Use of human intravenous immunoglobulin for the treatment of 12 dogs with newly diagnosed malignant disease and presumed secondary immune-mediated thrombocytopenia

OBJECTIVES

To evaluate the safety and efficacy of human intravenous immunoglobulin in dogs with newly diagnosed malignancy and presumed secondary immune-mediated thrombocytopenia.

MATERIALS AND METHODS

Twelve client-owned dogs with newly diagnosed malignant disease and presumed secondary immune-mediated thrombocytopenia were prospectively enrolled to receive a single infusion of human intravenous immunoglobulin at a dose of 0.5 to 1 mg/kg intravenous over 8 hours. A complete treatment response was defined as a platelet estimation of ≥40,000 platelets/μL within 24 hours and a partial response within 48 hours from the completion of human intravenous immunoglobulin infusion. No treatment response was defined as a platelet estimation remaining <40,000 platelets/μL over 48 hours from the completion of the human intravenous immunoglobulin infusion. This pilot study had a prospective, open-label, uncontrolled design.

RESULTS

Out of the 12 enrolled dogs, seven completed the study. A complete treatment response to human intravenous immunoglobulin was identified in one lymphoma dog and a partial response was noted in another lymphoma dog. The remaining 10 dogs had no response to human intravenous immunoglobulin. No clinically relevant adverse reactions to human intravenous immunoglobulin occurred in any of the 12 initially enrolled dogs during the infusion and over a 3-month follow-up period for the seven surviving dogs.

CLINICAL SIGNIFICANCE

The results of this study suggest that the use of human intravenous immunoglobulin in dogs with newly diagnosed malignant disease and presumed secondary immune-mediated thrombocytopenia appears safe, but not effective for the treatment of thrombocytopenia. Larger multi-centre, prospective, double-blinded, placebo-controlled, outcome-based, malignancy-specific studies are needed to further evaluate these preliminary findings.

[Symptomatic osteosynthesis in calcaneal fracture: implant colonization as a cause of pain]

Calcaneal fracture is unusual and carries high costs at long term because its associated morbidity. Surgical treatment of this fracture by extended lateral approach has risks like wound healing up to 20%. One of the causes of chronic pain is subtalar arthropathy, but it is important to rule out other causes as implant associated infection. The aim of this study is to demonstrate the presence of germs in the implant through extraction, sonication and culture. Cases with evident infection, subtalar arthropathy, non union or subtalar fusion concomitant surgery were excluded. The data includes open fracture history, wound healing complication, time between surgeries, cause to implant extraction and cultures results. A positive culture rate of 33.3% was obtained. We consider it is important to have in mind the implant associated infection as a cause of pain in these patients, with the aim to study microbiologically each case and choose the right strategy of treatment.

Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 3-Defining antithrombotic protocols

OBJECTIVES

To systematically examine the evidence for use of a specific protocol (dose, frequency, route) of selected antithrombotic drugs, in comparisons to no therapy or to other antithrombotic therapies, to reduce the risk of complications or improve outcomes in dogs and cats at risk for thrombosis.

DESIGN

Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence (LOE) and quality (Good, Fair, or Poor), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice.

SETTINGS

Academic and referral veterinary medical centers.

RESULTS

Databases searched included Medline via PubMed and CAB abstracts. Eight different antithrombotic drugs were investigated using a standardized Patient, Intervention, Comparison, Outcome (PICO) question format both for dogs and cats, including aspirin, clopidogrel, warfarin, unfractionated heparin (UFH), dalteparin, enoxaparin, fondaparinux, and rivaroxaban, generating a total of 16 worksheets. Most studies identified were experimental controlled laboratory studies in companion animals (LOE 3) with only four randomized controlled clinical trials in companion animals (LOE 1).

CONCLUSIONS

Overall, evidence-based recommendations concerning specific protocols could not be formulated for most antithrombotic drugs evaluated, either because of the wide range of dosage reported (eg, aspirin in dogs) or the lack of evidence in the current literature. However, clopidogrel administration in dogs and cats at risk of arterial thrombosis, notably in cats at risk of cardiogenic thromboembolism, is supported by the literature, and specific protocols were recommended. Comparably, aspirin should not be used as a sole antithrombotic in cats with cardiomyopathy. Using the available safety profile information contained in the literature, the panel reached consensus on suggested dosage schemes for most antithrombotics. Significant knowledge gaps were highlighted, which will hopefully drive novel research.

Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 2-Defining rational therapeutic usage

OBJECTIVES

To systematically review available evidence to determine when small animals at risk of thrombosis should be treated with antiplatelet agents and anticoagulants, which antiplatelet and anticoagulant agents are most effective, and when multimodal therapy is indicated.

DESIGN

Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence (LOE) and quality (Good, Fair, or Poor), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. Draft recommendations were presented at 2 international veterinary conferences and made available for community assessment, review, and comment prior to final revisions and publication.

SETTINGS

Academic and referral veterinary medical centers.

RESULTS

Databases searched included Medline via PubMed and CAB abstracts. Twelve Population Intervention Comparison Outcome questions were devised and generated corresponding worksheets investigating indications for use of antithrombotic drugs in small animals. Seventy-eight studies were reviewed in detail. Most studies assessed were experimentally controlled laboratory studies in companion animals (56 LOE 3) with smaller numbers of LOE 2 (1), LOE 4 (5), LOE 5 (6), and LOE 6 (4) studies assessed. Only 5 randomized controlled clinical trials were identified (LOE 1, Good-Fair). The 12 worksheets generated 21 guidelines with 17 guideline statements that were refined during 3 rounds of Delphi surveys. A high degree of consensus was reached across all guideline recommendations during the Delphi process.

CONCLUSIONS

Overall, systematic evidence evaluations generated 2 strong recommendations, 19 weak recommendations (formulated as suggestions), 9 situations where the evidence was insufficient to make strong recommendations, and 8 situations where no relevant evidence was retrieved to aid guideline generation. Numerous significant knowledge gaps were highlighted by the evidence reviews undertaken, indicating the need for substantial additional research in this field.

A prospective evaluation of oral Yunnan Baiyao therapy on thromboleastographic parameters in apparently healthy dogs

OBJECTIVE

To determine the effect of Yunnan Baiyao (YB) on hemostatic parameters measured by thromboelastography (TEG) in healthy dogs administered 1 capsule of YB orally twice daily for 1 week.

DESIGN

Prospective study of client-owned dogs at a small animal specialty hospital.

SETTING

Private referral center.

ANIMALS

Eighteen client-owned adult dogs weighing at least 15 kg.

INTERVENTIONS

Dogs had a baseline TEG performed and then each dog was administered 1 capsule of YB twice daily by mouth for 1 week and the TEG was reevaluated. Any side effects attributed to YB were noted at this time.

MEASUREMENTS AND MAIN RESULTS

All 18 enrolled dogs completed the study. Dogs that received 1 capsule (250 mg/capsule) of YB orally twice daily had significantly increased G as well as A30 and A60 values. There was also a significantly decreased LY30 and LY60 values after 1 week. The YB appeared well tolerated as only one dog developed mild diarrhea.

CONCLUSIONS

The results of this study suggest that YB at 1 capsule orally twice daily in healthy medium to large breed dogs increases the strength of the clot as measured by TEG and that YB was apparently well tolerated in the study population reported here. Larger prospective studies in different disease states are warranted to further evaluate these preliminary findings.

Treatment of refractory sino-nasal aspergillosis with posaconazole and terbinafine in 10 dogs

OBJECTIVES

To determine the safety and efficacy of posaconazole and terbinafine for the treatment of naturally occurring sino-nasal aspergillosis in dogs refractory to conventional topical and systemic treatment.

MATERIALS AND METHODS

Ten client-owned dogs with sino-nasal aspergillosis and not responsive to conventional treatments were prospectively enrolled to receive a dose of 5 mg/kg posaconazole orally every 12 hours for six months. All dogs were concurrently treated with doses of 30 mg/kg terbinafine orally every 12 hours and 5 mg/kg doxycycline orally every 12 hours for 6 to 18 months.

RESULTS

All 10 enrolled dogs completed the study. The treatment response was defined as complete clinical remission (n=7) or partial clinical remission (n=3). Two dogs relapsed after cessation of combination therapy. All dogs lived more than one year after starting combination therapy and eight dogs are alive at the time of writing. No clinically relevant adverse reactions or increases in hepatic enzyme activity occurred during the combination therapy.

CLINICAL SIGNIFICANCE

The results of this study suggest that this combination therapy appears safe and well-tolerated for the treatment of refractory sino-nasal aspergillosis in dogs. Long-term survival is possible with prolonged treatment, but relapse is possible. Larger prospective studies are warranted to further evaluate these preliminary findings.

Retrospective evaluation of pimobendan and sildenafil therapy for severe pulmonary hypertension due to lung disease and hypoxia in 28 dogs (2007-2013)

Pulmonary hypertension (PH) is the persistent abnormal increase in pulmonary artery (PA) pressure and in dogs is usually secondary to congenital disease causing pulmonary over circulation, chronic respiratory disease and elevated left atrial pressure. Sildenafil (SF) is a phosphodiesterase (PDE) V inhibitor that causes pulmonary artery (PA) vasodilation by increasing pulmonary vascular concentrations of cyclic guanosine monophosphate which subsequently increases the activity of endogenous nitric oxide. Pimobendan (PB) is a PDE III inhibitor with calcium sensitizing effects thereby exerting positive inotropy and vasodilation. The purpose of this retrospective study was to evaluate the long-term survival of dogs with severe PH treated with SF and PB compared to SF alone. The use of PB in combination with SF did not result in a statistically significant increase in survival times in dogs with pulmonary hypertension secondary to chronic respiratory disease compared to SF alone.

Use of Yunnan Baiyao and epsilon aminocaproic acid in dogs with right atrial masses and pericardial effusion

OBJECTIVE

To describe the utility of Yunnan Baiyao (YB) alone or in combination with epsilon aminocaproic acid (EAC) for the treatment of dogs with echocardiographically identified right atrial (RA) masses and pericardial effusion (PE).

DESIGN

Retrospective case-controlled study.

SETTING

Two private practice referral hospitals.

ANIMALS

Client-owned dogs with RA masses and PE identified echocardiographically over a 3-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 67 dogs identified with RA masses and PE during the study period. Sixteen dogs were treated with YB alone while 8 dogs were treated with YB in combination with EAC in addition to pericardiocentesis. Forty-three dogs were treated with pericardiocentesis alone and were considered to be the control group. There was no difference between the groups in regards to signalment, physical examination abnormalities, and diagnostic test results on presentation. There was no significant difference between the 2 groups with respect to number of pericardiocenteses performed and there were no side effects attributed to the YB or EAC in any of the dogs. Median time to recurrence of clinical signs was not significantly different between the treatment (12 d, range 1-186 d) and control group (14.5 d, range 1-277 d). The median survival of dogs treated with YB alone or in combination with EAC (18 d, range 1-186 d) was also not significantly improved compared to dogs treated with pericardiocenteses alone (16 d, range 1-277 d).

CONCLUSIONS

This study suggests YB alone or in combination with EAC is relatively safe but does not significantly delay recurrence of clinical signs or improve survival in dogs with RA masses and PE. Due to the small cohort size, further prospective studies evaluating these drugs and their effects on hemostasis in dogs with RA masses and PE are warranted.

Evaluation of the safety and tolerability of rivaroxaban in dogs with presumed primary immune-mediated hemolytic anemia

OBJECTIVE

To evaluate the safety and tolerability of rivaroxaban (RIV), an oral direct factor Xa inhibitory drug, in dogs with presumed primary immune-mediated hemolytic anemia (pIMHA).

DESIGN

Prospective, multicenter, positive-controlled, unblinded clinical trial. Client-owned dogs were enrolled between October 2012 and March 2014.

SETTING

Private referral centers.

ANIMALS

Twenty-four client-owned dogs with pIMHA. Enrolled dogs were randomized in 2 treatment groups to receive by mouth RIV or clopidogrel (CL) and low-dose aspirin (LDA). All dogs were monitored for 90 days from the enrollment in the study.

INTERVENTIONS

Enrolled dogs were given a standardized immunosuppressive protocol and RIV or CL and LDA.

MEASUREMENTS AND MAIN RESULTS

There was no identifiable adverse drug reaction, evidence of hemorrhage, significant prolongation of prothrombin time or activated partial thromboplastin time, or increase in transfusion requirements associated with RIV therapy compared to CL and LDA in dogs with pIMHA. There was no significant difference between treatment groups with respect to thrombotic events, survival rates to discharge, at 1 month and 3 months from diagnosis.

CONCLUSIONS

This study suggests that RIV at a median dose of 0.89 mg/kg by mouth once daily was safe and well tolerated in a small group of dogs with presumed pIMHA able to tolerate oral medications and treated with a standardized immunosuppressive treatment protocol. Conclusions regarding the relative efficacy of RIV as compared to CL and LDA cannot be made due to the small size of the treatment groups and because pharmacodynamic effects were not assessed.

Multi-scale analysis of simulated proton and alpha irradiation

This article presents the results of the simulated irradiation with protons and alpha particles of two different geometrical models, representing a cell nucleus and its chromatin content. The characteristics of the energy deposition are studied at both micrometric and nanometric length scales. In particular, the stochastic distributions of the quantities associated with the total energy deposit in the micrometric volume are derived and compared with the physical characteristics of the clusters of energy deposits. An innovative multi-scale correlation method is introduced and tested against the simulations' data. This new approach links the two relevant length scales exploiting the differences in the kinetic energy spectra of the secondary electrons produced by the primary particles. The characteristics of the energy deposition of the electrons in the chosen material are determined in the first instance. Few free parameters of the model, linking the electrons energy deposits with the total energy deposit of the primary particles, can be used for summarising the characteristic of the irradiation with the chosen radiation quality at the two different length scales.

RBE-LET relationship for proton and alpha irradiations studied with a nanodosimetric approach

Relative Biological Effectiveness (RBE) values are used to characterise the biological efficiency of different radiation qualities relative to photon irradiations. The RBE-high linear energy transfer (LET) relation for ion irradiations presents general features that the authors propose to look at using a nanometric description of the energy deposition of these ion irradiations (protons and alphas of different energies). In this work, the simulation of the energy transfer points in the tracks was made by Monte Carlo method using the Geant4-DNA processes and a nanometric description of the target of interest for studying biological effects, the DNA molecule. Results were obtained concerning the sensitive volume to be considered for direct DNA clustered damages that could be related to late biological effects.

Postresuscitation myocardial dysfunction in a dog

OBJECTIVE

To describe a clinical case of postresuscitation myocardial dysfunction in a dog.

CASE SUMMARY

An 11-month-old, 2.37 kg female spayed Chihuahua was referred for management post CPR after suffering cardiopulmonary arrest. Postresuscitation a gallop rhythm was identified and an echocardiogram revealed severe left ventricular dilation and severely impaired myocardial contractility with a mild eccentric jet of mitral regurgitation on color Doppler interrogation. The primary differentials were idiopathic or nutritional dilated cardiomyopathy, end-stage myocarditis, or postresuscitation myocardial dysfunction. Echocardiogram was repeated 48 hours later and showed normal left ventricular dimensions and contractility assessed as consistent with postresuscitation myocardial dysfunction.

NEW OR UNIQUE INFORMATION PROVIDED

Postresuscitation myocardial dysfunction is a common complication of CPR in human medicine and is associated with a worse outcome. This is the first clinical report of postresuscitation myocardial dysfunction in a dog.

Immune-mediated hemolytic anemia and severe thrombocytopenia in dogs: 12 cases (2001-2008)

OBJECTIVE

To identify and characterize the syndrome of immune-mediated hemolytic anemia (IMHA) with concurrent severe thrombocytopenia (<or=15.0 x 10(9) platelets/L; [15.0 x 10(3) platelets/microL]), and to evaluate prognostic factors, clinicopathologic findings, complications, treatment, outcome, and survival of dogs with this hematologic disorder.

DESIGN

Retrospective, observational study.

SETTING

Veterinary teaching hospital.

ANIMALS

Twelve client-owned dogs with IMHA and severe thrombocytopenia (<or=15.0 x 10(9) platelets/L; [15.0 x 10(3) platelets/microL]), without evidence of overt disseminated intravascular coagulation.

INTERVENTIONS

The following data were recorded and analyzed from the electronic medical record: signalment, history, concurrent diseases, clinical signs at presentation, clinicopathologic data, diagnostic testing, radiographic findings, treatment modalities, length of hospitalization, complications, and clinical outcome. All dogs were treated with immunosuppressive doses of corticosteroids.

MEASUREMENTS AND MAIN RESULTS

Twelve dogs were identified with the diagnosis of IMHA and severe thrombocytopenia; of these, 9 (75%) survived, 3 (25%) were euthanized, and none died. Dogs that survived were significantly younger than nonsurvivors (P=0.03). There were no specific clinical signs or therapies associated with survival.

CONCLUSIONS

Dogs in this study had a mortality rate similar to reported rates for dogs with either disease alone. Overall, younger dogs were more likely to survive. No association between different treatment modalities and overall survival was identified.

Treatment of Evans’ Syndrome With Human Intravenous Immunoglobulin and Leflunomide in a Diabetic Dog

An 11-year-old, spayed female miniature schnauzer with diabetes mellitus was presumptively diagnosed with Evans’ syndrome (ES). Because of the potential adverse effects of immunosuppressive doses of glucocorticoids in a diabetic dog, a single infusion of human intravenous immunoglobulin and oral leflunomide were used as first-line immunomodulatory therapy, after informed owner consent was received. This treatment resulted in complete remission of the ES, and leflunomide was discontinued after 10 months of therapy. Over a 19-month follow-up, the dog did not relapse and has remained a well-regulated diabetic.

Presumed primary immune-mediated thrombocytopenia in four cats

Feline primary immune-mediated thrombocytopenia (pIMT) is a rare hematological disorder. Platelet-bound antibody assays for cats have variable specificity and sensitivity and are not widely available. Diagnosis of pIMT is made on the basis of exclusion of other identifiable causes of thrombocytopenia and the response to immunosuppressive therapy. This report describes four cats with severe thrombocytopenia and no detectable underlying disease. One cat was euthanased because of pulmonary hemorrhage, while the other cats had frequent relapses, two of these cats developed diabetes mellitus due to long-term corticosteroid therapy. In these cats IMT had a chronic course and responded poorly to therapy with prednisolone. Alternative immunomodulatory drugs may be considered in the treatment of feline IMT.

Treatment of severe immune-mediated thrombocytopenia with human IV immunoglobulin in 5 dogs

BACKGROUND

Glucocorticoids with or without other immunotherapy are the initial treatment of choice for dogs with severe immune-mediated thrombocytopenia (IMT). The majority of treated dogs will have improvements in platelet counts within 5 to 7 days of starting therapy, but complications from hemorrhage often occur before a response is seen. Human IV immunoglobulin (hIVIG) blocks Fc receptors on mononuclear phagocytic cells in dogs; it is used in people with idiopathic thrombocytopenic purpura.

HYPOTHESIS

The purpose of this study was to describe adverse effects and benefit of hIVIG in addition to conventional immunosuppressive therapy in dogs with severe IMT.

ANIMALS

Five client-owned dogs with severe primary IMT.

METHODS

Case series. The hospital database was searched for dogs with primary IMT treated with hIVIG.

RESULTS

No adverse effects were noted during or after hIVIG infusion in any treated dog. Over a 6-month follow-up, all dogs were clinically normal when using conventional immunosuppressive therapy. Human IVIG was administered 3 days after initiation of immunosuppressive therapy in 4 dogs, and, after 2 days, in 1 dog. In all dogs, the mean platelet counts pre- and 24 hours post-hIVIG infusion (0.28-0.76 g/kg) were 2,500/pL and 50,600/microL (62,750/microL for the 4 responders), respectively. One dog failed to respond as promptly to hIVIG (0.34 g/kg), and the platelet count increased to 66,000/microL after 9 days of immunosuppressive therapy. The mean duration of hospitalization post-hIVIG in all 5 dogs was 1.8 days (12 hours for responders), and the mean total length of hospitalization was 4.6 days (3.5 days for responders). Active hemorrhage resolved and no packed red blood cell transfusions were required after hIVIG infusion for responders.

CONCLUSIONS AND CLINICAL IMPORTANCE

Human IVIG was well tolerated and appeared to be associated with rapid platelet count recovery and amelioration of clinical signs in most dogs with IMT.

Increased fetal nuchal translucency thickness at 10-14 weeks: is screening for maternal-fetal infection necessary?

OBJECTIVE

To investigate the relation between increased fetal nuchal translucency thickness at 10-14 weeks of gestation and maternal-fetal infection.

DESIGN

Prospective study.

SETTING

Harris Birthright Research Centre for Fetal Medicine.

POPULATION

Four hundred and twenty-six chromosomally normal pregnancies with increased fetal nuchal translucency thickness at 10-14 weeks of gestation and 63 with 'unexplained' second or third trimester fetal nuchal oedema or hydrops.

METHODS

Maternal serum infection screening and investigations for fetal infection in those with evidence of recent maternal infection.

MAIN OUTCOME MEASURES

Maternal and fetal infection.

RESULTS

Evidence of recent maternal infection was present in six of the 426 pregnancies (1.4%) with increased fetal nuchal translucency thickness at 10-14 weeks, but in all cases a healthy infant was born with no evidence of infection. In contrast, 'unexplained' second or third-trimester fetal hydrops was associated with maternal infection in six of the pregnancies (9.5%) and in all cases there was evidence of fetal infection.

CONCLUSIONS

Maternal-fetal infection is one of the causes of second or third trimester nuchal oedema or fetal hydrops. In contrast, the presence of increased nuchal translucency in the first trimester is not a marker of either maternal or fetal infection.

Intraamniotic surfactant for prevention of neonatal respiratory distress syndrome (IRDS): rationale and personal experience

OBJECTIVE

To evaluate the efficacy of intramniotic instillation of supplementary surfactant for the prophylaxis of neonatal IRDS in an emergency obstetric setting.

STUDY DESIGN

Supplementary natural surfactant (SS) was administered intra-amniotically (80 mg in 1 ml) under ultrasound guidance in the proximity of the fetal nostrils and mouth in six pregnant women at 24-32 weeks gestation, with immature amniotic fluid indices of fetal lung maturity, and whose delivery was imminent because of severe fetal distress, deteriorating maternal conditions, or refractory vaginal bleeding. The administration of SS was preceded by IV aminophylline to the mother (a bolus of 240 mg over 10 min, and a maintenance dose of 0.02-0.1 mg kg-1 min-1) in order to elicit sustained fetal breathing movements.

RESULTS

The clinical conditions of the six newborn infants were good with no respiratory problems in four cases, and with mild IRDS in the remaining two, which, however, resolved uneventfully.

CONCLUSIONS

It is suggested that this prophylactic approach has a great potential for becoming a reliable option for the antenatal prevention of IRDS.