Assessment of a standing position during abdominal point-of-care ultrasound on abdominal fluid score in dogs

OBJECTIVE

To assess the use of a standing position during abdominal point-of-care ultrasound (POCUS) examination when evaluating dogs for peritoneal effusion.

DESIGN

Randomized prospective study over 17 months.

SETTING

Single-center, university veterinary teaching hospital.

ANIMALS

Thirty dogs presenting for acute abdominal disease. Eligibility included suspicion for free peritoneal effusion and the ability to stand.

INTERVENTIONS

Dogs underwent standing abdominal POCUS, right lateral abdominal POCUS, and a full abdominal ultrasound. We originally had nothing listed. It now includes all three ultrasound evaluations that were performed for each patient.

MEASUREMENTS AND MAIN RESULTS

Patients underwent both a right lateral and standing abdominal POCUS via a previously described abdominal focused assessment with sonography for trauma (A-FASTrl and A-FASTs, respectively) technique in a randomized and sequential order followed by a full abdominal ultrasound (AUS-full). The A-FASTs examination included a right flank location in addition to the following standard views: subxiphoid, left flank, urinary bladder, and umbilicus. Five-second cine loops were obtained at each location for each examination and reviewed in the order they were obtained. Locations for both A-FAST exams were interrogated in the same order every time. The cine loops were scored for the degree of peritoneal effusion based on a previously published abdominal fluid scoring system by a board-certified radiologist, radiology resident, and radiology intern. The overall abdominal fluid score (AFS) was compared to a subjective full abdominal ultrasound score given by a board-certified radiologist. Six dogs had no peritoneal effusion, 13 had a small volume (AFS 1 or 2), and 11 had a moderate to large volume (AFS 3 or 4). Excellent agreement (intraclass correlation coefficient) was found between the A-FASTs and A-FASTrl techniques (0.95, 0.93, 0.94), good agreement between A-FASTs and AUS-full (0.80, 0.77, 0.82), and good agreement between A-FASTrl and AUS-full (0.80, 0.82, 0.84). The interobserver agreement was good (0.87) for the A-FASTs technique and excellent (0.91) for the A-FASTrl technique. Mean observer agreement score was excellent (0.94) when evaluating A-FASTrl to A-FASTs, good (0.86) when evaluating A-FASTs to AUS-full, and good (0.87) when evaluating A-FASTrl to AUS-full.

CONCLUSION

Performing a standing abdominal POCUS examination may be a valid option for identifying and quantifying peritoneal effusion in situations when a more traditional right lateral approach cannot be performed.

2022 AAFP/EveryCat Feline Infectious Peritonitis Diagnosis Guidelines

CLINICAL IMPORTANCE

Feline infectious peritonitis (FIP) is one of the most important infectious diseases and causes of death in cats; young cats less than 2 years of age are especially vulnerable. FIP is caused by a feline coronavirus (FCoV). It has been estimated that around 0.3% to 1.4% of feline deaths at veterinary institutions are caused by FIP.

SCOPE

This document has been developed by a Task Force of experts in feline clinical medicine as the 2022 AAFP/EveryCat Feline Infectious Peritonitis Diagnosis Guidelines to provide veterinarians with essential information to aid their ability to recognize cats presenting with FIP.

TESTING AND INTERPRETATION

Nearly every small animal veterinary practitioner will see cases. FIP can be challenging to diagnose owing to the lack of pathognomonic clinical signs or laboratory changes, especially when no effusion is present. A good understanding of each diagnostic test's sensitivity, specificity, predictive value, likelihood ratio and diagnostic accuracy is important when building a case for FIP. Before proceeding with any diagnostic test or commercial laboratory profile, the clinician should be able to answer the questions of 'why this test?' and 'what do the results mean?' Ultimately, the approach to diagnosing FIP must be tailored to the specific presentation of the individual cat.

RELEVANCE

Given that the disease is fatal when untreated, the ability to obtain a correct diagnosis is critical. The clinician must consider the individual patient's history, signalment and comprehensive physical examination findings when selecting diagnostic tests and sample types in order to build the index of suspicion 'brick by brick'. Research has demonstrated efficacy of new antivirals in FIP treatment, but these products are not legally available in many countries at this time. The Task Force encourages veterinarians to review the literature and stay informed on clinical trials and new drug approvals.

AFAST Target-Organ Approach and Fluid Scoring System in Dogs and Cats

Point-of-care ultrasonography as part of the physical examination is becoming considered a core skill. AFAST includes 5 acoustic windows over the abdomen and serves as a rapid screening test for free fluid (ascites, retroperitoneal, pleural and pericardial effusion) and soft tissue abnormalities (target-organ approach), and has an abdominal fluid scoring system (semiquantitating volume). Moreover, add-on skills are possible without additional views that include characterizing the caudal vena cava and hepatic veins (volume status), measuring the urinary bladder (volume estimation and urine output), screening for free air (pneumoperitoneum, pneumoretroperitoneum), and assessing gastrointestinal motility.

Cageside Ultrasonography in the Emergency Room and Intensive Care Unit

Global Focused Assessment with Sonography for Trauma (FAST) and point-of-care ultrasonography carry the potential to screen for and monitor conditions rather than traditional means without ultrasonography. Advantages include being point of care, cageside, low impact, rapid, safe, and radiation sparing, and requiring no shaving and/or minimal patient restraint. Moreover, information is real time for free fluid and soft tissue abnormalities of the abdomen, heart, and lung, which are missed or only suspected by physical examination, basic blood and urine testing, and radiography. A standardized approach with recording of patient data is integral to a successful Global FAST program.

The long-term impact of folic acid in pregnancy on offspring DNA methylation: follow-up of the Aberdeen Folic Acid Supplementation Trial (AFAST)

BACKGROUND

It has been proposed that maternal folic-acid supplement use may alter the DNA-methylation patterns of the offspring during the in-utero period, which could influence development and later-life health outcomes. Evidence from human studies suggests a role for prenatal folate levels in influencing DNA methylation in early life, but this has not been extended to consider persistent effects into adulthood.

METHODS

To better elucidate the long-term impact of maternal folic acid in pregnancy on DNA methylation in offspring, we carried out an epigenome-wide association study (EWAS) nested within the Aberdeen Folic Acid Supplementation Trial (AFAST-a trial of two different doses: 0.2 and 5 mg, folic acid vs placebo). Offspring of the AFAST participants were recruited at a mean age of 47 years and saliva samples were profiled on the Illumina Infinium Human Methylation450 array. Both single-site and differentially methylated region analyses were performed.

RESULTS

We found an association at cg09112514 (p = 4.03×10-9), a CpG located in the 5' untranslated region of PDGFRA, in the main analysis comparing the intervention arms [low- (0.2 mg) and high-dose (5 mg) folic acid combined (N = 43)] vs placebo (N = 43). Furthermore, a dose-response reduction in methylation at this site was identified in relation to the intervention. In the regional approach, we identified 46 regions of the genome that were differentially methylated in response to the intervention (Sidak p-value <0.05), including HLA-DPB2, HLA-DPB1, PAX8 and VTRNA2-1. Whereas cg09112514 did not replicate in an independent EWAS of maternal plasma folate, there was suggested replication of differential methylation in PAX8.

CONCLUSIONS

The results of this study suggest that maternal folic-acid supplement use is associated with changes in the DNA methylation of the offspring that persist for many years after exposure in utero. These methylation changes are located in genes implicated in embryonic development, immune response and cellular proliferation. Further work to investigate whether these epigenetic changes translate into detectable phenotypic differences is required.

Focused assessment with sonography in nontraumatized dogs and cats in the emergency and critical care setting

OBJECTIVE

To evaluate the use of abdominal- and thoracic-focused assessment with sonography for trauma (AFAST and TFAST) in nontraumatized dogs and cats in the emergency and critical care setting and to compare prevalence of free fluid identified via these techniques between stable and unstable patients.

DESIGN

Prospective observational study.

SETTING

University Distributed Veterinary Learning Community.

ANIMALS

One hundred client-owned dogs and cats presenting to an emergency service with no evidence of trauma.

INTERVENTIONS

AFAST and TFAST performed within 12 hours of presentation.

MEASUREMENT AND MAIN RESULTS

Free fluid was identified on AFAST or TFAST in 33% of dogs and cats in this study. Free fluid was identified in 27 of 36 (75%) cardiovascularly unstable or dyspneic patients, compared to 6 of 64 (9%) stable patients. A significantly greater proportion of unstable patients had free fluid compared to stable patients (P < 0.0001).

CONCLUSIONS

Results of this study support the use of AFAST and TFAST to detect free fluid in nontraumatized dogs and cats in the emergency and critical care setting, particularly patients that are unstable on presentation.

The use of the diaphragmatico-hepatic (DH) views of the abdominal and thoracic focused assessment with sonography for triage (AFAST/TFAST) examinations for the detection of pericardial effusion in 24 dogs (2011-2012)

OBJECTIVE

To evaluate the clinical usefulness of the diaphragmatico-hepatic (DH) view of the abdominal and thoracic focused assessment with sonography for triage (AFAST/TFAST) in detecting pericardial effusion (PE) in dogs.

DESIGN

Retrospective case series from 2011 to 2012.

SETTING

Private practice emergency and critical care hospital.

ANIMALS

Twenty-four dogs with PE diagnosed by FAST.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Fifty-two medical records from October 1, 2011 through September 30, 2012 had the terms "PE" within the medical record. Twenty-four dogs were diagnosed with PE by FAST with entries for the DH view. Of the 24 dogs, 7 had abdominal FAST, 6 had thoracic FAST (TFAST), and 11 had both exams performed. PE was noted on the DH view in 20 of 24 (83%) cases. Subjective PE volume assessment ranged from trivial (<5 mm) to severe. Of the 4 cases in which PE was absent via the DH view, PE was seen during the same exam at the TFAST pericardial views (n = 2) or detected on serial exam at the DH view (n = 2). The PE volume that was missed via the DH view was characterized as trivial (<5 mm; n = 1), mild (n = 1), and moderate (n = 2).

CONCLUSIONS

The DH view of FAST was found to be clinically helpful for the detection of PE. Veterinarians should make it routine practice and part of FAST training to look into the thorax via the DH view during both abdominal FAST and TFAST exams.