1
Q
What disease processes have a strong/high recommendation for the use of antithrombotics?
A
- IMHA
- Feline cardiomyopathy
- PLN
- > 1 disease/risk factor for thrombosis
2
Q
What disease processes should antithrombotics be considered to be used in but not always recommended?
A
moderate risk or only really risk if in combo with others:
- pancreatitis (d)
- glucocorticoids (d)
- Cancer
- Heart disease (d)
- sepsis (d)
- HyperA
3
Q
What type of thrombosis is usually seen with IMHA?
A
- PTE
4
Q
What type of thrombosis is usually seen with feline cardiomyopathy?
A
- Arterial (minimal evidence for venous)
5
Q
What type of thrombosis is usually seen with PLN?
A
- PTE >ATE> venous
6
Q
What type of thrombosis is usually seen with pancreatitis (d)?
A
- splenic vein thrombosis
- ATE
- portal vein thrombosis
7
Q
What neoplasias are most commonly associated with thrombosis?
A
- round cell
- carcinoma
- adrenal tumour
8
Q
Are antiplatelet or anticoagulants recommended for venous thrombosis prevention? Give example of this
A
- Anticoagulant
PTE due to HE => heparin superior to aspirin.
9
Q
Are antiplatelet or anticoagulants recommended for ATE prevention? Give example
A
- antiplatelet
Cats with FATE - clopidogrel
10
Q
When is aspirin recommended?
A
- prevention of ATE in dogs and cats
11
Q
When is clopidogrel recommended?
A
- prevention of ATE in dogs and cats
12
Q
When should antithrombotic drugs be discontinued?
A
- if high risk of thrombosis, should not be discontinued for invasive procedures but if multiple agents used, then reduce to single antiplatelet drug
- for low to moderate risk of thrombosis, discontinue 5-7 days prior
- if the underlying cause and the thrombus has resolved.
restart as soon as possible post op provided not ongoing bleeding.
13
Q
What antithrombotics should be weaned before discontinuation?
A
- UFH
- Direct Xa inhibitors.
14
Q
What are other causes of feline pancreatitis apart from idiopathic?
A
> 95% = idiopathic.
- Infectious
- parasites (Toxoplasma gondii, Eurytrema procyonis, Amphimerus pseudofelineus)
- viruses (coronavirus, parvovirus, herpesvirus, calicivirus) - Trauma inc surgery or hypotension
- Neoplasia
- Toxins:
- topical fenthion
- KBr
- Phenobarb
- hypercalcaemia
- snake bite. - Autoimmune
- With concurrent disease:
- diabetes mellitus,
- chronic enteropathies,
- hepatic lipidosis,
- cholangitis,
- nephritis
- IMHA
15
Q
What are u/s findings of acute pancreatitis in cats?
A
- equivocal or - pancreatic enlargement, - hyperechoic surrounding mesentery, - focal abdominal effusion - distension/corrugation of duodenum
16
Q
What does a normal feline pancreas look like on MRI? and with pancreatitis?
A
Normal: T1 hyperintense and T2 isointense to hypointense
Pancreatitis:
- T1 hypointensity
- T2 hyperintensity of the parenchyma,
- enlargement of the pancreas,
- pancreatic duct dilatation
- contrast enhancement.
17
Q
What is the PPV and NPV of Spec fPL in sick cats?
A
Specific and sensitive - better with more severe cases.
PPV 90%
NPV - 76%
18
Q
How should a “normal” and “abnormal” snap fPL be interpreted?
A
- normal - unlikely to have pancreatitis
- abnormal - may have pancreaitis.
19
Q
What is the difference in inflammatory cell types with acute suppurative vs chronic feline pancreatitis?
A
Acute - neutrophilic +/- necrosis, oedema
Chronic - lymphocytic or mononuclear + fibrosis or cysts
20
Q
What are the treatment recommendations for feline acute pancreatitis?
A
- treat any inciting cause
- IVFT
- Antiemetics (maropitant/ondans)
- gastric prokinetics (metoclop may be contraindicated due to dopamine antagonism, but no clinical studies support this. otheriwse cisapirde ro erythomycin)
- analgesia - buprenorphine/methadone/fent, maropitant, tramadol or gaba
- appetite stim - mirtazapine or capromorellin + feeding tube if req
- Gastrointestinal diet.
Abs and corticosteroids not recommended for the pancreatitis but may be indicated if concurrent disease would benefit from them
21
Q
What are the treatment recommendations for feline chronic pancreatitis?
A
- analgesia
- nutrition support (no specific diet recommended)
- antiemetic
- appetite stim
- cobalamin
- pred at antiinflam or immunosuppressant levels provided not hyperglycaemia. if so consider cyclosporine.
Abs not recommended
22
Q
What are the 5 main phenotypes of feline cardiomyopathy
A
- HCM
- Diffuse or regional increased LV wall thickness with a nondilated LV chamber. - RCM:
- Endomyocardial form: prominent endocardial scar that usually bridges the interventricular septum and LV free wall, => fixed, mid-LV obstruction and often apical LV thinning or aneurysm;
+ LA or biatrial enlargement is generally present.
- Myocardial form Normal LV dimensions (including wall thickness) with LA or biatrial enlargement - Dilated cardiomyopathy (DCM)
- LV systolic dysfunction with
increase in ventricular dimensions,
normal or reduced LV wall thickness,
atrial dilatation. - ARVC:
- Severe RA and RV dilatation
+/- RV systolic dysfunction and RV wall thinning.
+/- left side affected
- Arrhythmias and RSCHF - Nonspecific phenotype/unclassified
- A cardiomyopathic phenotype that is not adequately described by the other categories
23
Q
What proportion of cats have HCM?
what are the main clinical presentations?
A
- 15-30%
Presenation:
- asymptomatic
- CHF
- FATE
24
Q
What are the following genetic abnormalities associated with and in which breeds:
- MyBPC3-A31P
- MyBPC3-R820W
A
MyBPC3-A31P: myosin binding protein C in HCM in Maine Coon cats. = 35-42
MyBPC3-R820W: myosin binding protein C in HCM in ragdolls/
25
What are markers of increased risk of CHF or ATE in cats with HCM?
- a gallop sound or arrhythmia
- moderate to severe LA enlargement,
- decreased LA fractional shortening (LA FS%),
- extreme LV hypertrophy,
- decreased LV systolic function,
- spontaneous echo-contrast or intracardiac thrombus,
- regional wall thinning with hypokinesis,
- restrictive diastolic filling pattern
26
Is a palpable thrill (grade 5-6/6 murmur) in cats more likely associated with cardiomyopathy or congenital malformation?
Congenital malformation
27
What does an increased NT-proBNP in a cat with resp distress suggest?
What samples can it be checked on?
- more likely cardiac than respiratory origin
| - plasma or pleural effusion
28
What is NTproBNP used for in cats?
If echo is not available
Differentiate severe subclinical disease from mild or normal cats
differentiate cardiac or non-cardiac origin of resp distress/pleural effusion
29
What is normal end diastolic LV wall thickeness in most cats?
<5 mm
30
What treatment is recommended for stage B2 cardiomyopathy cats?
- clopidogrel
+/- aspirin
+/- Xa inhibitor (rivaroxaban)
(high risk - use additional meds, up to all 3)
If ventricular ectropy is present then atenolol or sotolol
if Afib - diltiazem, atenolol or sotolol
31
When should pimobendan be used in cats with cardiomyopathy?
- CHF without dynamic LVOFTO, especially if signs o low cardiac output inc, hypotension, hypothermia, bradycardia (INI - dobutamine)
- maybe chronic CHF without dynamic LVOFTO
32
Is thromboylic teatment recommended for cats with ATE?
no
33
In acute ATE, what drugs are recommended for cats?
| When discharged home, what drugs are recommended?
- analgesia (mu opioid)
- anticoag - LMWH, uFH or Factor Xa inhibitor.
- CHF management - frusemide, O2
at home:
- clopidogrel + Factor Xa inhibitor
- ongoing CHF management as appropriate
34
What are the different classes of pulmonary hypertension?
Group 1: pulmonary arterial hypertension including:
- idiopathic
- heritable
- drugs (tramadol, cyclosporine, amiodarone, cyclophosphamide)
- congenital hunts
- pulmonary vasculitis
- pulmonary vascular amyloid depoits
Group 2: secondary to left heart disease
- MMVD, DCM, outflow tract obstructions etc
Group 3: Secondary to respiratory disease, hypoxia or both:
- chronic obstructive airway disease
- pulmary parenchymal disease inc fibrosis, eosinofili pneumonia, infectious pnumoni, difffuse neoplasia
- high altitude
- westies - nonspecific interstitial pneumonitis (pred + mycophenolate)
Group 4: Pulmonary emboli, thrombi or thromboemboli.
Group 5 - parasitic (HW or angiostrongylus)
35
What are the pathophological causes of pulmonary hypertension and give examples?
1. Increased pulmonary blood flow
- L to R shunt eg PDA
2. Increased pulmonary vascular resistance
- pulmonary epithelial disease
- vasc remodelling
- perivasc inflam
- vasc lumen obstruction
- increased blood viscosity
- arterial wall thickness
- lung parenchyma destruction
3. Increased pulmonary venous pressure
- left heart disease
- compression of large pulmonary vein
36
What areas are looked at on echo to assist in diagnosis of pulmonary hypertension?
1. Ventricles
- flatten IVS esp during systole
- underfilling LV
- RV hypertrophy
- RV systolic dysfunction
2. Pulmonary Artery
- enlargement (PA/Ao >1.0)
- early peak diastolic pul regurg > 2.5m/s
- Right pul art distensibility <30%
- R outflow doppler acceleration tie (<52-58m/s) pr acceleration time to jection ratio (<0.30)
- systolic notiching of doppler RV outflow profile
3. Right atrium or CVC enlargement
* LA enlargement is a crude surrogate for chronically increased pul art wedge pressure
37
What measurements are used on echo to assess pulmonary hypertension?
1. Peak tricuspid regurg velocity
<3 - low
3-3.4 - intermediate
>3.4 - high probably of pul hypertension.
Increased risk level if other echo signs of pul hypertension noted.
2. Calc pressure gradient between RV and RA (= 4 x velocity {m/s}2) in diastole
> 15mmHg supports diastolic pul art hypertension.
38
What are pre-capillary causes of pulmonary hypertension and what echo changes/measurements are expected?
- Group 1 (pul art hypertension)
- Group 3 (resp disease/hypoxia)
- Group 4 (TE)
- Group 5 (parasitic)
no La enlargement
mean PAP >25mHg
PAWP <15mmHg
Increased pulmonary vasc resistance.
39
What are the post-capillary causes of pulmonary hypertension and what echo changes/measurements are expected
- Group 2 (Left heart disease)
- Group 6 (multi-factorial)
- La enlargement
- PAP > 25mmHg
Isolated post:
Diastolic pressure gradient <7mmHg
Pul vasc resistance not increased
Mixed pre and post:
Diastolic pressure gradient >7mmHg
Pul vasc resistance increased
40
What is the recommended measurement of intermediate to high likelihood of pulmonary hypertension?
Tricuspid regug > 46mmHg
Tricuspid regurg velocity >3.4m/s
~moderate pul hypertension.
Take into account shoudl be present with clinical signs of pul hypertension as well.
41
When should echo be used to assess for pulmonary hypertension?
1. if clinical signs + after physical exam and TXR rule out other causes
2. If TXR shows
- tortuous, blunted, or dilated pulmonary arteries;
- asymmetric radiolucent lung fields
- patchy, diffuse alveolar infiltrates
- bulge in the region of the pulmonary trunk or right-sided cardiac enlargement
3. Clinical signs + ascites or dilated CVC or hepatic veins.
4. Suspected parasitic or high risk of PTE
5. If CT shows:
- A pulmonary trunk-to-descending aorta ratio ≥1.4170
- Evidence of RA and RV enlargement
- decreased pulmonary vein-to-PA ratio, increased pulmonary trunk-to-ascending aorta ratio, increased RV-to-LV ratio
- pulmonary arterial filling defects
- mosaic attenuation pattern showing small vessels in a region of decreased attenuation (ie, hypoperfusion) on an inspiratory scan that fails to show accentuation of the mosaic attenuation pattern on an expiratory scan (ie, ruling out air trapping)
- Perivascular diffuse nodular to ill-defined patchy ground-glass opacity with a global distribution, compatible with pulmonary capillary hemangiomatosis (PCH) or pulmonary veno-occlusive disease (PVOD
6. If histopath shows whide spread pulmonary vascular disease
42
What general recommendations are recommended for dogs with high probability of pulmonary hypertesion?
- Exercise restriction
- Prevention of infectious resp disease inc HW, antiostrongyulus and KC
- Avoidance of pregnancy
- Avoidance of high altitude and air travel
- Avoidance of nonessential wellness procedures (eg, dental cleanings) and elective surgery requiring general anesthesia
43
With pulmonary hypertension, when is a PDE5i not recommended?
Group 1
- occlusive cellular or fibrotic vascular occlusive lesion (pulmonary vasculaitis or amyloid deposition) as could => pul oedema. Start in hospital if needed
Group 2
- uncontrolled LSCHF => pul oedema
All others, maybe useful? need to treat underlying disease first/concurrently.
44
What are the signs of pulmonary hypertension?
Strongly suggestive:
- syncope esp with activity, with no other cause
- Resp distress at rest
- Activity or exercise terminating in resp distress
- RSCHF
Possible pulmonary hypertension:
- tachyponea at rest
- increased resp effort at rest
- prolonged post-exercise or post activity tachyponea
- cyanotic or pale mucous membranes.
45
What are the signs of immune mediated RBC destruction?
- Spherocytes (dog)
- positive saline agglutination test
- positive saline agglutination test that persists with washing
- positive Coombes/Direct antiglobulin test or flow cytometry
46
What are signs of haemolysis?
Without funtion liver disease, post hepatic cholelestasis or sepsis:
- hyperbilirubinaemia
- significant bilirubinuria
- icterus
- Haemoglobinaemia
- haemoglobinuria
- RBC ghost cells.
47
What are non-immune mediated causes of spherocytes?
- oxidative damage
- acetaminophen
- envenomation
- hypersplenism (hepatosplenic lymphoma)
- pyruvate kinase deficiency
- RBC fragmentation (endocarditis, HSA, haemolytic uremic syndrome etc)
- dyserythropoiesis.
48
What is the threshold of spherocytes seen in blood to be considered IMHA?
sens and spec of this?
> or = to 5 spherocytes/x100 oil immersion filed
63% sens
95% spec
49
What is the spec of saline agglutination test for detecting IMHA?
4:1 saline to blood = 100%
50
What is the sens and spec of Coombs/DAT for IMHA in dogs and cats?
Dog
Sens: 61-82%
spec: 94-100%
Cat
Sens: 82%
Spec: 95-100%
51
What anticoagulants are recommended (in order of preference) for IMHA management?
why?
When not to use?
1. Unfractionated heparin (+/- antiplatelet)
2. LMH or Factor Xa inhibitor
3. Clopidogrel +/- aspirin
4. Aspirin
Predominantly venous thrombosis => thrombi formation is more dependant on Coag/fibrin than PLTs.
Not if PLT <30
52
What drugs are recommended for immunosuppression in IMHA?
1. Pred 2-3mg/kg or 50-60mg/m2/day for dogs >25kg
Second line:
- Azathioprine
- cyclosporine
- mycophenolate.
53
When should a second line immunosuppressant be started in dogs with IMHA?
second line if:
- severe, life threatening
- PCV not stable with decrease >5% in 24h in the first 7 days of treatment
- expected to have adverse reaction to pred
- increased BUN or Tbili (negative prognostic factors in other studies)
54
When do you start weaning the immunosuppressants used for IMHA?
When the PCV/Hct has remained stable and >30% for 2 weeks after starting treatment,
+
an improvement in the majority of measures of disease activity (spherocytosis, agglutination, TBil level, reticulocyte count),
=> decreased prednisolone by 25%.
55
What infectious agents are associated with acute hepatitis?
- toxoplasma
- neospora
- sarcocystis
- Histoplasma
56
What infectious agents are associated with chronic hepatitis and what is the predominant inflammatory type?
- Lepto - pyogranulomatous
- Mycobacteria - granulomatous
- Anaplasma - granulomatous
- E. canis - mixed
- babesia - non--suppurative.
57
What are the following mutations associated with? and in what breeds?
- COMMD1 deletion mutation affecting ATP7B protein
- ATP7A and ATP7B
Copper toxicity
- COMMD1 deletion mutation affecting ATP7B protein - bedlington terrier
- ATP7A and ATP7B - labrador.
58
What metabolic genetic conditions may be associated with chronic hepatitis and in what breeds?
- alph-1 antitrypsin - cocker spaniels
| - erythropoietic protoporphyria in German shepherds.
59
What is the earliest biochemical indicator of chronic hepatitis?
ALT followed by ALP then GGT
60
What staining can be used to provide a subjective assessment of copper accumulation?
Where does copper usually accumulate if pathologic?
Rhodanine/rubeanic acid staining
Pathologic = centrilobular
Periportal often non-specific:
61
What additional staining/techniques can be used to assess for infectious hepatitis on liver biopsies?
- Acid fast: Mycobacteria
- Periodic acid Schiff stain or silver stain: Fungi
- FISH for bacteria
- Immunohistochemistry for virus and protozoa
62
What treatment is recommended for copper hepatitis?
1. dietary copper restriction
+ use distilled bottled water
2. D penicillamine for 6-9m to normal ALT or on repeat biopsy + treat for further 1 month.
3. Zinc after chelation
4. SAMe or Vit E to reduce oxidative injury
5. +/- immunomodulatory therapy
63
What immunomodulatory therapy is recommended for chronic hepatitis?
- Pred +/- cyclosporine
| maybe azathiopine or mycophenolate.
64
What are the criteria for stage B2 MMVD?
- murmur intensity ≥3/6;
- LA : Ao ratio in early diastole ≥1.6
- Left ventricular internal diameter in diastole, normalized for body weight (LVIDDN) ≥1.7
- breed-adjusted, vertebral heart score (VHS) >10.5. (or VHS >11.5 if breed adjustment to possible)
likely VLAS > or = 3
65
What medications are recommended fro dogs with stage B2 mMVD?
only pimobendan +/- cough suppressant
66
What is NT-proBNP useful for in dogs with clinical signs of heart failure?
if normal or near normal, then unlikely to be CHF and clinical signs are more likely to be pulmonary related.
67
What disease are associated with systemic hypertension?
- CKD
- AKI
- DM
- HyperA
- Hyperaldosteronism
- Phaeo
- HypoT4
- HyperT4
68
What toxicities are commonly associated with systemic hypertension?
- Cocaine
- Methamphetamine
- 5-hydroxytryptophan (serotonin precursor)
69
What drugs may cause systemic hyper tension?
- Glucocorticoids
- DOCP
- EPO
- Phenylpropanolamine
- Phenylephrine
- Pseudoephedrine
- Ephedrine
- Toceranib
- Cyclosporine (humans)
70
What brain damage can be seen with hypertension?
- Encephalopathy (white matter oedema: occipital and parietal lobes)
- Vascular accidents
- Cranial cervical myelopathy (ischaemic) in old cats: tetraplegia.
CSx: altered mentation, seizures, vestibular signs, focal CN deficits.
Higher risk with rapid hypertension or hypertension greater than 180mm Hg.
71
What are the recommended first line drugs for hypertension in dogs and cats?
Dog - ACEi +/- amlodipine of SBP >200mmHg
Cats - amlodipine
72
What medications are recommended for the management of hypertension in patients with phaeo?
phenoxybenzamine (alpha adrenergic block)
+/- beta blocker (atenolol) once alpha adrenergic stim is well controlled.
73
What treatment is recommended in patients with SBP >180mmmHg and signs of intracranial target organ damage?
Emergency treatment.
If sustained hypertension, need to incrementally decrease BP otherwise hypoperfusion => need to be titratable drug
1. Fenoldopam (dopamine-1 agonist): renal arterial vasodilation ** (none of the others do this), natriuriesis and increased GFR.
2. Labetalol: alpha and beta antagonist
3. Hydralazine: smooth muscle relaxant (direct vasodilator)
4. Nitroprusside: NO vasodilator
5. Phentolamine: alpha blocker, reported in phaeo surgery
If no TOD => Hydralazine or amlodipine to reduce BP faster.
74
What antibodies to borrelia burgdorferi are only present in naturally infected dogs, not vaccinated?
antibodies against:
- C6
- VLsE (variable major protine-like sequence, expressed)
- OspF
75
Antibodies to what are stimulated by vaccination against B.burgdorferi?
- OpsC
76
What antibodies to borrelia burgdorferi are present in both naturally infected and vaccinated dogs? What does this mean from a testing perspective?
- OpsC
If not vaccinated and positive for Abs again OpsC then likely recent exposure.
If vaccinated and postivie for Abs against OpsC then could be exposure or vaccination => look at other abs that are not stim by vaccination (C6, VLsE or OspF)
**Presence of positive Abs doesn't = cause of clinical signs or prediction of developing clinical signs.
77
What testing is recommended to confirm borrelia b exposure in clinically unwell animals?
Which of these are quantitative and for what?
Serology with C6 based testing:
- SNAP4Dx
- SNAP4DxPlus
- Lyme Quant C6
- Vetscan canine lyme rapid assay
- Accuplex4 test
- Multiplex test.
Quantitative:
- Lyme Quant C6 - for C6
- Multiplex - OspA, OspC and OspF
78
After treatment for lyme borreliosis what monitoring is recommended?
Why?
Measurement of quantitative titres to C6 +/- OspF before and 6 months post treatment
- establish a new baseline post treatment
- confirm reduction in antigenic load.
79
What testing is not recommended for Lyme disease in clinically unwell animals?
why?
- Whole cell ELISA
- IFA
- Western blot
- cross reaction with other spirochete
- IgM vs IgG because dogs do not usually present with acute illness.
80
Should non clinical dogs with positive Bb serology be treated with antibiotics?
- generally no.
81
Should unwell or proteinuric dogs be vaccinated against lyme disease?
- no
82
What is the recommended treatment for lyme arthritis and lyme nephritis?
polyarthritis - doxycycline 10mg/kg/day for 1 month
Nephritis - doxycycline for 1-3 months
+/- mycophenolate +/- short course pred if patients are not responding to antibiotics alone + standard PLN management.
83
When is it recommended to start anti-epilepsy medications?
- Identifiable structural lesion present or previous history of brain disease or injury
- Seizure ≥ 5 min duration
- ≥ 3 generalized seizure in 24h
- ≥ 2 seizures in 6 month period
- Prolonged, severe or unusual postictal period.
84
What initial drugs as monotherapy are recommended for dogs with seizures?
- Phenobarbital
- Imepitoin
+/- Bromide (less effective)
85
When should a second anti-epilepsy medication be added?
What additional factors should be considered for this next medication?
- increasing seizure frequency, severity (duration, cluster, post ictal) and overal QOL.
factors to consider:
- Selection of an AED with a different MOA
- Minimizing drug-drug interactions
- Avoiding additive toxicity
- Determination of risk-benefit of polypharmacy versus quality of life
86
What adjunctive therapies could be considered for seizure managment?
- Vagal nerve stimulation
- accupuncture
- dietary - use of medium chain triglyceride diet.
- maybe CBD oil?
87
What condition is most likely?
1. ↑TSH, ↓ TT4, ↓ FT4, ↑ AntiTg Ab
2. ↓ TSH, ↓ TT4
3. ↓ TSH, ↓ TT4 + ↓ TRH
4. ↓ TSH, ↓ TT4 + ↑ TRH
5. ↑ TSH, normal TT4, ↑ AntiTgAb
6. ↑ TSH, ↓ TT4, ↓ FT4, ↓AntiTgAb.
1. ↑TSH, ↓ TT4, ↓ FT4, ↑ AntiTg Ab
- overt lymphocytic/immune med hypothyroidism
2. ↓ TSH, ↓ TT4
- sick euthyroid
- Secondary hypothyroid
- Tertiary hypothyroid
3. ↓ TSH, ↓ TT4 + ↓ TRH
- Tertiary hypothyroid
4. ↓ TSH, ↓ TT4 + ↑ TRH
- secondary hypothryoid
5. ↑ TSH, normal TT4, ↑ AntiTgAb
- subclinical lymphocytic/immune med hypothyroidism
6. ↑ TSH, ↓ TT4, ↓ FT4, ↓AntiTgAb.
- likely non-inflammatory, atrophic, hypothryoidism
(ddx sick euthyroid can occasionaly have increased TSH but not routinely)
88
What genetic mutation is associated with pituitary hypoplasia?
What are the clinical signs?
What hormone production is reduced?
- LHX3
- proportionate dwarf with secondary hypothyroidism.
- Malformation of atlantoaxial joint.
↓ Growth Hormone
↓TSH
↓ Prolactin
↓ Gonatotropin
* ACTH ok.
89
What is LHX3 mutation asssociated with?
| What is the treatment?
Combined pituitary hormone deficiency
(↓ Growth Hormone, ↓TSH, ↓ Prolactin, ↓ Gonatotropin, normal ACTH)
- Levoxythryine
- Porcine growth hormone or progestin (medroxyprogesterone acetate)
90
What infectious disease can cause primary hypothyroidism?
- leishmania
91
What are the two different types of congenital hypothyroidism and what is the clinical difference?
1. Hypothalamic-pituitary acid deficit (Central congenital hypothyroidism)
=> TSH deficiency +/- ↓GH and Prolactin
- Giant schnauzer
- no goitre
2. T4 receptor deficiency or or TPO mutation.
Occurs with:
iodine deficiency (dam or pups), dyshormonogenesis or thyroid dysgenesis.
=> goitre
=> dysproportionate dwarfism (cretinism)
92
What coagulation factors could be affected by hypothyroidism?
- Factors VIII and IX
- vWF
- Platelet adhesion.
93
What changes with thyroid scintigraphy are expected with:
- Normal dogs
- Primary hypothryoidism
- Secondary hypothryoidism
- Congenital iodination defects
- non-thyroidal illness
- Thyroiditis
- Normal dogs: 1:1 thyroid to salivary gland uptake
- Primary hypothryoidism: <0.33 uptake and small gland
- Secondary hypothryoidism: low/undetectable uptake
- Congenital iodination defects: normal to increased uptake with low TT4
- non-thyroidal illness - normal
- Thyroiditis - can be false +ve with normal to increased uptake in hypothyroid dogs.
94
What potential neurological changes are seen with hypothryoidism?
- CP defecit
- reduced spinal reflexes
- Cranial nerve dysfunction
- facial
- vestibulochoclear (Vestibular)
- trigeminal
- laryngeal paralysis?
95
What radiation is produced from I131 therapy? and what does it induce?
- gamma rays and Beta particles.
| B-particles=> ionising effect => follicular cell death.
96
How does carbimazole/methimazole control hyperthyroidism?
- concentrated within thyroid gland and inhibits:
- oxidation of iodine
- organification
- couple of T3 and T4 via inhibition of thyrogloblin peroxidase
=> inhibites synthesis of thyroid hormones
* no peripheral effects.
97
What is a "cold nodule" on thyroid scintigraphy?
- no uptake suggestive of either poorly differentiated or other type of thyroid tumour.
98
What scintigraphy findings are suggestive of thyroid carcinoma?
- ectopic tissue/mets
- mediasteinal mass
- distorted thryoid gland
- multiple foci of uptake
- hterogenous or irregular margins
- extension into the thoracic inlet
- linear multifocal uptake => suggest extension along fascial planes.
99
On scintigraphy, what aspects assist in determining if a thyroid mass is resectable or functional?
resectable:
- solitary
- homogenous
- well defined borders
Function:
- homogenous and diffuse uptake.
- usually grader the 1:1 update with salivary gland
100
What medications can interfere with scintigraphy?
- methimazole
- ioheol/iodine contrast
- ketamine and midazolam
101
What is the recommended managment options for canine thyroid tumours?
- no mets
- non-resectable or incomplete resection
no mets + resectable = surgery.
```
non-resectable:
- debulking + chemo/I131/radiation
- radiation MST 2y
- I131
- Chemo:
metronomic chlorambucil (2y)
Doxo - 9m
palladia 6m
Cisplatin 3m
```
102
What is the renal tubular threshold for glucose in dogs and cats?
Dogs - 10-12mmol/L
| Cat - 11-16mmol/L
103
What are the blood glucose targets in diabetes management for?
- all values
- average
- nadir
- duration of effect
- all values: <17mmol/L
- average <14mmol/L
- nadir 4.5-7.3 mmol/L and occurring < 8h or >12h after injection.
- Duration of effect -10-14h.
104
Why are diabetic patients polyphagic?
Inability of glucose to enter satiety center in the brain => ongoing stimulation.
105
What dose stomatostatin do in relation to blood glucose control? What are 3 drugs that mimic this effect?
Stomatostatin - growth hormone inhibiting hormone
- inhibits secretion of insulin and glucagon.
- inhibits growth hormone release
=> decreases/stabilizes blood glucose
Stomatostatin analogues:
- Pasireotide
- Lanreotide
- Octreotide
106
A reduced sensitivity to glucose by which transporter is associated with insulin resistance in cats?
- GLUT-4
107
When is a diabetic cat considered to be in remission?
no insulin + 4 weeks of normoglycaemia
- Blood glucose between 4.5-7mmol/L
- fructosamine <350umol/L
108
What is hyperosmolar hyperglycaemia?
| When does this mean for treatment?
```
blood glucose >34mmol/L
Osmolality >350mosm/kg
- no ketosis
+/- acidosis (lactic vs BHB so could be DKA)
Dehydration
```
- Has often been going on much longer than DKA
- Need to rehydrate first before giving insulin
- slowly reduce blood glucose as rapid changes in BG can lead to risk of cerebral oedema from ECF osmolality changes.
- aim for 2.8mmol/L/h reduction in blood glucose.
109
What are the aims of DKA treatment?
- restore hydration/water and elyte losses (K+, phos, Na+ and Mg+)
- Give adequate insulin to suppress liposysis, ketogenesis and hepatic gluconeogenesis
- correct acidosis (IVFT +/- biocarb)
- Identify factors that precipitated DKA
- Provide carbohydrate source when needed to allow ongoing insulin without hypoglycaemia
- slowly return to normal over 24-48h
110
When should you change to SC insulin from CRI in DKA patients?
Blood glucose <14mmol/L
- no ketones
- off IVFT
- eating well.
111
What changes are expected with eletrolytes with DKA and during DKA treatment?
K+, Mg++, Phos and Na+
- lost during DKA but serum levels variable and may be normal, ↓ or ↑
With insulin => moved intracellular or increased losses through urine
=> ↓ K+, ↓Mg++, ↓Phos, ↓Na+
all should be supplemented with insulin
↓ Mg+ =>
↓ K+ (loss via kidneys)
↓ Ca++ (due to inhib of PTH by ↓ Mg+)
↓ Na+
112
What is the primary ketone produced with DKA ? How is this measured?
BHB
- need to check blood levels as not detected with urine ketones.
- can use plasma on dipstick to rule OUT DKA.
113
What hormones are increased with reduced insulin?
↑ homone sensitive lipase => ↑lipolysis => ↑ FFA
↑Glucagon > ↑ ketosis, insulin resistance, hepatic glucose production (gluoneogenesis glycogenolysis) and ketogenesis
↑ Cortisol and growth hormone => ↑ lipolysis + block insulins action in peripheral tissues
↑ adrenaline => ↑ insulin resistance
114
What are the areas of the adrenal cortex and what hormones do they predominantly produce?
Zona glomerulosa - aldosterone
- lacks 17aHydroxylase to make others.
Zona Fasiculata - cortisol
Zona reticularis - sex hormones
* all areas make corticosterone and all need cholesterol/LDL
115
What region of the pituitary are most masses associated with PDH located?
80% pars distalis
| 20% pars intermedia
116
What other tumours can produce ectopic ACTH?
What would this show on HDDST and imaging?
- hepatic carcinoma
- metastatic neuroendocrine tumour
- lung carcinoma
- phaeo
No suppression with HDDST
Normal pituitary size
Bilateral adrenomegaly.
117
What is the sens and spec of UCCR for HyperA diagnosis in dogs?
What are the limitations of this?
Sens: 995
Spec:77%
Limitation: screening only. if increased then need to do confirmation test
118
What is the sens and spec of ACTH for HyperA diagnosis in dogs?
What are the limitations of this?
Sens: 57-90%
PDH - 80%
AT - 60%
Spec: 60-90%
Limitation:
- lower sens than LDDST esp for adrenal tumour
- doesn't differentiate AT vs PDH
- Iatrogenic and hypoA both low
- Affected by glucocorticoids, progreatgens, ketoconazole.
- can be low with adrenal tumours.
119
What is the sens and spec of LDDST for HyperA diagnosis in dogs?
What are the limitations of this?
Sens: 85-1005
Spec: 44-75%
Limitation:
- false positives with non-adrenal illness and stress
- can only confirm PDH not AT
- Drugst that affect cytochrome P450 may also impact strest results eg phenobarb may not show suppression due to increased P450
120
What findings is consistent with hyperA for:
1. UCCR
2. ACTH stim
3. LDDST
1. UCCR - elevated
2. ACTH stim - post ACTH cortisol increased
3. LDDST - 8h post dex cortisol > lab cut off
121
Which tests can be used to help differentiate PDH from AT?
1. LDDST
2. HDDST
3. eACTH
4. CRH Stim or ADH response test
5. Imaging
122
What LDDST results can be see with PDH?
- no suppression
- 8h no suppression + is <50% of basal cortisol
- 8h no suppression + 4h suppression or 4h is <50% of basal cortisol.
Inverse pattern:
4h no suppression but 8h suppression.
=> suspicious - do second test.
123
What LDDST results are seen with AT?
| does this confirm AT?
- no suppression at 4 or 8h
Doesn't confirm AT.
124
What HDDST results are seen with PDH?
- no suppression
- suppress below the lab cut off at 4 or 8h
- suppress to <50% of basal cortisol at 4 or 8h
125
What HDDST results are seen with AT?
| does this confirm AT?
- no suppression.
| doesn't confirm AT
126
What are the limitations of eACTH to differentiate AT from PDH?
- labile
- grey zone
- episodic ACTH secretion
- strees, ectopic ACTh and food stimulated hyperA can cause discordant results.
127
What findings would be expected with eACTH for:
- Adrenal tumour
- PDH
AT - no eACTH due to negative feedback
PDH - increased eACTH to due excessive production by pituitary.
128
What findings would be expected with ADh stimulation test for:
- Adrenal tumour
- PDH
AT - no increase in cortisol with ADH/desmopressin
PDH- >10% increase in cortisol from baseline with desmopressin.
129
How can food dependant hyperA be diagnosed?
- doubling of UCCr in response to food
- low plasma eACTH without an adrenal tumour but bilateral adrenal enlargement
- prevention of meal induce increase in cortisol with the use of octreotide.
130
What findings are suggestive of an adrenal carcinoma?
>2cm
- perpheral fibrosis
- capsular invasion
- haemorrhage and necrosis/red and friable
- mets.
131
What testing is recommended to diagnose feline hyperA?
| Sensitivity?
- LDDST
| sens: "100%" at 8h
132
What endocrine disease can ear tip curling in cats be associated with?
Ear tip curlin g- feline hyperA.
133
What are more common clin path abnormalities in cats with hyperA?
```
↓ K+
↓ Mg+
↓ RBC
↓ Albumin + ↓total Ca
diabetic neuropathy
↑ globulins.
```
134
What treatment is recommended for cats with hyperA?
- Surgery - hypophysectomy or uni/bilateral adrenalectomy
- trilostane
- radiation (pituitary)
- Metyrapone: inhibits 11beta-hydroxylase enzyme that converts 11-deoxycortisol to cortisol, proved effective at least transiently in controlling clinical signs. suitable for pre-op stabilization.
135
How is feline hypoA different from canine?
- can occur with lymphoma commonly
- ACTH stim test with cortisol at 0, 30 and 60 min and give 1/2 vial IM
- much slower reponse time. Takes 3-5 days.
136
What disease does hypoA in dogs commonly mimic on lab results?
```
1. liver failure
↓ Blood glucose
↓ Alb
↓ Cholesterol
↓ GI haemorrhage
↑ ALT and ALP
* BATT normal
```
2. Renal failure
- azotaemia + ↓ USG
- anaemia
- ↑ Ca++, ↑ Phos, ↑ K+
3. Insulinoma
↑ ALP and ALP
↓ Glucose => hypoglycaemic seizures.
```
4. PLE
↓ Alb
↓ Cholesterol
GI haemorrhage
Non-regen anaemia.
```
137
What CBC changes can be seen with hypoA?
- anaemia - potentially non-regen or iron deficiency
↑ lymphocytes
↑ Eosinophils
normal, mildly ↑ or ↓ Neut with no stress leukogram.
138
what are the medical management options for phaeo?
1. phenoxybenxamine - a-adrenoreceptor blocker.
2. Amlodipine - CCB. reduces hypertension and vasoconstriction
3. B blocker - propranolo/atenolol - if tachycardia or tachyarrhythmia, but must have phenoxybenzamine effective first or => severe hypertension.
4. Metyrosine - inhib the enz that catylases the rate limiting step in catecholamine synthesis => less produced.
139
What testing can be used to confirm phaeo?
Urine metneprhine or normetnephrine testing. both higher in urine or plasma. compare with creatinien for ration. >4 x upper limit of normal
suspicious if low inhibin with AT in desexed dog.
140
What conditions is ↑PTH seen in?
| What do Ca+ and Phos do in these conditions?
Primary hyperPTH
↑PTH, ↑ iCa++, normal to ↓ phos
Secondary renal hyperPTH
↑PTH, normal to ↓ iCa++, normal to ↑Phos
141
What conditions is ↑ Vit D3 (Calcitriol) seen in?
| What do Ca+, Phos and PTH do in these conditions?
Primary HyperPTH:
↑ Vit D3, ↑iCa++, normal to ↓ phos, normal to ↑ PTH
↑ Vit D3/Calcitriol toxicity:
↑ Vit D3, ↑ iCa++, normal to ↑ phos, ↓ PTH.
142
What do cats with idiopathic hypercalcaemia usually have for their:
- phosphate
- PTH
- PTHrP
- iMg
- 25 hydroxyvit D
- Calcitriol
- all within ref range
| only increased iCa++ with no evidence of malignancy and all other levels wnl.
143
What medications should be given to patients with primary hyperparathryoidism perioperatively?
- Vitamin D3 (Calcitriol) +/- oral Ca++ started 12-24h before surgery or after surgery
Acute hypocalcaemia => IV calcium gluconate.
144
How do patients with central DI respond to:
- water deprivation testing
- ADH stimulation?
What is the treatment for central DI
- unable to concentrate urine
- respond to ADH stimulation
complete central DI= >50% increase in urine osmolality
Partial central DI = >15% increased in urine osmolality
treat with desmopressin + always have water available
145
How do patients with nephrogenic DI respond to:
- water deprivation testing
- ADH stimulation?
What is the treatment for nephrogenic DI
- unable to concentrate urine
- no or minimal response to ADH => no increase in urine osmolality.
treatment:
- low sodium diet
- thiazide diuretic
- always have water available.
146
What is the difference between somatostatin and somatotropin?
Somatostatin = growth hormone inhibiting hormone (statins = stops)
```
Stomatotropin = growth hormone
(trophin = stimulate/grows)
```
147
What cell type is this surface protein/s associated with?
| Cytokeratin Ab AE1/AE3
Synovial cell sarcoma
148
What cell type is this surface protein/s associated with?
| ALP
Osteosarcoma
149
What cell type is this surface protein/s associated with?
| - Smooth muscle actin
Malignant fibrous histiocytoma
150
What cell type is this surface protein/s associated with?
| CD34+
ALL
151
What cell type is this surface protein/s associated with?
CD3
CD4
CD8
T cell lymphoma
152
What cell type is this surface protein/s associated with?
CD21
CD79a
B cell lymphoma
153
What cell type is this surface protein/s associated with?
| CD 11
MCT
154
What cell type is this surface protein/s associated with?
| CD117
Kit mutation - MCT
155
What cell type is this surface protein/s associated with?
| MUM
plasma cell tumour
156
What cell type is this surface protein/s associated with?
| RF4
Plasma cell tumour
157
What cell type is this surface protein/s associated with?
| Melan A
Melanoma
158
What cell type is this surface protein/s associated with?
| PNL 2
Melanoma
159
What cell type is this surface protein/s associated with?
| S100
Melanoma
160
What cell type is this surface protein/s associated with?
CS1a
CD11c
CD18
Histocytic disease including
- histiocytic sarcoma
- haemophagocytic histocytic sarcoma (CD11d instead of CD 11c though)
- feline progessive histocytosis ( + CD5)
- Histocytoma (+ E cadherin)
- Langerhans histocytosis (+ Ecadherin)
- Reactive cutaneous or systemic histiocytosis (+ CD4 and CD90)
161
What cell type is this surface protein/s associated with?
| CD11d
- haemophagocytic histiocytis sarcoma
162
What cell type is this surface protein/s associated with?
| CD5
feline progressive histiocytosis
| T cells
163
What cell type is this surface protein/s associated with?
| Ecadherin
histiocytoma or langerhand histiocytosis
164
What cell type is this surface protein/s associated with?
| CD4
Tcells
thymocytes
monocytes
= MCH class II
165
What cell type is this surface protein/s associated with?
| CD 8
MCH class I => cytotoxic T cells
166
What cell type is this surface protein/s associated with?
| CD 9
```
PLT
immature B cells
eosionophil
basophil
activated T cells
```
167
What cell type is this surface protein/s associated with?
| CD10
precursor T and B cells
168
What cell type is this surface protein/s associated with?
| CD 14
Macrophages
| Granulocytes
169
What cell type is this surface protein/s associated with?
| CD15
NK cells
170
What cell type is this surface protein/s associated with?
| CD18
All leukocytes
171
What cell type is this surface protein/s associated with?
| CD19
B cells and dendritic cells but not plasma cells
172
What cell type is this surface protein/s associated with?
| CD21
B cells
some T cells
dendritic cells
173
What cell type is this surface protein/s associated with?
| CD117
c-Kit assoc with tyrosine kinase
174
What cell type is this surface protein/s associated with?
| CD54
= ICAM
| vasc endothelial cells
175
What cell type is this surface protein/s associated with?
| CD56
NK cells and nerve cells
176
What cell type is this surface protein/s associated with?'
| CD66e
malignant intestinal cells
177
What immunohistochem markers are found in :
| histocytic sarcoma
CD1a
CD11c (CD11d = haemophagocytic HA)
CD18
178
What immunohistochem markers are found in :
| osteosarc
ALP
179
What immunohistochem markers are found in :
| synovial cell sarcoma
cytokeratin Ab AE1/AE3
180
What immunohistochem markers are found in :
| malignant fibrous histiocytoma
smooth muscle actin
181
What immunohistochem markers are found in :
| ALL
CD34
182
What immunohistochem markers are found in :
| Tcell lymphoma
CD3
CD4
CD8
183
What immunohistochem markers are found in :
| B cell lymphoma
CD21
| CD79a
184
What immunohistochem markers are found in :
| MCT
CD11
| CD117 (c-kit mutation)
185
What immunohistochem markers are found in :
| c-kit mutation
CD117
186
What immunohistochem markers are found in :
| Plasma cell tumour
MUM
| RF4
187
What immunohistochem markers are found in :
| Melanoma
Melan A
| PNL2S100
188
What immunohistochem markers are found in :
| histiocytoma
CD1a
CD11c
CD18
Ecadherin
