high fiber low fat food fed twice a day prior to insulin administration. Exercise helps to lower insulin requirement so regular, consistent exercise is recommended. The amount of insulin required varies from patient to patient. The animal will be hospitalized and a glucose curve plotted to determine optimum amount and time of insulin administration. The animal should be monitored on a regular basis to keep glucose levels within the ideal range of 100-200-mg/%. Oral hypoglycemic agents (glipizide) may help. Prognosis with treatment is good. Treatment, in all but a few cases, must continue for the life of the animal. 4) HYPERADRENOCORTICSM "CUSHINGS DISEASE"

Hyperadrenocorticism is due to an excess production of cortisol by the adrenal cortex. There may be several underlying causes: pituitary tumor or hyperplasia producing too much adrenocorticotropic hormone (ACTH) or adrenal tumors (benign or occasionally malignant). It is also possible to cause iatrogenic hyperadrenocorticism with the administration of glucocorticoids (steroids). This is one of the most common endocrinopathies of dogs. It is rare in cats. Most dogs with adrenal tumors are female. Poodles, Dachshunds and Boston Terriers appear to be at higher risk for this disease. Clinical signs include polyuria, polydypsia, obesity, hair loss, lethargy, muscle atrophy, thin skin, pendulous abdomen, hyperpigmentation, pyoderma. comedones and muscle weakness. Diagnosis is based on clinical signs. Blood work will show elevated glucose, cholesterol and liver enzymes. Urinalysis will reveal a low specific gravity often with evidence of a urinary tract infection. Additional testing using the high dose dexamethasone suppression test or plasma ACTH levels will be helpful in differentiating pituitary dependent hyperadrenocorticism from adrenal dependent. Radiographs, ultrasound, cat scan (CT) and magnetic resonance imaging (MRI) may also help. Treatment involves administering mitotane (o, p-DDD) to shrink the adrenal gland and decrease the amount of cortisol produced. Surgery may be indicated for a malignant adrenal tumor, but this is rare. Prognosis depends on the underlying problem. Generally patients respond well to treatment unless the tumor is malignant.

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Unit 12 IMMUNE SYSTEM

1) ANAPHYLAXIS "HYPERSENSITIVTY REACTION"

Anaphylaxis occurs when the body releases the contents of mast cells (histamines, leukotrines and bradykines) in response to foreign substance introduced into the body (injection, ingestion or exposure). An antibody:antigen reaction occurs of the mast cell membrane causing degranulation. This is associated with IgE antibodies. Some animals produce a higher level of reagenic antibody so it appears that there is a familial/genetic predisposition for this problem. It is primarily a problem of dogs but has been reported in many species. A common cause of anaphylaxis is the leptospirosis portion of the DHLPP vaccine in dogs. The primary organ affected is the animals airway. The airway constricts and the animal will have difficulty breathing. Other clinical signs include salivation, hives, colic, vomiting diarrhea, bradycardia, cyanosis and pruritus. Diagnosis is based on clinical signs. Treatment consists of removal of the antigen if possible and anti-histamines. In severe cases, shock therapy will be required. Avoidance of the allergen is the only way to prevent this problem. 2) SYSTEMIC LUPUS ERYTHEMATOSUS

Systemic lupus erythematosus is an immune complex disease that is characterized by heightened antibody responsiveness with production of autoantibodies. This disease has been reported in dogs and occasionally in cats. It is believed to have a genetic basis. Symptoms include synovitis, oral ulcers, skin lesions, myositis, neuritis, meningitis, arteritis, myopathy and glomerular nephritis. The most common manifestation in dogs is autoimmune hemolytic anemia and or thrombocytopenia. Glomerular nephritis and psychosis are more likely to be seen in cats. The disease is characterized by the deposition of antinuclear antibodies in the cell. Diagnosis is based on clinical signs and the identification of the antinuclear antibodies (ANA) via various tests. Treatment is designed to suppress the immune system to prevent further deposition of autoantiboides. Glucocorticoids are the drugs of choice. If necessary other stronger chemotheraputic agents can be used. Diagnosis is guarded. Relapses are common. 3) PEMPHIGUS

Pemphigus is an autoimmune diseases characterized by the production of antibodies against substances in the cell layers which cause separation of the cells. Pemphigus is seen in much more 34

frequently in dogs as and rarely in cats. Typical lesions include blisters erosions, and secondary bacterial infections. Lesions are commonly seen at the mucocutaneous junction. Diagnosis is based o clinical sings and skin biopsies. Treatment is aimed at suppressing the immune response. Glucocorticoids are the drug of choice. Stronger chemotheraputic agents may need to be used if initial response to therapy is poor. 4) AUTOIMMUNE HEMOLYTIC ANEMIA

Autoimmune hemolytic anemia is characterized by the production of autoantibodies against red blood cells. It is a disease that is seen most commonly in middle aged female dogs. Typical signs include pallor, lethargy, spleenomegally, icterus, billirubinemia, tachycardia, hemoglobinuria, thrombocytopenia, tachypnea, icterus, bleeding, anemia, decreased packed cell volume, rouleaux and red blood cell aggregation. Diagnosis is based on clinical signs and a positive Coombs test result. The Coombs test detects antibodies against red blood cells. Treatment included the use of glucocorticoids or other immune suppressing drugs. Blood transfusions are controversial because the introduction of more foreign protein may actual cause the production of additional antibodies. Blood MUST be cross-matched. Relapses are common so the prognosis is guarded.

Unit 13 INFECTIOUS DISEASES

1) RABIES

Rabies is an acute encephalomyelitis that occurs in mammals. It is zoonotic. It is caused by a virus and is transmitted via bite wounds. Occasionally it is spread by aerosol (bat strain). The incubation period is extremely variable. In dogs it can take from 3 weeks to 6 months for an animal to show clinical signs of the disease. Clinical signs are neurologic. The animal may be lethargic and depressed (dumb rabies) or hyperactive and aggressive (furious rabies). Diagnosis is based on clinical signs and examination of the brain for the virus (immunofluorescent antibody-IFA).

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Treatment is not effective. Prevention with vaccinations is the key. Puppies and kittens should be vaccinated at 12 weeks of age and again at one year of age. Adults should be vaccinated every one to three years depending on state regulations and the incidence of rabies in the area. Vaccinations are available for humans at high risk of exposure. In the United States humans are most often exposed to rabies by feral cats or wildlife (bats). A successful oral vaccine for wildlife has also been developed. 2) CANINE PARVOVIRAL ENTERITIS "PARVO"

Parvo is gastroenteritis of acute onset and variable morbidity and mortality. It is caused by a virus and transmitted via feces, fomite and direct contact. It infects dogs. Remember that this virus is highly contagious. Infected animals should be isolated and precautions taken to prevent spread of the disease. Clinical signs include vomiting, diarrhea, dehydration, fever, leukopenia, soft cough, painful abdomen and myocarditis in puppies. Diagnosis is based on clinical signs, typical blood work (leukopenia) and immunologic testing of the feces for virus (ELISA test). Treatment consists of supportive care and antibiotics if indicated for secondary bacterial infection. In some cases canine anti-parvo serum has been used. Prognosis is variable. Many animals survive with aggressive supportive care. 3) CANINE CORONAVIRAL ENTERITIS "CORONA"

Corona is a gastroenteritis of acute onset very similar to Parvo but not as severe. A virus causes it and a vaccine is available. 4) FELINE RESPIRATORY DISEASES

This group of diseases includes feline viral rhinotracheitis (FVR), feline pneumonitis (Chlamydia psittaci), mycoplasma and feline calicivirus (FCV). Recent studies indicate that Bordetella and Pasturella may also be involved in this complex. These diseases are not zoonotic with the exception of chlamydia, which has been reported to cause conjunctivitis in humans and Bordetella, which is thought to cause respiratory disease in susceptible individuals. Clinical signs include coughing, sneezing, pneumonia, conjunctivitis, ulcerative keratitis, oral ulcers, depression, anorexia, dehydration, fever, nasal discharge, salivation and ocular discharge. Diagnosis is based on clinical signs. It is difficult to determine which of the etiologic agents is involved or if several agents may be contributing to the disease. FCV is more likely to cause oral ulceration while FVR is more likely to cause ocular lesions. Treatment is based on supportive care. Antibiotics are indicated if a bacterial component is suspected. There have been mixed results with anti-viral agents. 36

Prognosis is good. A few animals may develop chronic disease such as a non-responsive sinusitis. Cats that have recovered from FVR will be chronic carriers. Stress may cause a relapse and clinical manifestation of the disease. There are good vaccines available. The vaccines will minimize the disease but NOT prevent it. Vaccinations are normally given at 8 weeks of age and then boostered every 2-4 weeks until the animal reaches 16 weeks of age. The adult animal receives a booster annually. The same controversy exists for this vaccine as does for feline panleukopenia. The vaccines, however, are only licensed for annual use. In catteries with respiratory disease outbreaks, a more aggressive vaccination protocol may be recommended. 5) FELINE INFECTIOUS PERITONITIS "FIP"

A corona virus causes feline infectious peritonitis. It is spread by ingestion although aerosol transmission is possible. The disease can manifest itself in two ways; the "wet or effusive form and the "dry" or pyogranulomatous form. Young cats from 3 weeks to 3 years of age are more likely to be affected. Cats from multi-cat households are at greater risk for this disease. Exotic cats such as cheetahs are especially vulnerable. Clinical signs included gradual weight loss, anorexia, stunted growth, fever, abdominal effusion, pleural effusion, granulomatous masses in the chest and/or abdomen, neurologic signs and ocular lesions. Diagnosis is based on clinical signs. There is no one-laboratory test that is definitive for FIP. Serum antibody tests for the corona virus are of limited value because there are a number of corona viruses. Testing positive to a corona virus is NOT equivalent to having FIP. Only 10% of the cats that test positive for corona virus will develop clinical signs of FIP. A two samples taken two weeks apart and demonstrating a rising titer is more accurate in establishing a diagnosis. Examination of the peritoneal or pleural fluid for typical characteristics of the disease is often helpful. Necropsy can be used to establish a diagnosis based on typical histopathological lesions. There is no known effective treatment for this disease. Treatment of the symptoms will make the animal more comfortable. There is a vaccine available but its use is controversial. It is thought to speed up the disease process in some cats and have limited efficacy. Because the incidence of this disease is so low in the general cat population, the routine use of this vaccine is not recommended. Prognosis once an animal develops clinical signs of the disease is poor. Mortality is nearly 100% 6) FELINE PANLEUKOPENIA "FELINE DISTEMPER"

Feline panleukopenia is a viral disease (feline parvovirus-FPV) of cats that causes severe gastrointestinal signs. It is not commonly seen anymore probably due to widespread use of vaccines, but the incidence of this disease remains high in feral populations of cats. Remember that 37

this disease is highly contagious and similar to canine parvovirus. It is spread in all body secretions and can be transported by fomites. Symptoms include anorexia, depression, dehydration, vomiting, diarrhea, abdominal pain and fever followed by subnormal temperature as the diseases progresses. Kittens infected in utero or at a very young age may develop cerebellar hypoplasia and neurologic signs. Many cases are subclinical. Diagnosis is based on clinical signs. Blood work is useful as this disease is characterized by a panleukopenia. Leukocytes will drop to between 500-3000 cell/microl. Canine parvovirus antigen test (CITE test) will detect FPV (this kit is not licensed for this use). Paired serum titers may also help to confirm the disease. Treatment consists of symptomatic care. Cats should be isolated. This disease is highly contagious. Clients should be warned that the virus can survive for years in the environment and that all future animals introduced into the household should be vaccinated. Prognosis is initially guarded but if the cat survives the acute phase of the disease (5-7 days) the animals usually recover rapidly. There are excellent vaccines available on the market. Kittens should be vaccinated every 2-4 weeks starting at 8 weeks of age until they are 16 weeks old. They should be vaccinated annually thereafter. There is some controversy as to how often to revaccinate an adult cat. The vaccines are licensed as annual boosters. 7) CANINE DISTEMPER

Is an acute viral disease that infects the gastrointestinal and respiratory tract and nervous system. It infects dogs and ferrets and is spread by aerosol, direct contact and fomites. In utero transmission has been reported. Clinical signs include fever, leukopenia, mucopurulent discharge from the eyes and nose, photophobia, depression, anorexia, diarrhea, hyperkeratosis of the pads and nose and neurologic signs (ticks, paresis, paralysis, ataxia, convulsions, paddling, chewing gum fits). Diagnosis is based on clinical signs, immunofluorescent antibody tests and ELISA tests. Treatment is symptomatic. Prognosis is guarded especially in animals showing neurologic signs. Prevention is the key. Puppies should be vaccinated every 2-4 weeks starting at 6 weeks of age until they reach 16 weeks. Adults should be boostered annually thereafter. 8) INFECTIOUS CANINIE HEPATITIS "ADENOVIRUS"

Adeno is a contagious disease that is caused by a virus. It infects the liver of dogs and fox. It is spread via direct contact, fomites and occasionally aerosol.

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Clinical signs include fever, anorexia, serous ocular and nasal discharge, depression, leukopenia, icterus, abdominal pain, petechiation, vomiting, edema, convulsions, corneal opacities (blue eye) and prolonged bleeding times. Diagnosis is based on clinical signs, liver biopsy and necropsy. Treatment is symptomatic. Chronic hepatitis may develop. Vaccination prevents this disease. The schedule for vaccination is the same as for canine distemper. 9) LEPTOSPIROSIS "LEPTO"

Leptospirosis is a bacterial disease that can cause fatal nephritis. It infects many mammals including man. It is zoonotic. Rats act as reservoirs but other animals can harbor the disease as well. The bacteria is shed primarily in the urine but can be found in milk, placental material and aborted feti. Animals can shed for moths after clinical recovery and some animals can become carriers Clinical signs include fever anorexia, depression, vomiting, icterus, muscle stiffness, mucosal sloughs, bloody diarrhea, frequent urination, nephritis, leukocytosis and elevated BUN. Diagnosis is based on clinical signs and the identification of bacteria (spirochetes) in the urine. Treatment consists of antibiotics and supportive care. Vaccines are available to prevent this disease. Their use is controversial because Leptospirosis comes in many serovars (types) and the vaccine does not protect against all types of lepto. In addition, the lepto portion of the vaccine is one of the more common antigens responsible for anaphylactic reactions in dogs. From a public health stand point, it should be remembered that this is a zoonotic disease and that we have a responsibility to protect the public. The vaccination schedule is the same as for distemper. 10) CLOSTRIDIAL INFECTIONS

Dogs and cats are relatively resistant to clostridial diseases including botulism and tetanus. There have been reports of enterocolitis caused by Clostridium perfringens in dogs. It is estimated that 1015% of cases of large bowel diarrhea in dogs is caused by clostridium. Clinical signs include diarrhea with mucus, blood, tenesmus and small amounts of feces more frequently. Diagnosis is based on clinical signs and the elimination of other causes of large bowel diarrhea. Anaerobic fecal cultures, enterotoxin assay and fecal cytology to look for the presence of spores may all help to establish the diagnosis. Treatment involves symptomatic care. High fiber, low fat diets help. Antibiotics are indicated.

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Prognosis is good. Occasional chronic cases may develop. The zoonotic potential of this disease is not known. 11) BORELLIOSIS "LYME DISEASE"

Lyme disease is caused by a spirochete, Borrelia burgdorferi. It is one of the most common ticktransmitted zoonotic diseases in the world. The incidence of this disease is highest in the Northeast. Up to 80% of the dogs in an endemic area will be seropositive (exposed) to Lyme disease but only 5% of those dogs will develop clinical signs of the disease. The main vector for transmission is the Ixodes (deer) tick. Lyme disease has been reported in dogs and to a much lesser extent, cats. Humans and animals develop arthritis, lameness, anorexia, depression, cardiac, renal and neurologic disease. In humans a typical target shaped rash develops around the bite wound of the tick in 70% of the cases. This is not a common finding in dogs. Diagnosis is based on clinical signs and by ruling out other causes of arthritis. Serology will also help to establish the diagnosis. Treatment consists of long-term antibiotic therapy with either doxycycline or amoxicillin. Response to therapy should be seen within 2-3 days. Reoccurrence are possible but they normally respond to antibiotic therapy as well. Prevention is best achieved by preventing dogs from roaming through tick infested areas. The use of a topical repellent/tick medication such as Frontline is suggested. Vaccinations are available. They are not 100% effective but they do help to reduce the incidence of the disease. Dogs do not transmit this disease to humans. Humans are infected by ticks just like the dogs are. 12) INFECTIOUS TRACHEOBRONCHITIS "KENNEL COUGH "

A respiratory disease complex in dogs characterized by coughing and caused by canine adenovirus (CAV-1 or CAV-2), canine parainfluenza (CPI), canine herpesvirus, canine reoviruses and canine distemper virus. Bacteria such as Bordetella bronchiseptica and other bacteria (Pseudemonas, E. coli and Klebsiella) are also involved. Mycoplasma plays a role as well. Environmental conditions such as overcrowding, stress, poor ventilation, high humidity and heavy dust contamination also contribute to the severity of the disease. Aerosol transmission and direct contact spread the disease. Clinical signs in mild cases are limited to an elicitable cough and decreased appetite. Depending on the extent of involvement of the respiratory tract the signs can vary from the mild case to severe, life-threatening pneumonia. In more severe cases anorexia, depression, dehydration, fever, nasal discharge and a productive cough are all indications that the disease is progressing. Diagnosis is based on clinical signs. Typically dogs will start to cough within 5-7 days of exposure to an infected individual so a careful history is useful in confirming a diagnosis. Treatment involves symptomatic care and antibiotics if indicated. Any environmental factors that might contribute to the severity of the disease should be eliminated. Ideally theses animals should

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not be hospitalized if possible due to the contagious nature of the disease and because of the increased stress to the animal. Good vaccines are available. Any animal that boards, shows or meets and greets outside animals should be vaccinated. The intranasal vaccine takes at least 48 hours to provide immunity while the injectable vaccine takes 10-14 days. This time lag should be taken into account before boarding an animal. The vaccine minimizes the disease but is NOT 100% effective in preventing the disease. 13) FELINE IMMUNODEFICIENCY VIRUS "FIV"

Feline immunodeficiency virus (FIV) is a virus that causes suppression of the immune system in cats. The virus is shed in the saliva is spread by bites. It is seen primarily in adult intact male cats that are allowed to roam. Clinical signs include fever, weight loss, depression, anorexia, poor hair coat, chronic respiratory infection, persistent diarrhea, chronic skin and ear infections. Diagnosis is based on clinical signs. A history of reoccurring infections is also a clue. Serologic testing to detect antibodies to FIV will confirm the diagnosis. Treatment is symptomatic. There is no cure. The prognosis is guarded. Once animals shows clinical signs of the disease, the survival rate is poor, but many animals survive for years as asymptomatic carriers. Clients should be advised to keep positive cats indoors to prevent spread of the disease. Clients should also be warned against introducing another cat into the household. There is no vaccine for this disease. Prevention is achieved by castrating male cats and preventing them from roaming. 14) FELINE LEUKEMIA VIRUS "FELUK"

A virus causes feline leukemia. It primarily infects domestic cats. There is an increased incidence of this disease in males. It is spread via oral-nasal secretions, but because the virus is very fragile, it requires prolonged close contact before transmission occurs. Bites and sharing of food and litter pans may also facilitate transmission. The virus can be transmitted in utero. 70% of the cats that are exposed to FELUK clear the virus on their own and do not become persistently viremic. Clinical signs include depression, anorexia, weight loss, chronic illness, periodontal disease, lymphoma, leukemia and fibrosarcoma. It is impossible to differentiate from FIV without serologic testing. Diagnosis is based on clinical signs and either ELISA or IFA testing. Treatment consists of supportive care. There is no cure for FELUK. The prognosis is guarded. 80% of the infected cats will die within 2-3 years. 41

There are excellent vaccines available. Cats should be tested for FELUK before vaccination. Other preventative measures include keeping cats indoors and testing all cats before introducing them into the household. 15) SALMONELLOSIS

Salmonella is a bacterium that can cause severe gastrointestinal disease and septicemia in dogs and cats. It is zoonotic. The bacterium is spread via feces. It can be transmitted through contaminated food, water and through fomites (dishes, cages, etc). The actual incidence of the disease in dogs and cats is not known but surveys conducted on normal dogs and in hospitals and boarding facilities indicated infections rates between 1-30%. Clinical signs include vomiting, diarrhea, fever, anorexia and depression. Stress may cause an asymptomatic carrier to become clinical. Diagnosis is based on clinical signs and by ruling out other causes of disease. The only way to definitively diagnose salmonella is through fecal culture. There is no vaccine available. Prevention consists of maintaining good hygiene, avoiding overcrowding or stressful conditions, vaccinate and prevent any other diseases. Prognosis is excellent for gastroenteritis patients. Aged or neonatal animals that develop septicemia have a guarded prognosis.

Unit 14 ZOONOTIC DISEASES

The following is a list of the diseases that are zoonotic. SKIN Dermatophytosis Sarcoptic Mange Chyletiella Notoedres Otodectes (theoretically)

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DIGESTIVE SYSTEM Intestinal parasites INFECTIOUS DISEASES Rabies Feline Respiratory Diseases (Chlamydia & Pasturella) Leptospirosis Clostridial infections Borrelisosis Kennel Cough (Bordetella) Salmonellosis

UNIT 15 PRINCIPLES OF SURGERY

I. II. III. IV. V. Surgical Instruments Preparing the Equipment for Surgery Preparing the Patient for Surgery Sutures and Suture Handling Wound Healing

I. Surgical instruments They exist in vast numbers and varieties. The following are examples of the basic instruments: 1) Scissors All types of scissors can have blunt or sharp blades (A: Sharp:Sharp, B: Blunt:Blunt). All types can have either straight or curved blades Mayo and Metzenbaum Mayo scissors are used for cutting heavy fascia and sutures Metzenbaum scissors are more delicate than Mayo scissors. Metzenbaum scissors are used to cut delicate tissues. Metzenbaum scissors have a longer handle to blade ratio.

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2)

Dressing and tissue forceps

Forceps: consist of two tines held together at one end with a spring device that holds the tines open. Forceps can be either tissue or dressing forceps. Dressing forceps have smooth or smoothly serrated tips. Tissue forceps have teeth to grip tissue. Many forceps bear the name of the originator of the design, such as Adson tissue forceps. Rat Tooth: A Tissue Forceps Interdigitating teeth hold tissue without slipping Used to hold skin/dense tissue Adson Tissue Forceps Small serrated teeth on edge of tips. The Adsons tissue forceps has delicate serrated tips designed for light, careful handling of tissue. Intestinal Tissue Forceps: Hinged (locking) forceps used for grasping and holding tissue. Allis: An Intestinal Tissue Forceps Interdigitating short teeth to grasp and hold bowel or tissue. Slightly traumatic, use to hold intestine, fascia and skin. Babcock: An Intestinal Tissue Forceps More delicate that Allis, less directly traumatic. Broad, flared ends with smooth tips Used to atraumatically hold viscera (bowel and bladder). Sponge Forceps Sponge forceps can be straight or curved. Sponge forceps can have smooth or serrated jaws. Used to atraumatically hold viscera (bowel and bladder). Hemostatic forceps: Hinged (locking) Forceps. Many hemostatic forceps bear the name of the designer (Kelly, Holstead, Crile). They are used to clamp and hold blood vessels.

Classification by size and shape and size of tips Hemostatic forceps and hemostats may be curved or straight Kelly Hemostatic Forceps and Mosquito Hemostats Both are transversely serrated. Mosquito hemostats are more delicate than Kelly hemostatic forceps. Comparison of Kelly and Mosquito tips: Mosquito hemostats have a smaller, finer tip Carmalt Heavier than Kelly. Preferred for clamping of ovarian pedicle during an ovariohysterectomy surgery because the serrations run longitudinally. 44

Scissors and Hemostats: The thumb and ring finger are inserted into the rings of the scissors while the index and middle finger are used to guide the instrument. The instrument should remain at the tips of the fingers for maximum control. Thumb Forceps: Thumb forceps are held like a pencil Thumb Forceps are not held like a knife Thumb Forceps are not called 'tweezers' Scalpels: The scalpel is held with thumb, middle and ring finger while the index finger is placed on the upper edge to help guide the scalpel. Long gentle cutting strokes are less traumatic to tissue than short chopping motions. The scalpel should never be used in a "stabbing" motion Towel clamps secure drapes to a patient's skin. They may also be used to hold tissue Backhaus Towel Clamp Locking forceps with curved, pointed tips.

Handles - #3 Handle and #4 Handle Blades #10, 11, 12, 15 fit the #3 handle Blades #22, #23 fit the #4 handle and are commonly used for large animals Needle holder: Hinged (locking) instrument used to hold the needle while suturing tissue. Mayo-Hegar Heavy, with mildly tapered jaws. No cutting blades Olsen-Hegar Includes both needle holding jaw and scissors blades. The disadvantage to having blades within the needle holder is the suture material may be accidentally cut. Intestinal Forceps Doyen Intestinal Forceps Doyen intestinal forceps are non-crushing intestinal occluding forceps with longitudinal serrations. Used to temporarily occlude lumen of bowel. Payr Pylorus Clamps Payr pylorus clamp is a crushing intestinal instrument. Used to occlude the end of bowel to be resected. Self-retaining Retractors Weitlaner Ends can be blunt or sharp 45

Has rake tips. Ratchet to hold tissue apart

Gelpi Has single point tips. Ratchet to hold tissue apart. Hand-held Retractors Senn Blades at each end. Blades can be blunt (delicate) or sharp (more traumatic, used for fascia). Hohman Levers tissue away from bone during orthopedic procedures.

II. A.

B.

Preparing the Equipment for Surgery Sterilization Techniques i. Steam ii. Ethylene oxide iii. Cold iv. Radiation and Filter v. Gas Plasma Selecting and Packaging Gowns i. Disposable vs. Line and Plastic Gowns ii. Wrap Around vs. Front Sterile Gowns Folding of a Gown for Sterilization

A.

Steam Sterilization: Autoclaving Autoclave

An autoclave is a self locking machine that sterilizes with steam under pressure. Sterilization is achieved by the high temperature that steam under pressure can reach The high pressure also ensures saturation of wrapped surgical packs.

Autoclave Settings General Wrapped Items Bottled Solutions 'Flashing' Preparation for sterilization

Temperature (F) 250 250 270

Pressure (PSI) 20 20 30

Time (min) 30 30 4-7

All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization.

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'Flashing' is when an instrument is autoclaved unwrapped for a shorter period of time. 'Flashing' is often used when a critical instrument is dropped.

Biological sterilization indicators contain spores that are supplied in closed containers and are included with the instrument being autoclaved. Inability to culture the spores after autoclaving confirms adequate sterilization. Biological indicators are the most accurate sterilization indicators. Ethylene Oxide Sterilization: ETO Gas Large Two-Chamber EtO Sterilizer

Colorless gas, very toxic and flammable. Requires special equipment Odor similar to ether. Used for heat sensitive instruments: plastics, suture material, lenses and finely sharpened instruments. Materials must be well aerated after sterilization. Materials/instruments must be dry. This specific type of EtO sterilizer is only found in larger veterinary hospitals

Compact One-Chamber EtO Sterilizer

Cartridges release 100% pure ethylene oxide Kills all known viruses,bacteria (including spores), and fungi Annual safety inspections are recommended

Cold (Chemical) Sterilization:

Instruments must be dry before immersion. Glutaraldehyde (Cidex) is the most common disinfectant. 3 hours exposure time is needed to destroy spores. Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal.

Radiation Sterilization:

High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked surgical equipment Used for instruments that can't be sterilized by heat or chemicals. Radiation sterilization is being promoted as an alternative to ETO sterilization. Care needs to be taken because not all materials can be irradiated successfully Currently used by manufacturers, but not used in veterinary hospitals Common sources of radiation include electron beam and Cobalt-60

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Filter Sterilization:

Filters are used for removal of microorganisms in fluids and gases. They come in a wide variety of types and sizes. A 0.2 micron filter is required to remove bacteria from fluids. The filter is placed in the IV line or on a syringe, so that the contaminated solution is sterilized before reaching the patient.

Gas Plasma:

Based on a patented process involving the generation of a low-temperature hydrogen-peroxide gas plasma Recently on the market, its efficiency in practice is still unproven Requires only a 74 minute cycle time and leaves no toxic residues or emissions Unlike EtO, it does not require special installation, ventilation, or aeration Effectively sterilizes most heat- and moisture-sensitive medical devices and surgical instruments

Disposable Paper Gown Advantages:

Paper gowns are resistant to wetting so they are less permeable to bacteria. They are preferred for wet bloody surgery (equine abdominal surgery). Donning a new gown for each surgery and disposing of it at the end ensures sterility.

Disadvantages:

Paper is less ecologically sound because it is not reusable.

Linen (cloth) Gowns Advantages:

Linen gowns are both comfortable and reusable. Previously worn gowns can be autoclaved to regain sterility.

Disadvantages:

Linen is a woven material so that when it becomes wet, bacteria can permeate through its interstices. Linen is not the gown material of choice for wet, bloody surgical procedures.

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Plastic Gowns Advantages:

Plastic is superior in its resistance to wetting and bacterial penetration. Plastic can be used to reinforce paper gowns during wet surgery (plastic sleeves for abdominal surgery).

Disadvantages

Plastic is extremely uncomfortable to wear because of the inability to shed heat and perspiration. Preparing the Patient for Surgery

III.

Prep of the Large Animal Patient Step 1: Clipping: Generously clip area around the proposed incision with #40 surgical clipper blade. Isopropyl alcohol poured on site will facilitate clipping. Vacuum or brush and dispose of clipped hair and debris. Step 2: Gross Preparation: Use a surgical scrub product (Chlorhexidine [Nolvasan], or Providone-iodine [Betadine]) and tap water. Scrub and rinse until area is free of debris and water beads as it flushes across skin. Rinse with tap water Step 3: White Glove Test: Soak 10-15 white 4x4 gauze sponges with isopropyl alcohol (70%). Wipe the scrubbed skin (always work from proposed incision site to the periphery) and check for remaining dirt and debris. Discard gauze if you pick up debris. Once you reach the periphery, discard gauze and start again at the proposed incision site with a new gauze sponge Step 4: Final Skin Preparation: Saturate 10-15 gauze sponges with antiseptic solution (2% Nolvasan Betadine). Add ten milliliters of Nolvasan or Betadine surgical scrub to the top sponges. Scrub in a circular motion starting at the surgical site and moving toward the periphery. Never scrub in the direction of the periphery towards the proposed incision site. Total contact time should be 5 minutes When picking up the sponges to begin scrubbing, fold and hold the corners of the sponge so that you do not touch the surface of the sponges that will be in contact with the surgical site Starting with 1 to 3 sponges, scrub in circular motion starting at the proposed incision site and moving towards the periphery. Discard sponges as you reach the periphery (do not move peripheral debris toward the central incision site). Repeat for a total of five minutes Step 5: Rinse: Rinse with sterile saline or 70% isopropyl alcohol. Continue rinsing until the area is free of fat and/or surgical scrub residue (rinsing solution will bead as it is flushed 49

across skin. Rinsing solution should always flow from central (clean) to periphery (contaminated). Step 6: Final Antiseptic Preparation: Apply 70% Isopropyl alcohol to skin and let dry. Finish by applying an even coating of 2% Nolvasan or Betadine solution with spray bottle Surgical Prep of the Small Animal Patient Step 1: Clipping: Clip operative site (wide borders) and remove all hair (central vacuum). Wipe skin with clean moist 4x4 gauze sponge to remove all hair and debris.

Hair is removed in order reduce contamination of the surgical site by bacteria on the patient's skin and in the patient's hair follicles. Shaving is a less acceptable method of removing hair because shaving damages the skin to a greater degree than clipping. Any method of hair removal damages the patient's skin. Inflammation increases the risk of bacterial colonization. In order to reduce this risk, hair is removed immediately prior to surgery. For orthopedic procedures on long bones, the entire limb must be clipped to dorsal midline. Wounds within the surgical site must be coated with a water soluble jelly so that they do not collect hair and debris during the process of clipping. Step 2:Initial Scrub

Soak scrub brush with tap water and 2% Chlorhexidine Gluconate (Nolvasan). Using foam side of brush, apply mixture to entire clipped area. Collect and remove any loose hairs and debris

Step 3: Scrub Incision Site

With a new brush, scrub at the incision site for 2 full minutes. Do not stray from the incision site.

Step 4: Periphery Scrub Soak a new scrub brush with tap water and Chlorhexidine Gluconate scrub. Step 5: Rinse

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Step 6: Final Antiseptic Spray

The entire scrubbed area is then sprayed with a final preparation solution of 0.5% Chlorhexidine Diacetate in 70% isopropyl alcohol. This spray solution is made by diluting 1 part Nolvasan (2% Chlorhexidine Diacetate) in 3 parts 70% isopropyl alcohol. The entire scrubbed area is then sprayed with a final preparation solution of 0.5% Chlorhexidine Diacetate in 70% isopropyl alcohol. This spray solution is made by diluting 1 part Nolvasan (2% Chlorhexidine Diacetate) in 3 parts 70% isopropyl alcohol.

Selection Of Appropriate Antiseptic

Alcohol Chlorhexidine Gluconate Iodophors Hexachlorophene

Isopropyl Alcohol (70%) Advantages:

Causes protein denaturation, cell lysis, and metabolic interruption. Degreases the skin.

Disadvantages:

Ineffective against bacterial spores and poorly effective against viruses and fungi.

Chlorhexidine Gluconate (Nolvasan) Advantages:

Rapid action Residual activity is enhanced by repeated use Less susceptible to organic inactivation than providone iodine

Disadvantages:

Occasional skin sensitivity. Inactive against bacterial spores Activity against viruses and fungi is variable and inconsistent

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Iodophors: Iodine complexed with an organic substrate. (Povidone Iodine - Betadine)

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Advantages:

Bactericidal, viricidal, and fungicidal.

Disadvantages:

Occasional skin sensitivity. Partially inactivated by organic debris. Less residual activity than chlorhexidine. Poor sporicidal activity.

Hexachlorophene: a Phenol Derivative (Phisohex) Action: Disrupts cell walls, precipitates cellular proteins. Disadvantages:

NOT USED: Neurotoxic. Slow onset of action.

Draping Technique for the Small Animal Patient Four Corner Draping: The function of draping is to separate the sterile surgical site from contaminated areas of the patient.

Placement of Drapes:

The drape should be floated above the patient and placed in the appropriate position (i.e. do not drag the sterile drape along the patient's contaminated body). When applying the drapes make sure the sterile drape is in between the surgeon's sterile gown and the unsterile (undraped) surgical table. The drape should only be adjusted minimally once it has been laid onto the patient. If the drape needs to be adjusted it should only be moved in a direction AWAY from the sterile surgical site and NEVER towards the sterile site.

Securing the Drapes:

Drapes are secured to each other and to the patient's skin with Backhaus towel clamps. 53

The towel clamps are tucked underneath the drapes, making sure that they are not lying on the patient's skin. Drapes are secured to each other and to the patient's skin with Backhaus towel clamps. The towel clamps are tucked underneath the drapes, making sure that they are not lying on the patient's skin.

Equine Orthopedic Draping During orthopedic procedures a stockinette is used to cover the distal part of the limb. The entire circumference of the distal limb is covered so that the surgeon can grasp and manipulate the limb. Proximal to the proposed incision site, a 'V' shaped drape is folded over the limb so that the entire circumference is covered and can be manipulated. In addition to the limb, the entire horse is covered with drapes. V. Wound Healing

Three phases of wound healing:, inflammation, tissue formation, and tissue remodeling Inflammatory phase: initial injury - clot formation recruitment of inflammatory cells into the wound this phase occurs in the first few days as inflammatory cells migrate into the wound. Migration of epithelial cells has been shown to occur within the first 12-24 hours, but further new tissue formation occurs over the next 10-14 days. Tissue formation: Epithelialization and neovascularization result from the increase in cellular activity. Stromal elements in the form of extracellular matrix materials are secreted and organized. This new tissue, called granulation depends on specific growth factors for further organization to occur in the completion of the healing process. This physiologic process occurs over several weeks to months in a healthy individual. Finally, tissue remodeling, in which wound contraction and tensile strength is achieved, occurs in the next 6-12 months. Systemic illness and local factors can affect wound healing. Traditionally, at least 2 types of wound healing: Primary intention method surgical wound closure facilitates the biological event of healing by joining the wound edges. Surgical wound closure directly apposes the tissue layers, which serves to minimize new tissue formation within the wound. Remodeling of the wound does occur, however, and achieves tensile 54

strength between the newly apposed edges. Closure can serve both functional and aesthetic purposes. These include elimination of dead space by approximating the subcutaneous tissues, minimization of scar formation by careful epidermal alignment, and avoidance of a depressed scar by precise eversion of skin edges. Correspondingly, atraumatic handling of tissues combined with avoidance of tight closures and undue tension contribute to a better result. Secondary intention method (spontaneous healing) can be used in lieu of complicated reconstruction for certain surgical defects. This method also depends on the 3 stages of wound healing to achieve the ultimate result. The ideal suture possesses the following characteristics: Sterile

All-purpose (composed of material that can be used in any surgical procedure) Ease of handling Holds securely when knotted (no fraying or cutting) High tensile strength Favorable absorption profile Resistance to infection Minimal tissue injury or tissue reaction Nonelectrolytic Noncapillary Nonallergenic Noncarcinogenic

Essential suture characteristics All sutures should be manufactured to assure several fundamental characteristics: Sterility Uniform diameter and size Pliability for ease of handling and knot security Uniform tensile strength by suture type and size Freedom from irritants or impurities that would elicit tissue reaction

Other suture characteristics The following terms describe various characteristics related to suture material:

Absorbable: Progressive loss of mass and/or volume of suture material occurs. This does not correlate with its initial tensile strength. Breaking strength - Limit of tensile strength at which suture failure occurs Capillarity - Extent to which absorbed fluid is transferred along the suture Elasticity - Measure of the ability to regain original form and length after deformation 55

Fluid absorption - Ability to take up fluid after immersion Knot-pull tensile strength - Breaking strength of knotted suture material (10-40% weaker after deformation by knot placement) Knot strength - Amount of force necessary to cause a knot to slip (related to the coefficient of static friction and plasticity of a given material) Memory - Inherent capability of suture to return to or maintain its original gross shape (related to elasticity, plasticity, and diameter) Plasticity - Measure of ability to deform without breaking and to maintain a new form after relief of the deforming force Pliability - Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to suture material, filament type, and diameter) Straight-pull tensile strength - Linear breaking strength of suture material Tensile strength - Measure of a material or tissue's ability to resist deformation and breakage Wound breaking strength - Limit of tensile strength of a healing wound at which separation of the wound edges occurs Suture pullout value: Applying force to a loop of suture located where tissue failure occurs measures the strength of a particular tissue. Variations occur depending upon anatomic site and histologic composition Fat - 0.2 kg Muscle - 1.27 kg Skin - 1.82 kg Fascia - 3.77 kg

Suture size The United States Pharmacopeia (USP) classification system was established in 1937 for standardization and comparison of suture materials, corresponding to metric measures. Three classes of sutures exist; namely, collagen, synthetic absorbable, and nonabsorbable. Size refers to the diameter of the suture strand and is denoted as zeroes (0s). The more 0s characterizing a suture size, the smaller the resultant strand diameter (eg, 4-0 or 0000 is larger than 5-0 or 00000). The smaller the suture, the less tensile strength the strand possesses. Sutures are sized under two systems, one from the United States Pharmacopoeia and another from Europe. In the United States, sutures are assigned a size which is based on a combination of diameter, tensile strength and knot security. The precise criteria vary depending on whether the suture is natural or synthetic fiber, absorbable, or among three "classes" of nonabsorbable sutures. The U.S.P. sizing is numerical. Suture sizes are listed as whole numbers or whole numbers followed by an "ought" or "zero". Larger whole numbers indicate larger sutures, number 2 suture is larger than 1. However, larger numbers followed by an "ought" are smaller. A 5-0 (pronounced "five ought" or "five zero") is smaller than 2-0. The smallest sutures which are used for ophthalmic and microsurgery range down to 12-0 size. Number 2 is about the largest standard suture in common manufacture, but a few specialty sutures range up to 5. Descending Suture Sizes from Left to Right

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5 ---- 2 ---- 1---- 0 ----1-0 ---- 4-0 ---- 7-0 ----12-0 Suture sizes are matched to certain tissues and function best when the suture strength and the tissue strength are similar. Natural sutures

Natural sutures can be made of collagen from intestines of mammals or from synthetic collagen (polymers). Tissue reaction and suture antigenicity lead to inflammatory reactions, especially with natural materials. Synthetic nonabsorbable sutures elicit the least tissue reaction. Sutures may be coated with agents that improve handling characteristics. Initial tissue injury from suture passage can affect the outcome of wound closure (less injury from monofilament vs braided material). Special coatings allow sutures to pass more easily through tissues (less coefficient of friction) and also improve handling characteristics. Sutures also may be colored with dye to increase visibility.

Monofilament vs multifilament sutures Monofilament suture

made of a single strand relatively more resistant to harboring microorganisms ties relatively more easily less resistance to passage through tissue crushing/crimping occurs during handling and tying that nick or weaken the suture and lead to undesired and premature suture failure.

Multifilament suture

composed of several filaments twisted or braided together less stiff but have a higher coefficient of friction generally has greater tensile strength and better pliability and flexibility handles and ties well because has increased capillarity, the increased absorption of fluid may act as a tract for the introduction of pathogens

Absorbable vs non-absorbable sutures

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Absorbable sutures provide temporary wound support, until the wound heals well enough to withstand normal stress. Absorption occurs by enzymatic degradation in natural materials and by hydrolysis in synthetics. Hydrolysis causes less tissue reaction than enzymatic degradation. The first stage of absorption has a linear rate, lasting for several days to weeks. The second stage is characterized by loss of suture mass and overlaps the first stage. Loss of suture mass occurs due to leukocytic cellular responses that remove cellular debris and suture material from the line of tissue approximation. Chemical treatments, like chromic salts, lengthen the absorption time. Nonabsorbable sutures elicit a tissue reaction that results in encapsulation of the suture material by fibroblasts. Nonabsorbable sutures are commonly used in percutaneous skin closure and are removed after sufficient healing has occurred. Healing typically occurs 6-8 days in an otherwise healthy patient. Nonabsorbable sutures also have internal use, and in these situations the sutures permanently become encapsulated in tissue. Absorbable sutures Natural Collagen (submucosa of sheep intestine or serosa of beef intestine) Surgical gut, plain: Tensile strength is maintained 7-10 days postimplantation (variable with individual patient characteristics). Absorption is complete within 70 days. This type of suture is used in rapidly healing tissues requiring minimal support, the ligation of superficial blood vessels, and suturing subcutaneous fatty tissue. Fast-absorbing surgical gut: This type of suture is indicated for epidermal use (required only for 5-7 days) and is not recommended for internal use. Surgical gut, chromic (treated with chromium salt): Tensile strength is maintained 10-14 days. Absorption rate is slowed by chromium salt (90 days). This type of suture may be used in the presence of infection. Tissue reaction is due to the noncollagenous material present in these sutures. Also, patient factors affect rates of absorption and make tensile strength somewhat unpredictable. Synthetic Chemical polymers are absorbed by hydrolysis and cause a lesser degree of tissue reaction following placement. Polyglactin 910 (Vicryl): braided multifilament suture; coated with a copolymer of lactide and glycolide (polyglactin 370); with water-repelling quality of lactide; bulkiness of lactide leads to rapid absorption of suture mass once tensile strength is lost; coated with calcium stearate, which permits easy tissue passage, precise knot placement, and smooth tie-down; tensile strength is approximately 65% at 14 days postimplantation; absorption is minimal for 40 days and complete in 56-70 day; cause minimal tissue reaction and may be used in the presence of infection. Vicryl sutures are used in general soft tissue approximation and vessel ligation.

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Poliglecaprone 25 (Monocryl): monofilament suture that is a copolymer of glycolide and Ecaprolactone; has superior pliability = ease in handling and tying; tensile strength high initially, 5060% at 7 days, and lost at 21 days; absorption complete at 91-119 days; used for subcuticular closure/soft tissue approximations and ligations. Polydioxanone (PDS II): monofilament suture - a polyester made of poly (p-dioxanone); provides extended wound support and only elicits slight tissue reaction; tensile strength is 70% at 14 days and 25% at 42 days; absorption minimal for the first 90 days and essentially complete within 6 months; low affinity for microorganisms (like other monofilament); used for soft tissue approximation, especially in pediatric, cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic) situations Nonabsorbable sutures Natural Surgical silk: made of raw silk spun by silkworm; may be coated with beeswax or silicone; considered by many surgeons as the standard of performance (superior handling characteristics); although classified as nonabsorbable material, becomes absorbed by proteolysis and often is undetectable in the wound by 2 years; tensile strength decreases with moisture and lost by 1 year; problem - acute inflammatory reaction triggered by it; host reaction leads to encapsulation by fibrous connective tissue. Surgical cotton: made of twisted, long, staple cotton fibers; tensile strength is 50% in 6 months and 30-40% by 2 years; nonabsorbable and becomes encapsulated within body tissues. Surgical steel : made of stainless steel (iron-chromium-nickel-molybdenum alloy) as a monofilament and twisted multifilament; can be made with flexibility, fine size, and the absence of toxic elements; high tensile strength with little loss over time and low tissue reactivity; holds knots well; used primarily in orthopedic, neurosurgical, and thoracic applications; also may be used in abdominal wall closure, sternum closure, and retention; can be difficult to handle because of kinking, fragmentation, and barbing

Synthetic Nylon : polyamide polymer suture material available in monofilament and braided forms; elasticity makes it useful in retention and skin closure; quite pliable, especially when moist; braided forms are coated with silicone; has good handling characteristics, although its memory tends to return the material to its original straight form; has 81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years; is stronger than silk suture and elicits minimal acute inflammatory reaction; hydrolyzed slowly, but remaining suture material is stable at 2 years Polybutester (Novofil): made of a copolymer of polyglycol terephthate and polytrithylene terephthate; very elastic and has very low coefficient of friction = ideal for surface closure,

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permitting adequate tissue approximation while allowing for tissue edema and detumescence; does not lose tensile strength or become absorbed. Polyester fiber (Mersilene/Dacron [uncoated] and Ethibond/Ti-cron [coated]): formed from polyester, a polymer of polyethylene terephthalate; multifilament braided suture comes coated with polybutilate (Ethibond) or silicone (Ti-cron) = reduces friction for ease of tissue passage and improved suture pliability and tie-down; elicits minimal tissue reaction and lasts indefinitely in the body; stronger than natural fibers and do not weaken with moistening; provides precise consistent suture tension and retains tensile strength; commonly used for vessel anastomosis and the placement of prosthetic materials. Polypropylene (Prolene): an isostatic crystalline stereoisomer of a linear propylene polymer permitting little or no saturation; does not adhere to tissues and is useful as a pull-out suture (eg, subcuticular closure); holds knots better than other monofilament synthetics; biologically inert and elicits minimal tissue reaction.; not subject to degradation or weakening and maintains tensile strength for up to 2 years; useful in contaminated and/or infected wounds, minimizing later sinus formation and suture extrusion. SUTURE SELECTION Generally, the surgeon selects the smallest suture that adequately holds the healing wound edges. The tensile strength of the suture should never exceed the tensile strength of the tissue. As the wound heals, the relative loss of suture strength over time should be slower than the gain of tissue tensile strength. Aesthetic concerns are at a premium in the anatomic regions of the head and neck, such as the eyelid, periorbital area, nose, pinna, lip, and vermillion. In these areas, tensile strength requirements tend to be less, and smaller suture sizes are preferred. However, the mobility of the lip and vermillion requires a relatively higher suture tensile strength. The activity and mobility of the face, anterior/posterior neck, scalp, superior trunk, and nasal/oral mucosa demands higher tensile strength requirements in suture selection. Additionally, major musculocutaneous flaps tend to be closed under significant tension, requiring maximal long-term tensile strength. Certain general principles can be applied to suture selection. Sutures no longer are needed when a wound has reached maximum strength. Therefore, consider nonabsorbable suture in skin, fascia, and tendons (slowly healing tissues), while mucosal wounds (rapidly healing tissues) may be closed with absorbable sutures. Because the presence of foreign bodies in contaminated tissues may facilitate infection, special consideration of suture selection in these locations, such as a contaminated posttraumatic wound, is imperative. Multifilament sutures are more likely to harbor contaminants than monofilament sutures; thus, monofilament sutures generally are preferable in potentially contaminated tissues. Use the smallest inert monofilament suture materials, such as nylon or polypropylene, in this setting. Optimal suture size generally is the smallest size necessary to achieve the desired tension-free closure. If wound tension is high, smaller diameter sutures actually may injure tissues by cutting through them. Therefore, closely match the tensile strength of the suture and tissue. 60

NEEDLES Wound closure and healing is affected by the initial tissue injury caused by needle penetration and subsequent suture passage. Needle selection, surface characteristics of the suture (eg, coefficient of friction), and suture-coating materials selected for wound closure are important factors that must be considered by the surgeon. Ideal surgical needle characteristics

High quality stainless steel Smallest diameter possible Stable in the grasp of the needle holder Capable of implanting suture material through tissue with minimal trauma Sharp enough to penetrate tissue with minimal resistance Sterile and corrosion-resistant to prevent introduction of microorganisms/foreign materials into the wound

Needle performance characteristics/definitions Ductility - Resistance (of a needle) to breakage under a given amount of deformation/bending Sharpness - Measure of the ability of the needle to penetrate tissue. Factors affecting sharpness include the angle of the point and the taper ratio (taper length to needle diameter). Clamping moment - Stability of a needle in a needle holder, determined by measuring the interaction of the needle body with the jaws of the needle holder. Strength - Resistance to deformation during repeated passes through tissue (increased needle strength results in decreased tissue trauma) Ultimate moment - Measure of maximum strength determined by bending the needle to 90 degrees Surgical-yield moment - Amount of angular deformation that can occur before permanent needle deformation

ANATOMY OF A NEEDLE Point: This extends from tip to maximum cross-section of body. Body: incorporates the majority of length of needle; body is important for interaction with the needle holder and the ability to transmit the penetrating force to the point Swage: The suture attachment end creates a single continuous unit of suture and needle. The swage may be designed to permit easy release of needle and suture material (pop-off).

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Channel swage: A needle is created with a channel into which the suture is introduced, and the channel is crimped over the suture to secure it into place. The diameter of the channel swage is greater than the diameter of the needle body. Drill swage: Material is removed from the needle end (sometimes with a laser), and the needle is crimped over the suture. The diameter of the drill swage is less than the diameter of the needle body. Alternatively, the suture may be passed through an eye, similar to that found in a sewing needle. In a closed eye configuration, the shape may be round, oblong, or square. In a French (split or spring) eye, a slit is in the end of the needle with ridges that catch and hold the suture in place. Several disadvantages are associated with the use of a nonswaged needle. Tissue passage of a double strand of suture leads to more tissue trauma. In a swaged needle, the suture is less likely to become unthreaded prematurely. Also, decreased handling helps maintain suture integrity. Swaged sutures are not subject to suture fraying or damage due to sharp corners in the eye of eyed needles.

Needle coating: may be coated with silicone to permit easier tissue passage. The coating helps to reduce the force needed to make initial tissue penetration and the frictional forces as the body of the needle passes through the tissue. Needle measurements Chord length - Linear distance from the point of the curved needle to the swage (bite width) Needle length - Distance measured along the needle from the point to the swage. Needle length, not chord length (bite width), is the measurement supplied on suture packages. Radius - Distance from the body of the needle to the center of the circle along which the needle curves (bite depth) Diameter - Gauge/thickness of needle wire

Point types Taper point (round needle): penetrates and passes through tissues by stretching without cutting. A sharp tip at the point flattens to an oval/rectangular shape. The sharpness is determined by taper ratio (8:1-12:1) and tip angle (20-35 degrees). The needle is sharper if it has a higher taper ratio and lower tip angle. The taper point needle is used for easily penetrated tissues (eg, subcutaneous layers, dura, peritoneum, abdominal viscera) and minimizes potential tearing of fascia. Blunt point: dissects friable tissue rather than cuts it. The point is rounded and blunt, ideal for suturing the liver and kidneys. Cutting: At least 2 opposing cutting edges are present (point usually is triangular). Designed for penetration through dense, irregular, and relatively thick tissues. This point cuts a pathway through tissue and is ideal for skin sutures. Sharpness is due to the cutting edges. Conventional cutting: Three cutting edges are present (triangular cross-section that changes to a flattened body). The third cutting edge is on the inner concave curvature (surfaceseeking).

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Reverse cutting: The third cutting edge is on the outer convex curvature of needle (depthseeking); are stronger than conventional cutting needles and have a reduced risk of cutting out tissue; designed for tough-to-penetrate tissue (eg, the skin, tendon sheaths, oral mucosa); beneficial in cosmetic and ophthalmic surgery, causing minimal trauma. Side-cutting (spatula): flat on top and bottom surfaces to reduce tissue injury; allow maximum ease of penetration and control as they pass between and through tissue layers; designed initially for ophthalmic procedures.

Body types Straight: used to suture easily accessible tissue that can be manipulated directly by hand; useful in microsurgery for nerve and vessel repair; e.g. Keith needle, which is a straight cutting needle used for skin closure of abdominal wounds, and the Bunnell needle, which is used for tendon/GI tract repair. Half-curved ski: used in skin closure because of difficulty handling the needle. The straight portion of the body does not follow the curved point, resulting in an enlarged curved point, which makes handling of the needle difficult. Curved: has a predictable path through tissue and requires less space for maneuvering than a straight needle. The semicircular path is the optimal course for suture through tissue and provides an even distribution of tension. Body curvature commonly is 1/4, 3/8, 1/2, or 5/8 circle. Three-eighths circle most commonly is used for skin closure. One-half circle was designed for confined space, and more manipulation by the surgeon is required (ie, increased wrist motion is required). Compound curved: This needle curvature originally was designed for anterior segment ophthalmic surgery. The body has a tight 80-degree curvature at the tip, which becomes a 45-degree curvature throughout the remainder of the body. A microvascular compound curved needle also may facilitate vessel approximation in microvascular surgery. Needle/Needle Holder Interaction And Selection Criteria The stability of the needle within the needle holder affects needle control and performance. The jaws of the needle holder must be appropriate to the needle size to hold it securely and prevent rocking, turning, and twisting. An ovoid cross-section of the needle body often maximizes both the surface contact with the needle-holder jaws and the bending moment of the needle. The needle-holder handle must be appropriate for the depth needed for placement of the suture. The difference between length of the handle and the jaw creates a mechanical advantage for exerting force through the needle point. Needle-holder clamping moment is the force applied to a suture needle by a needle holder. The jaws of the needle holder contact a curved needle at 1 point on the outer curvature and 2 points along the inner curvature. The force against the needle creates a moment arm, which acts to flatten the curvature of the needle. Technically speaking, the needle-holder clamping moment must be less than the surgical yield of the needle, or the needle will bend and ultimately may break. A bent needle takes a relatively traumatic path through soft tissue and may cause increased soft tissue injury. Repetitive injury by the needle holder also may cause the needle to break. If the broken portion of the needle is not identified and retrieved immediately, surgery may be delayed in efforts to find it. The need for intraoperative radiology and other potential difficulties may ensue. 63

Selection criteria No standardized sizing system or nomenclature is available for needles or needle holders. The main consideration in needle selection is to minimize trauma. A taper needle is sufficient for tissues that are easy to penetrate. Cutting needles typically are reserved for tough tissues. As a general guide, select tapered sutures for all closures except skin sutures. The length, diameter, and curvature of the needle influence the surgeon's ability to place a suture. The needle-body diameter ideally matches the suture size. Suturing Techniques Simple suture or everting interrupted suture Insert the needle at a 90 angle to the skin within 1-2 mm of the wound edge and in the superficial layer. Exit the needle through the opposite side equidistant to the wound edge and directly opposite the initial insertion. Oppose equal amounts of tissue on each side. A surgeon's knot helps place the nonabsorbable suture. Strive to evert the edges and avoid tension on the skin, while approximating the wound edges. Place all knots on the same side. Simple running suture This suture method entails similar technique to the simple suture without a knotted completion after each throw. Precision penetration and tissue opposition is required. The speed of this technique is its hallmark; however, it is associated with excess tension and strangulation at the suture line if too tight, which leads to compromised blood flow to the skin edges. Another variant is the simple locked running suture, which has the same advantages and similar risks. The locked variant allows for greater accuracy in skin alignment. Both styles are easy to remove. Additionally, the running sutures are more watertight. Mattress suture Vertical mattress sutures can aid in everting the skin edges. Employ this technique also for attachments to a fascial layer. The needle penetrates at 90 to the skin surface near the wound edge and can be placed in deeper layers, either through the dermal or subdermal layers. Exit the needle through the opposite wound edge at the same level, and then turn it to repenetrate that same edge but at a greater distance from the wound edge. The final exit is through the opposing skin edge, again at a greater distance from the wound edge than the original needle entrance site. Place the knot at the surface. A knot placed under tension risks a stitch mark. The horizontal mattress can be used to oppose skin of different thickness. With this stitch, the entrance and exit sites for the needle are at the same distance from the wound edge. Half-buried mattress sutures are useful at corners. On one side, an intradermal component exists, in which the surface is not penetrated. Place the knot at the skin surface on the opposing edge of the wound. Subcuticular suture

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Sutures can be placed intradermally in either a simple or running fashion. Place the needle horizontally in the dermis, 1-2 mm from the wound edge. Do not pass the needle through the skin surface. The knot is buried in the simple suture, and the technique allows for minimization of tension on the wound edge. In a continuous subcuticular stitch, the suture ends can be taped without knotting to the skin surface. References:

Edlich RF, Towler MA, Rodeheaver GT, et al: Scientific basis for selecting surgical needles and needle holders for wound closure. Clin Plast Surg 1990 Jul; 17(3): 583-602 Herrmann JB: Tensile strength and knot security of surgical suture materials. Am Surg 1971 Apr; 37(4): 209-17 Sykes JM, Byorth PJ: Suture needles and techniques for wound closure. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis, Mo: Mosby; 1995. Tera H, Aberg C: Tissue holding power to a single suture in different parts of the alimentary tract. Acta Chir Scand 1976; 142(5): 343-8 Van Winkle W Jr, Hastings JC: Considerations in the choice of suture material for various tissues. Surg Gynecol Obstet 1972 Jul; 135(1): 113-26 VanWinkle W Jr: The healing of skin and visceral wounds and the effect of suture materials. In: Krizek TJ, Hoopes JE eds. Symposium on Basic Science in Plastic Surgery. St. Louis, Mo: Mosby; 1976.

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