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Knies M, Teske E, Kooistra H. Comparison of Doppler ultrasonic sphygmomanometry, oscillometry and high-definition oscillometry for non-invasive blood pressure measurement in conscious cats. J Feline Med Surg 2024; 26:1098612X241231471. [PMID: 38546192 PMCID: PMC10983607 DOI: 10.1177/1098612x241231471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVES Systemic arterial hypertension is a common occurrence and can have serious adverse consequences in cats. Therefore, measuring blood pressure is very important. There are many indirect blood pressure measurement devices available. This study compared Doppler, oscillometric (petMAP Graphic II, SunTech Vet20, the Cardell Insight-X0000) and high-definition oscillometry devices for the non-invasive measurement of blood pressure in conscious cats. METHODS In this prospective study, blood pressure was measured in 32 cats using the different devices according to the recommendations of the American College of Veterinary Internal Medicine Consensus Statement. Blood pressures (systolic blood pressure [SBP], diastolic blood pressure [DBP], mean arterial pressure [MAP]), time to complete measurements, number of attempts needed, coefficient of variation (CV) between the blood pressure measurements of the different devices, ease of completing measurements and apparent stress level of the cat were assessed. RESULTS There was a significant difference between devices in the time taken to obtain blood pressure readings and the number of attempts necessary to obtain six reliable measurements. The CV of the Doppler device was significantly smaller than that of the rest of the devices, but there were no other differences between the devices. The mean SBP, DBP and MAP measured by the petMAP device were significantly higher than the measurements from the other devices. The perceived ease of measurement was not significantly different between the various machines. The perceived level of stress of measurement with the Doppler device was significantly higher compared with the other devices but did not lead to an increased SBP. CONCLUSIONS AND RELEVANCE Using a Doppler device to measure blood pressure in conscious cats is fast, relatively easy and gives reliable results. A disadvantage is that the Doppler device can only measure SBP, while oscillometric devices also provide DBP and MAP. However, in veterinary medicine, systolic hypertension is considered the most relevant.
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Affiliation(s)
- Marieke Knies
- AniCura Veterinary Referral Centre Haaglanden, Dordrecht, The Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Erik Teske
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Hans Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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Knies M, Kooistra HS, Teske E. Prevalence of persistent hypertension and situational hypertension in a population of elderly cats in The Netherlands. J Feline Med Surg 2023; 25:1098612X231172629. [PMID: 37278217 PMCID: PMC10811978 DOI: 10.1177/1098612x231172629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Systemic arterial hypertension is increasingly recognised and can have serious adverse consequences in cats. Unfortunately, the act of measuring blood pressure itself may cause an increase in blood pressure, known as situational hypertension. It is currently unknown how often this phenomenon occurs. The aim of this study was to evaluate the prevalence of persistent hypertension and situational hypertension in an elderly population of cats in a first-opinion clinic and to assess which factors were associated with systolic hypertension. METHODS In this prospective study, systolic blood pressure was measured in 185 cats aged ⩾10 years using the Doppler sphygmomanometry method according to the recommendations of the American College of Veterinary Internal Medicine consensus statement. Age, sex, body weight, body condition score, position during blood pressure measurement and apparent stress level were assessed. If a systolic blood pressure >160 mmHg was found, measurements were repeated to evaluate if persistent hypertension or situational hypertension was present. The first set of blood pressure measurements were used for all the statistical analyses. RESULTS The median systolic blood pressure for this population was 140 mmHg. The prevalence of persistent hypertension was at least 14.6% and situational hypertension at least 5.4%. Factors significantly associated with hypertension were age, higher apparent stress levels and a sitting position during measurement. Sex, body weight or body condition score did not significantly influence systolic blood pressure. CONCLUSIONS AND RELEVANCE Both persistent hypertension and situational hypertension are common in elderly cats. There are no reliable parameters to distinguish between the two, underlining the importance of a standard protocol and repeating measurements during a follow-up visit when hypertension is found. Age, demeanour and body position during blood pressure measurement influenced blood pressure in this population of elderly cats.
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Affiliation(s)
- Marieke Knies
- AniCura Clinic Drechtstreek, Dordrecht, The Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Hans S Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Erik Teske
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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Sparkes A, Garelli-Paar C, Blondel T, Guillot E. 'The Mercury Challenge': feline systolic blood pressure in primary care practice - a European survey. J Feline Med Surg 2022; 24:e310-e323. [PMID: 35757930 PMCID: PMC9511504 DOI: 10.1177/1098612x221105844] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to collect data from a substantial number of older cats having their systolic blood pressure (SBP) measured in a variety of clinical practices, to describe the findings and assess variables that affected the duration of assessment and the values obtained. METHODS An international (European-based) multicentre convenience sample survey of cats ⩾7 years of age attending veterinary clinics and having SBP measured as part of their clinical assessment. Information gathered included details of the cat, concomitant disease(s) or therapies, SBP results, device used, time taken to assess SBP and the demeanor of the cat. RESULTS Useable data were available from 8884 cats aged 7-26 years, from 811 clinics across 16 countries. The device used to measure SBP was Doppler in 47.4% and oscillometry in 48.5%. The demeanor of the cat was reported to be calm in 45.7%, anxious in 41.9% and nervous in 8.9%; and the duration of assessment was reported to be <5 mins in 50.4%, 5-10 minutes in 41.7% and >10 mins in 7.9%. Concomitant chronic kidney disease (CKD) was reported in 21.8%, hyperthyroidism in 12.0% or both in 3.1%. The median SBP was 150 mmHg (range 80-310), with 18.6% classified as hypertensive (SBP 160-179 mmHg) and 21.1% as severely hypertensive (SBP ⩾180 mmHg). The measured SBP was significantly affected by the cat's demeanor, duration of SBP assessment, presence of CKD and/or hyperthyroidism, the cat's sex and age, and the presence of concomitant therapy. The duration of SBP assessment was significantly affected by the cat's demeanor. CONCLUSIONS AND RELEVANCE In veterinary clinics, SBP can be measured in most cats within a short period of time using either Doppler or oscillometric equipment. The presence of CKD or hyperthyroidism was associated with significantly higher SBP values, and anxious or nervous cats had higher SBP values and took longer to obtain SBP assessments.
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Affiliation(s)
- Andrew Sparkes
- Simply Feline Veterinary Consultancy, Shaftesbury, Dorset, UK
| | | | - Thomas Blondel
- Innovation and Development, Ceva Santé Animale, Libourne, France
| | - Emilie Guillot
- Companion Animal Franchise, Ceva Santé Animale, Libourne, France
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Lyberg M, Ljungvall I, Häggström J, Ahlund E, Pelander L. Impact of equipment and handling on systolic blood pressure measurements in conscious dogs in an animal hospital environment. J Vet Intern Med 2021; 35:739-746. [PMID: 33586197 PMCID: PMC7995364 DOI: 10.1111/jvim.16062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Situational hypertension and differences between devices complicate interpretations of systolic blood pressure (SBP) measurements in dogs. Hypothesis/Objectives To evaluate if time point of in‐clinic SBP measurement, type of oscillometric device, and operator affect SBP measurements in conscious dogs. Animals Sixty‐seven privately owned dogs with or without chronic kidney disease, divided into 2 study samples (A and B). Methods Cross‐sectional diagnostic study. In part A, SBP measurements in dogs were performed using 2 different devices (HDO and petMap) after acclimatization at 3 standardized time points during a clinical visit. In part B, SBP measurements (HDO) were performed in dogs by a trained final year veterinary student and by the owner alone, at the same occasion. Results For all dogs, there was no difference in mean SBP (mSBP) among the 3 time points for HDO (P = .12) or petMAP (P = .67). However, intraindividual mSBP differences of up to 60 mm Hg between time points were documented. Mean SBP obtained with petMAP was on average 14 (95% CI: 8‐20) mm Hg higher than mSBP obtained with HDO, and this difference increased with increasing SBP. Mean SBP measurements obtained by the trained student were 7 (95% CI: 2‐11) mm Hg higher than mSBP measurements obtained by the owner. Conclusions and Clinical Importance According to the results of this study, time point of in‐clinic SBP measurement in dogs is of minor importance, and instructing owners to perform measurements might reduce suspected situational hypertension. Differences in mSBP measured with HDO and petMAP underscore the need for validation of BP devices used clinically.
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Affiliation(s)
- Maria Lyberg
- University Animal Hospital, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Ingrid Ljungvall
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Jens Häggström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | | | - Lena Pelander
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
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Cerna P, Archontakis PE, Cheuk HO, Gunn-Moore DA. Comparison of Doppler ultrasonic and oscillometric devices (with or without proprietary optimisations) for non-invasive blood pressure measurement in conscious cats. J Feline Med Surg 2020; 23:121-130. [PMID: 32580610 PMCID: PMC7838334 DOI: 10.1177/1098612x20932407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives This study compared Doppler and oscillometric (PetMAP+) devices (with or without proprietary optimisations) for the non-invasive measurement of blood pressure in conscious cats. Methods Twenty-three cats were enrolled; however, five were excluded as fewer than five measurements were obtained for each assessment. All measurements were obtained according to American College of Veterinary Internal Medicine consensus guidelines. Oscillometric device modes A and B were operated according to the manufacturer’s guidelines. Doppler and oscillometric devices were used alternately as the first device. Results Systolic arterial blood pressure (SAP) measurements were obtained by Doppler (SAPd) and oscillometry; the mean of each set of five values was used for statistical analysis. There was a significant difference between SAPd and SAP measurements in oscillometric modes A (P <0.001) and B (P <0.001). While both modes measured SAP higher than SAPd, B had a smaller bias (+15.72 mmHg) and narrower limits of agreement (LOA). There was also a significant difference between SAPd and mean arterial pressure (MAP) on oscillometric modes A (P = 0.002) and B (P <0.001). Both modes’ MAP readings were lower than SAPd and oscillometric A MAP was closer to SAPd (–14.94 mmHg), with a smaller bias and narrower LOA. Conclusions and relevance The findings support that Doppler and oscillometric devices cannot be used interchangeably, with or without proprietary optimisations. Methodology should always be taken into account and reference intervals (RIs) need to be defined for the different methodologies. Until methodology-specific RIs are published, definitive diagnosis of hypertension and sub-staging of patients with kidney disease according to the International Renal Interest Society guidelines remains challenging.
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Affiliation(s)
- Petra Cerna
- Department of Internal Medicine, Hospital for Small Animals, The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, UK.,The University of Veterinary and Pharmaceutical Sciences Brno, Czech Republic
| | - Panos E Archontakis
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, UK
| | | | - Danièlle A Gunn-Moore
- Department of Internal Medicine, Hospital for Small Animals, The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, UK.,The Roslin Institute, University of Edinburgh, Edinburgh, UK
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Chetboul V, Passavin P, Trehiou-Sechi E, Gouni V, Poissonnier C, Pouchelon JL, Desquilbet L. Clinical, epidemiological and echocardiographic features and prognostic factors in cats with restrictive cardiomyopathy: A retrospective study of 92 cases (2001-2015). J Vet Intern Med 2019; 33:1222-1231. [PMID: 30924221 PMCID: PMC6524389 DOI: 10.1111/jvim.15464] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 02/14/2019] [Indexed: 12/15/2022] Open
Abstract
Background Restrictive cardiomyopathy (RCM) is a common primary cardiomyopathy of cats. However, little information is available regarding prognostic variables in large populations of cats with RCM. Objectives To characterize the epidemiological, clinical, and echocardiographic features of cats with RCM and to document their survival times and risk factors for cardiac death (CD). Animals Ninety‐two cats with RCM. Methods Retrospective study. Diagnosis of RCM was based on echocardiographic and Doppler criteria. Median survival time to CD and adjusted hazard ratios (HR) were estimated by the Kaplan‐Meier method and multivariate Cox models, respectively. Results The feline population (median age [interquartile range], 8.6 years [4.1‐12.4]; body weight, 4.0 kg [3.3‐4.7]) included 83 cats (90%) with the myocardial RCM form and 9 (10%) with the endomyocardial fibrosis RCM form. Most RCM cats (64/92, 70%) were symptomatic at the time of diagnosis, with dyspnea related to congestive heart failure in 57 of 64 cats (89%). The median survival time of the 69 cats with the myocardial RCM form and available follow‐up was 667 days (range, 2‐3710 days) considering CD. Independent of age, biatrial enlargement, and arrhythmias, increase of the left atrium (LA)‐to‐aorta (Ao) ratio (hazard ration [HR], 2.5 per 0.5‐unit increase; 95% confidence interval [CI], 1.5‐4.2; P < .001) and presence of severe LA enlargement (end‐diastolic LA : Ao ≥2; HR, 3.4; 95% CI, 1.3‐8.7; P = .01) were significantly associated with shorter time to CD. Conclusions and Clinical Importance Cardiac death is common in RCM cats, and LA enlargement seems independently associated with decreased survival time in these cats.
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Affiliation(s)
- Valérie Chetboul
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France.,INSERM, Unité 955, Equipe 03, Université Paris-Est Créteil, Paris, France
| | - Peggy Passavin
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Emilie Trehiou-Sechi
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Vassiliki Gouni
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France.,INSERM, Unité 955, Equipe 03, Université Paris-Est Créteil, Paris, France
| | - Camille Poissonnier
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Jean-Louis Pouchelon
- Alfort Cardiology Unit, Université Paris-Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Loic Desquilbet
- U955-IMRB, INSERM, École Nationale Vétérinaire d'Alfort, UPEC, Maisons-Alfort Cedex, France
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Bourazak LA, Hofmeister EH. Bias, sensitivity, and specificity of Doppler ultrasonic flow detector measurement of blood pressure for detecting and monitoring hypotension in anesthetized dogs. J Am Vet Med Assoc 2018; 253:1433-1438. [DOI: 10.2460/javma.253.11.1433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Acierno MJ, Brown S, Coleman AE, Jepson RE, Papich M, Stepien RL, Syme HM. ACVIM consensus statement: Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats. J Vet Intern Med 2018; 32:1803-1822. [PMID: 30353952 PMCID: PMC6271319 DOI: 10.1111/jvim.15331] [Citation(s) in RCA: 265] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022] Open
Abstract
An update to the 2007 American College of Veterinary Internal Medicine (ACVIM) consensus statement on the identification, evaluation, and management of systemic hypertension in dogs and cats was presented at the 2017 ACVIM Forum in National Harbor, MD. The updated consensus statement is presented here. The consensus statement aims to provide guidance on appropriate diagnosis and treatment of hypertension in dogs and cats.
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Affiliation(s)
- Mark J Acierno
- Department of Medicine, College of Veterinary Medicine, Midwestern University, 5715 W. Utopia Rd, Glendale Arizona 85308
| | - Scott Brown
- College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Amanda E Coleman
- College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, London, United Kingdom
| | - Mark Papich
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Rebecca L Stepien
- Department of Medical Sciences, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
| | - Harriet M Syme
- Department of Clinical Science and Services, Royal Veterinary College, London, United Kingdom
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Taylor SS, Sparkes AH, Briscoe K, Carter J, Sala SC, Jepson RE, Reynolds BS, Scansen BA. ISFM Consensus Guidelines on the Diagnosis and Management of Hypertension in Cats. J Feline Med Surg 2017; 19:288-303. [PMID: 28245741 PMCID: PMC11119534 DOI: 10.1177/1098612x17693500] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Practical relevance: Feline hypertension is a common disease in older cats that is frequently diagnosed in association with other diseases such as chronic kidney disease and hyperthyroidism (so-called secondary hypertension), although some cases of apparent primary hypertension are also reported. The clinical consequences of hypertension can be severe, related to 'target organ damage' (eye, heart and vasculature, brain and kidneys), and early diagnosis followed by appropriate therapeutic management should help reduce the morbidity associated with this condition. Clinical challenges: Despite being a common disease, routine blood pressure (BP) monitoring is generally performed infrequently, probably leading to underdiagnosis of feline hypertension in clinical practice. There is a need to: (i) ensure BP is measured as accurately as possible with a reproducible technique; (ii) identify and monitor patients at risk of developing hypertension; (iii) establish appropriate criteria for therapeutic intervention; and (iv) establish appropriate therapeutic targets. Based on current data, amlodipine besylate is the treatment of choice to manage feline hypertension and is effective in the majority of cats, but the dose needed to successfully manage hypertension varies between individuals. Some cats require long-term adjuvant therapy and, occasionally, additional therapy is necessary for emergency management of hypertensive crises. Evidence base: These Guidelines from the International Society of Feline Medicine (ISFM) are based on a comprehensive review of the currently available literature, and are aimed at providing practical recommendations to address the challenges of feline hypertension for veterinarians. There are many areas where more data is required which, in the future, will serve to confirm or modify some of the recommendations in these Guidelines.
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Affiliation(s)
| | | | - Katherine Briscoe
- Animal Referral Hospital, 250 Parramatta Road, Homebush, Sydney, NSW 2140, Australia
| | - Jenny Carter
- PO Box 128209, Remuera, Auckland 1541, New Zealand
| | | | - Rosanne E Jepson
- Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, Hatfield, Hertfordshire, AL9 7TA, UK
| | | | - Brian A Scansen
- Associate Professor, Department of Clinical Sciences, Colorado State University, Campus Delivery 1678, Fort Collins, CO 80523, USA
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Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I, Langston C, Lefebvre HP, White J, Quimby J. ISFM Consensus Guidelines on the Diagnosis and Management of Feline Chronic Kidney Disease. J Feline Med Surg 2016; 18:219-39. [PMID: 26936494 PMCID: PMC11148907 DOI: 10.1177/1098612x16631234] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
PRACTICAL RELEVANCE Chronic kidney disease (CKD) is one of the most commonly diagnosed diseases in older cats. In most cats, CKD is also a progressive disease and can be accompanied by a wide range of clinical and clinicopathological changes. These ISFM Consensus Guidelines have been developed by an independent panel of clinicians and academics to provide practical advice on the diagnosis and management of this complex disease. CLINICAL CHALLENGES Although CKD is a common clinical problem in cats, the manifestations of disease vary between individuals. Thus there is a need for careful and repeat evaluation of cats with CKD and adjustment of therapy according to individual needs. In addition to addressing problems arising from CKD and improving quality of life (QoL) for the patient, therapy may also target slowing the underlying progression of disease and hence prolonging life. While maintaining QoL is of paramount importance in our patients, this can be challenging when multiple therapies are indicated. In some cases it is necessary to prioritise therapy, given an understanding of what is likely to most benefit the individual patient. EVIDENCE BASE In preparing these Guidelines, the Panel has carefully reviewed the existing published literature, and has also graded the quality of evidence for different interventions to help to provide practical recommendations on the therapeutic options for feline CKD. This is a field of veterinary medicine that has benefited from some excellent published clinical research and further research findings will undoubtedly modify the recommendations contained in these Guidelines in the future.
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Affiliation(s)
| | | | - Serge Chalhoub
- Faculty of Veterinary Medicine, University of Calgary, Canada
| | - Jonathan Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, UK
| | - Natalie Finch
- Bristol Renal, School of Clinical Sciences, University of Bristol, UK
| | | | | | - Hervé P Lefebvre
- Clinical Research Unit, National Veterinary School of Toulouse (ENVT), France
| | - Joanna White
- Small Animal Specialist Hospital, Sydney, Australia
| | - Jessica Quimby
- Department of Clinical Veterinary Sciences, Colorado State University, USA
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